ARMY MEDICAL  LIBRARY
       FOUNDBD 1836
WASHINGTON, D.C 
 
 
THE

TO WHICH ARE ADDED,
           INSTRUCTIONS




FOR THE TREATMENT OF LYING-IN WOMEN
J
     THE PRINCIPAL DISEASES OF CHILDREN




            CHIEFLY DESIGNED FOR





STUDENTS AJVD EARLY PRACTITIOffEK-
      FIRST AMERICAN, FROM THE FOURTH J.O.Nl/^i7^T^*^fcv



         EDITION CORRECTED AND HUPROYEf'  f   »'dd''



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                  NEW-YORK:




      PUBLISHED BY JAMES V. SEAMAN



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     1820. 
 
           ADVERTISEMENT

                      TO

      THE  SECOND  EDITION.



The object of the following  pages  is to convey
to the Student in Midwifery much useful  informa-
tion  in a portable form, and, by  faithfully exhibit
ing the  present state of the practice  in the metro
polis, to  offer some  occasional bints to  the  more
experienced  Practitioner.  The First Edition was
so fortunate as to obtain the sanction and recom-
mendation  of the most eminent Professors  and
Lecturers ;  and the consequent sale of a  large im-
pression  has  stimulated  the  Editor  to  renew his
exertions for its  improvement.  The language has,
in the present Edition,  been rendered more clear
and  perspicuous—a copious Index has been added,
many important facts  have been  inserted, and the
whole work has been most carefully  corrected and
revised.   With  these   improvements,  the  Editor
trusts that  it will  not  be found  less productive of
 the  utility  for which it was originally compiled. 
            ADVERTISEMENT

                       TO

       THE FOURTH EDITION



11 is hardly necessary <o say any thing  in commen-
dation  of a work which has already passed through
iluce  Editions.  Part of its  success is no doubt to
be attributed to the amusing and lively style in which
it is composed,  a style which has  by  some critics
been considered  as unsuitable to  the dignity  of the
subject.  It must, however,  be confessed, that the
sprightliness of the Author has not trenched upon the
doctrine  and  practical  utility of  the Work; on the
contrary, the method of treatment recommended is
for  the most part such  -a* the gravest Practitioner of
Midwifery would approve.   It is indeed to be  regret-
ted, that the Author not unfrequentry lowers himself
tu the eyes of the world, by choosing to effect that
by finesse, which a more direct and open procedure
would just as easily have brought about.   The Work,
however, in every page contains some useful matter,
especially interesting to the  young Practitioner, and
is therefore well  deserving of being reprinted.
  in the present  Edition, care has been takes to avoid
the typographical errors which were but too frequent in
the former ones; and sometimes the structure of the
sentences  has been  altered,  to render  them  more
clear and intelligible.  This, and an occasional refer-
ence in the Notes, which it was thought might be
useful, is all that the present Editor has attempted to
wards improving the Book. 
CONTENTS.
    CHAP. I.

ON MENSTRUATION.
Page
 Sect. i. General Nature of the Menstrual Dis-
            charge     .....    1
       ii. Influence of the Moon upon Menstru-
            ation  ......    7
      in. Plethora, as influencing Menstruation    8
      iv. Probable Cause of Menstruation    .   10
       v. Irregular Menstruation   .          .12
      vi. Obstructed Menstruation  .     .     .14
     vn. Profuse Menstruation    .     .     .23
     vin. Painful Menstruation     .     .     .28
      ix. Final Cessation of the Menses, and the
           Treatment to  be  pursued  at  that
           Period......30
       x. Spurious Pregnancy      •     •     .31

                   CHAP. II.

DISEASES OF THE FEMALE PARTS OF  GENERATION.

 Sect. i. Enlarged Nyraphae  .     .     •     .34
      ii. Hymen imperforate, and diseased La-
           bia Pudendi  .    .     .     •    .  ibv
                      a2 
		Pagf
. III.	Itching of the Parts .	. 36
IV.	Fluor Albus, or Lcucorrhcca	. 37
V.	Procidentia Uteri	. ib,
VI.	Polypous Tumours .	. 39
VII.	Tubercle of the Uterus	. 40
VIII.	Scirrhous Uterus	. ib.
IX.	Dropsy of the Ovarium	. 43
X.	Supposed Dropsy of the Uteni9 CHAP. III. ON CONCEPTION.	. 44
>£CT. I.
    II.
    III.
    IV.
    V.
    VI.
    VII.
IX.
 X.
Preliminary Observations   .     .     .46
Different theories of Generation .    .  49
Ovum and Corpus Luteum  .    .     .61
Membranes     .     .     .    .     .62
Liquor Amnii   .....  63
Placenta and Funis Umbilicalis   .     .  66
Changes that take place  in  the  Child
   immediately after it is born   .     .71
Consequences of  Pressure  upon  the
   Navel-string  .     .     .     .     .73
Different states of the Child when born  74
Changes of the Uterus in consequence
   of Impregnation    .     .     .     .78
CHAP.  IV.
 ON THK  SIGNS OF CONCEPTION, AND THE DISEASES
                 OF  PREGNANCY.

Sect. i. Signs of Conception   .     .     .     .82
     n. Suppression  of   the   Menses  during
           Pregnancy    .     •     •     .     •  84
    in. Peculiar Symptoms that sometimes at-
           tend Pregnancy    .     .          .84 
                   CONTENTS.              '   Vli
                                            Page
Sect, iv. Sickness, Vomiting, and Heartburn     86
       v. Costiveness     .....  87
      vi. Hemorrhoids and Diarrhoea     .     .  88
      vii. Inflammation about the Neck of the
            Bladder, and  Suppression of Urine  ib.
     vin. Retroverted Uterus  .    .     .     .90
      ix. Cramp, and Pain, in the lower Extrem-
            ities    ......  95
      x. Varicose  Veins, (Edema, and Febrile
           State......96
      xi. Affections of the Head and Chest     .  ib,
     xn. Soreness  and  Cracking of the  Skin
           covering the Abdomen  .     .     .97
    xm. Abortion   .     .     .    .     .     .  98

                   CHAP.  V.

              ON  TJTERO-GESTATION.

 >m.t. i. Situation of the Foetus in Utero   .     .  Ill
      n. Period of Utero-Gestation  .     -     .113
     in. Causes of Labour     ....  114

                   CHAP.  VI.

                   ON  LABOUR.
>kct. i. Division of Labours
    ii. Signs of Labour  .
    m. Examination per Vaginam  .
    iv. Natural Labour   .
    v. First Sta«;e of Labour  .
    vi. Second Stage of Labour
   vn. Third Stage of Labour
   vm. Fourth Stage of Labour
    ix. Symptoms which accompany Labour
118
119
120
125
126
129
130
131
132 
vii,                  contents-

Sect, x. Labour Pains   .     •     •     •
     xi. False Pains
    xn. Treatment of Natural Labour    .
   xm. Things to be attended to by  the Prac
           titioner during Labour   •     •
    xiv. On  tying   and  cutting  the  Navel
           string    .
     xv. Extraction of the Placenta  •
m.
  CHAP. VIU.

ON INSTRUMENTS.
>EGT.I
     II
IV
Page
133
134
136

137

145
146
                  CHAP. VII.

             ON  DIFFICULT  LABOUH.

Sect. i.  Species of difficult Labour  .     .     •  J.48
     n.  Predisposing Causes of difficult Labour   ib.
        Arrest and Impaction       •     .     •  le"
    Origin of Instruments  .     •    •     -16/
  ..  The vectis......lb-
hi.  On the Application of the Vectis .     .168
    The Forceps.....169
v.  On the Application of the Forceps     . 172
                 CHAP.  IX.

              DEFORMED PELVIS.

ect. i.  Difficult  Labour  occasioned  by  the
         Pelvis  being deformed from  Rickets
         and Mollities Ossium    ••     .     .  17t- 
                    CONTESTS.                  IX
                                             Page
Sect. ii.  Caesarean Operation  .         .    .177
      in.  On opening the  Child's Head, and the
           Means of ascertaining whether it is
           alive or dead.....180
      iv.  In what Cases  the Life of the Mother
           or of the Child must be sacrificed   . 182
      v.  In what Cases the Child's Head should
           be opened    .     .     .    .    .183
      vi.  How the Head is to be opened  .  . . 184
     vo.  On opening the  Head very early     . 187
    vnf.  On faciliating Labour by turning the
           Child    .    .  ,  .     •         • 188
      ix.  Reasons for bringing  on premature La-
           bour    ...... 189
      x.  Distinction between a Pelvis deformed
           from Rickets and a Pelvis deformed
           from Mollities Ossium   .    .    .190
      xi.  How to  obtain premature Labour    .  ib.
                   CHAP. X.

            PRETERNATURAL LABOUR.

^ect. i.  Division and Cause  of praeternatural
           Labour  .     •     •     •     •     .193
      "•  First Division of praeternatural  Labour  ib.
     in.  Second Division  of prseternatural La-  j$3
           hour......196 
X
CONTENTS.
                  CHAP.  XL

                COMPLEX LABOUR.
                                            Page
Sect. »• Presentation of the Funis   .     .     . 202
     n. Cases where there  are more than one
          Child......204
     in. Labour attended  with Convulsion     . 208
     i*v. Treatment of puerperal Convulsions  . 217
     v. Of Convulsions that may remain after
          Delivery.....220
     vi. Rupture of the Uterus     ,     .     .221
     vn. Uterine Hemorrhage .... 224
    vin. Treatment of Hemorrhage .     .     .231
     ix. Hemorrhage continuing  after the Pla-
          centa is extracted   .    .    .     .238
     x. Consequences of the Placenta remain-
          ing, and its Treatment   .    .     . 245
     xi. Consequences of a Portion of the Pla-
          centa remaining    .... 245
     xn. Iuverted Uterus     .               246

                  CHAP.  XII.

     MANAGEMENT OF  WOMEN AFTER  DELIVERY.

Sect. i. The  Woman not to  be  moved imme-
          diately after Delivery     .     .    , 250
     u. Fainting     *..... 251
    m. Retention of Urine     .... 253
     IV. Effusion  of Blood  into  the  cellular
          Membrane of the Labia Pudendi    . 254
     v. Lochial Discharge     ....  255
     vi. Lacerated  Perinaeum   .... 256
    vn. After-pains ....         , 25/ 
CONTENTS.
XI
                                          Page
Sect. vni. General  Treatment  of a  Woman
            after Delivery   .     •          .258
       ix. Sore Nipples.....261
       x. Swelled Leg of Lying-in Women, or
            Phlegmasia Dolens   .         . 263

                 CHAP. XIII.
                 OP INFANTS.

Sect i. Food of Infants   .
    ii. Symptoms of Health or Disease
   hi. Gestures    ....
   iv. Skin                      »
    v. Respiration  .     .    •
267
271
272
274
 ib,
CHAP.  XIV.
             DISEASES OF INFANTS.

Sect. i. Inflammation of the eyes
     ii. Jaundice    ....
    in. Indigestion, and Green Stools
    iv.  Infantile Fever
     v. Spina Bifida
    vi. Abdominal Tumour
   vn. Worms
   vm< Hydrocephalus Internus
    ix.  Scald Head  .
    "x. Convulsions .
   ! xi. Cynanche Trachealis, or Croup
   xh. Marasmus   .     •    •
 277
 279
 280
 284
 288
,289
 290
 292
 295
 297
 299
 300 
 
MIDWIFERY.
                  CHAPTER I.

                ON  MENSTRUATION.

  Sect . i.   General Nature of the menstrual Discharge.

By  the menses we  mean a periodical discharge  of
fluid resembling blood, from the vagina of a woman,
returning  every month;  and   continuing  from  the
age of puberty till late in life, unless interrupted by
impregnation,  disease,  or  suckling.   From  the  name
given to  it in  different  parts of the  world, we should
be led to suppose that the opinion  of most  nations
agreed, both as to  the  cause and period of its return ;
in every language  the expression denoting this dis-
charge, also implies  the regular courses or returns of
the moon.  Now, although  courses,  considered  in
itself  as  a word,  cannot  imply any indelicacy, yet,
from  its  general  acceptation, it is such a word as
never must be mentioned; therefore we must  never
speak of the  menses in presence of a woman  upon
any account;  but rather inquire thus, Pray when were
you unwell last, or regular last ? Or, if it is a young
girl, we ask her, Whether she  has  been regular yet 1
  There  have been a great variety  of opinions  a3 to
where the  menstrual fluid comes from ; it can only be
from one of three parts; either the vagina, os externum,
or uterus.
  Arguments have been adduced to prove its  coming
from  each of these  parts.  Those  who will  have it
<*ome from the  vagina, advance, that the vessels  of
                        B 
2      THE LONDON PRACTICE OF MIDWIFERY.

the vagina are larger and more numerous  than those
of the other parts ; and that women menstruate after
their uterus is cut out, as a  woman who has an os ex-
ternum, only; these then are so many arguments in
favour of its coming from the vagina.  As to a wo-
man's, being  without an  os tincce, we may as  well
suppose her without a mouth; anil the belief of  the
uterus having been cut away,  in all  likelihood was
nothing more than a  tumour removed from the va-
gina,  high up.  Are we then to suppose  it to come
from  the uterus?   The  reasons  for  this  belief are
surely of much more  weight  than  any that can be
produced of its coming from any other part.
  The best way is to come to matter of fact, and we
have two  diseases in which we possess  demonstration:
first,  where  the uterus is inverted, and hangs down
from the os externum ;  or where it is prolapsed, the os
tincai being protruded beyond the os externum.   Now,
though we may have never seen the blood  forming on
the surface of an inverted womb, yet surely we may
be satisfied of the  fact  from the authority of the  late
Dr. Hunter, who has seen the blood flowing from the
orifices of the  arteries;  and from  the  testimony of
other respectable practitioners, amongst  whom is the
late Dr. Clarke,  who  have frequently, in prolapsed
uterus, seen the menses  flowing out of the os tinco3,
while the  vagina was inverted and dry.
   There  have  been disputes about the vessels which
separate the fluid  in question; some  will have  them
to be arteries,  whilst others are equally sure of their
being  veins.   Those  who argue for- veins, observe,
that they are more liable  to congestion  than arteries,
and are more apt  to be relaxed.  From some micro-
scopical observations, we are told, not only that it is
by the veins that  the menstrual fluid is separated,
but that  it is a proof of the wisdom  of Nature, who
has made  holes in the  sides of the veins, which ori- 
      NATURE OF  THE MENSTRUAL DISCHARGE.     {J

fice3 are  guarded by sphincters;  and  that  these
sphincters, at  the  end of every  month, relax them-
selves, by which means the fluid escapes : however, as
no other person except Dr. Johnson* who made this
assertion, has been able to see these vessels with their
little sphincters, we will say no more about them.
  Looking into the nature  of the fluid, and  seeing
what it really is,  should  be  the  first step in  finding
out its  true history ; and  then let us  ask  where it
comes  from.  Now it so  happens, that the fluid of
menstruation is not blood at all ;  blood  is fluid while
it is circulating in  its vessels, and, when drawn away
and at rest, possesses certain properties distinguishing
it  from all other  fluids: being  allowed to stand, it
separates into a solid and fluid part.  This fluid, when
in a state of quiescence, will alike coagulate either in,
or out of the body.  If two drops of blood are drawn
from a  pricked  finger, one drop being on the finger,
both jelly alike, and  as  soon  as  if they had  been a
stream of blood :  this we mention  here, because it has
been asserted that the  menstrual  fluid  does not fix,
because it comes away in a stillatitious manner.  Heat
does not prevent blood from coagulating, for the heat
is as great in one part of the body  as another, and the
blood will coagulate if it is out of  the circulation even
in  its own vessels, which we can prove by tying up
the vein of a living animal; we also see  it in the  dis-
ease called  Aneurism, where there are laminoz of co-
agulated blood found  in those parts of the sac which
are out of the course of circulation.  Suppose we say
that the blood-vessels being diseased may have coagu-
lated the  blood; how then can we explain  the bind-
ing of an artery,  by  stopping the  circulation, coagu-
lating the blood which lies between  the ligature  and

  * A Xevv System of  Midwifery, by Robert  Wallace Johnson..
M. D. 4to. p. 30. 
 j.       THE LONDON  PRACTICE OF MIDWIFEAt

the next anastomosing branch ?  So that the fact must
be established, independent of any disease, " that blood
at rest coagulates."
  The menstrual fluid will not coagulate, even if kept
in the heat of the body, which is  the case in imperfo-
rated hymen, where it remains fluid.*  Its colouring
matter  is very  peculiar; it is  permanent, while that
of blood is not so.  This  fluid does not become putrid
if exposed to a summer heat; it inspissates, leaving
a hard chocolate-coloured friable mass.  But if we ex-
pose  blood for a few  days only in a warm room, we
shall soon  find out that it putrefies.  This  fluid, there-
fore, is not blood ;  it must be a secretion ;  and it  must
be  pretty evident that  this secretion is from  the  arte-
ries themselves, as it has been seen flowing from  their
curling extremities.
  We therefore may define the menstrual fluid to  be
a secretion,  perfectly  different  from  blood, which it
resembles  in  colour; which secretion  returns once in
every lunar month.  When we say it  returns at the
completion of the  month, we should not lay it down
as  an  invariable rule; for women in perfect health
have  been  known  to   menstruate every twenty-five
days ; while others as regularly  pass to the thirty-first;
but the average period is still twenty-eight days.

  *  Mr. Brande  analysed  some menstruous  discharge sent to
iiim, by Mr. William Money, House-surgeon to the General
Hospital at Northampton, which was collected from a woman
with prolapsus uteri, and, consequently, perfectly free from  ad-
mixture of other secretions.  It bad  the  properties of a very
concentrated solution of the colouring matter of  the blood in a
diluted serum.  It has been observed that the artificial solutions of
the  colouring matter of the blood invariably exhibit a green tint
when viewed by transmitted light: ^this peculiarity is remarkably
distinct in the menstruous discharge.  No globules could be dis-
covered in this fluid ;  and, although a very slight degree of  pu-
trefaction bad commenced in it, yet the globules observed in
*hc blood would not have been destroyed by so trilling a change* 
      NATURE OF THE  MENSTRUAL DISCHARGE.      5

  When the menstrual  discharge takes place, its time
of  lasting  is generally three or four days;  it will
sometimes  continue  only for one  or two;  but the
average time is three or four days ;  and as to the pro-
portional quantity lost  on each day, on the  first, and
third day, the  woman loses a  fourth of the whole
quantity each day, and, on the middle day, about the
other half.   The  quantity lost will generally be three
or four ounces all together, a single ounce on the first
day, two on the second, and the fourth and last ounce
on  the third  day.  There is nothing, however, more
affected by  the climate than this: in warm  climates
the quantity being increased, while  it is diminished in
cold ones.   Linnaeus,  in his  account of  Lapland,
says, that the quantity  lost there is  never above half
an ounce or an ounce.   In the islands of the Archi-
pelago, Hippocrates  observed, that the  women lost
near twenty  ounces of blood by  this evacuation—
" Avo   KorvXott  AtImm  ;" and  it is  very  curious that
Dr. Freind, in writing  an account of the  discharge as
it happens in this country, has copied the sentiments
of Hippocrates; it is certainly a very odd mistake to
deliver as his own the opinions of a man who lived in
so different a part of the world as well as at so distant
a date, when he might, without any difficulty,  have
discovered the truth by  asking any woman two or three
simple questions.
  Artificial  warmth  promotes the  menstrual flux as
powerfully  as that of  the sun.  Van Swieten states,
that in Holland, where the temperature is as mild as
it is here,  in winter, when the ladies go to church on
the Sunday, the servant is behind with a chafing-dish
to set under their petticoats.  Now this evidently must
determine the blood to  those parts with greater force
than it  otherwise would be;  from  the  same cause
which would render the veins in one of our arms full
and turgid, while the veins in the other were not so,
                       b 2 
G       THE LONDON PRACTICE OF MIDWIFERY.

by putting one of our hands into hot,  and the other
into cold water.  The females in that country are ex-
tremely liable to leucorrhcea in consequence  of this
custom.
  This  discharge begins  at  a certain period of life,
termed  puberty; which varies according to climate.
In Persia the females  are fit for all the purposes of
women at ten years old ;  in Lapland, not till twenty;
in our country, about sixteen: and this period is cha-
racterized  by certain attendant  circumstances: the
age of puberty  is evinced  by hair growing on the
pubes and in the axilla ; the breasts are formed and
made perfect; there is also a change in the ovaria.
   The  discharge  when  it first appears is not often
red, generally it is without  colour.  The  succeeding
periods are very regular, being every month, unless
the woman lives in a state of nature, and falls with
child, when, upon a pretty  accurate  calculation, she
will menstruate  about once in twenty months, if she
suckles.  Menstruation  having begun,  will   go on
regularly,  unless  interrupted  by  disease, or preg-
nancy,  for a  great  number of  years*  usually till
between the fortieth and fiftieth year; and the time
of its cessation  is generally  regulated by  the age at
which  it  commenced.   In  regard to the  final cessa-
tion of the menses, they  may be known to be going
by  certain irregularities in their appearance :  instead
of the  discharge lasting three, it shall  continue for ten
days:  then  there  shall nothing be  seen for two
months;  then it  shall   come once  a  fornight, and
 profusely.  This is called the dodging time by many
 women, and properly enough, as far as  regards the
 general acceptation of the word.
    The menstrual  discharge  is very apt  to   be  af-
 fected  by the diseases of the  female body; and even
 when it is not so, women themselves  universally be-
 lieve it is: they suppose that discharge to be the cause 
                      . -d«&"'
      NATURE OF THE «ENSTRUAL DISCHARGE,     J

(f every complaint.  For which reason, when attend-
iig  a woman,  let her illness be  what it may, we
slould always inquire  when she was last unwell,  and
wien she expects to  be so again: this is no trouble,
and, if it does no  further good, it gives them a satis-
faction.
  Another reason  for attending  to this discharge is,
that our opinion respecting  the pregnancy is founded
upon our physiological knowledge of this fluid.

  Sect. ii.  Influence  of the Moon upon Menstruation.

  Every physiological  subject,  which  admits  of a
difference in  opinion, has, at all  times, found parties
to support each of those  opinions which  might be
brought forward ; and every physiologist taking up an
opinion, cherishes it with as much care and fondness as
he would h"i3  own  child.  Several opinions having
been  advanced  on the subject of the menses being
under the influence of the  moon, arising from gene-
ral or  from  partial  plethora,  it will be proper to ex-
amine  such opinions.   It is not  surprising  that  the
ancients should first have perceived the  coincidence
between the moon and certain changes and effects on
this earth.  The various dispositions and returns of the
moon  were  likely to engage their  attention:  they
iaw that the moon regulated the  tides, and therefore
possessed an influence  over inanimate matter;  they
might also have noticed, that at certain periods  of the
moon lunatics were  uniformly worse than  at others;
so that it was observed to affect animate and inanimate
matter.
   Dr. Mead  had so  high an opinion of this lunar gov-
ernment, that he says, if women lived perfectly regu-
lar,  committing no  excesses, they would menstruate
 n« regularly as the return of the  tides ; but there art 
8       THE LONDON PRACTICE OP MIDWIFERY.

some circumstances decidedly against this belief; tie
truth  being,  that women  menstruate  regularly  <n
every day throughout the year : if the former opinim
were just, it  would happen that the  majority shoild
menstruate on certain fixed and regular days; this is
not the case,  for as many menstruate on one day as
on any other.  We know there are some situations in
which women live regularly; in a nunnery, and in a
madhouse, which  is  very near akin to  it.   In  those
places we  find they are not  more regular than any
where else.  Next, we should expect that every wo-
man would have her day, which she would know;
this however we  find is not the case; and  to  prove
it is not, we will suppose that the day falls on the first
day of the moon : now, if this woman, by any chance,
gets wet feet, or catches cold, sits in a damp room, or
is exposed to any trifle  of that kind  about the day on
which she should  have been regular, she will not men-
struate  until three or  four days later lhan she should
have done: when then should this woman  be unwell
again? Under the lunar influence, on the first day of
the next month.   No, she  will menstruate on  the
third or  fourth day of the month, and not on  the first:
so that  the whole  influence  of the  moon  does not
equal that of a piece of damp  leather,  or a wet
stocking; for which reason we  may  safely venture to
give the moon up.

   Sect. hi.  Plethora, as influencing Menstruation.

  Menstruation has been  supposed to be dependant
on a general plethora, and (his  opinion originated with
Aristotle; it was  afterwards taken up by Galen; and
in  modern times, more particularly  by Dr. Freind.
He asserts its dependance on plethora, and sets out to
prove his doctrine by calculating the areas of the ves-
sels ; and has,  by  diagrams, shown what he meant  to 
    PLETHORA, AS INFLUENCING MENSTRUATION.    9

prove; and  this is not one of the  least plausible of
the suppositions which  have been brought forward on
the subject; if we consider that the  constitution of
the woman has to prepare blood sufficient to nourish
two creatures, while that of a man has only need to
support one. A woman,  when she falls with  child,
loses the menstrual discharge; but  if she remain un-
impregnated, this flux returns once   every month.
In the pregnant state, the breasts do not secrete milk,
nor do the menses appear.  Let us examine this theory
of menstruation depending on plethora.
  A theory must, in  order to stand the test, be good
and perfect in  all its  points.  How is  it that weak
women, women who go to bed at sun-rise, and do not
get up again till  mid-day, who are of a  pale, pasty
complexion, and perhaps, once in the week, are drawn
round Hyde-park, shut up in a coach, and for  dinner,
by great effort,  swallow a wing of a chick;  how is it
that these women  menstruate  regularly ?   It cannot
be for a moment said, that such  women are of a ple-
thoric habit; so that it  must depend on something of
more consequence.   We  suppose, however, for  the
sake  of argument, that it does depend  on  plethora,
and add the quantity  which is retained in the body,
while the contents of the uterus are augmenting during
pregnancy,  say five  ounces each period,  for  nine
months ; that gives forty-five ounces, which  would go
but a small way towards forming a child eight or
ten  pounds in weight.   Suppose a  woman to lose five
ounces of fluid at each period ; just before the  period,
if sixteen  ounces of blood are taken away from the
arm, what should be expected ? why,  that she would
not menstruate; but she will, and that in the same pro-
portion that she  usually has done :  now, this  ought not
to take place upon the idea of plethora, because that
must be removed by evacuating the system.
   Dr,  Cullen  supposed  that  the discharge of th* 
10      THE LONDON PRACTICE OP MIDWIFERY.

menses  did not depend  on a general, but a partial,
plethora, a  local plethora;  a plethora  of the uterus,
and vessels and parts belonging to  the uterus.   This
will  account for its  happening with  the  greatest re-
gularity to the weakest women,  as we frequently see
local plethora may be produced by any  cause in any
habit of body.   A blister applied to the skin produces
a  temporary  accumulation  of blood  in that part.
Another opinion is, that the discbarge is  the effect of
fermentation.  The converts  to this doctrine assert,
that  the womb  requires  purging, and that the  fiecal
matter is formed by the menses.  It ,is an  easy matter
to state an  opinion ; but till if is received, it will not
require proving or disproving, therefore  this  may be
allowed to  go to rest quietly.

      Sect. iv. Probable Cause of Menstruation.

  The true cause of the  menses seems to be  shortly
this.  It is  a law of nature, implanted by the Creator
in that species of animals whose uterus is fleshy, and
in that only, that the uterus should secrete  a fluid
once in every month.  We do not know the reason of
this or of any other law of nature ; we  do not know
why digestion could not go on as well  without the
pancreatic  juice; we  do not  know why the  animal
should drink,  when, if  the secretion  of saliva had
been  increased, it appears to be the same, and ac-
complished in an easier way.  Digestion  is capable of
stopping putrefaction and preventing it, but we do not
understand why or wherefore.
  The cause  of the flow of the menses has,  in the
oldest  books, been supposed to  be for the evacuation
of noxious humours.  We know that the physiological
opinion of  Moses was, that  this fluid was noxious; but
it  has never been proved.   If it were so, a woman
should  not be  well above fourteen days at  a time 
      PROBABLE CAUSE OF MENSTRUATION.        H

throughout the year,  except when she is with child j
now this we know  is not true in any part of the world.
The only  opinion which has reason  on its  side, is,
that in  not climates  the menses might be  noxious
from disease,  owing to  want  of cleanliness.   A
great part of the book of Leviticus is taken up with
directions  for  the observing of cleanliness in  its
fullest extent, which  laid  the  foundation for another
practice; that of taking away the prepuce,  or fore-
skin of the penis; phymosis  would sometimes hap-
pen ; when there being  accumulations of acrid fluid
behind the glans, ulcerations might have arisen, which
was quite prevented by  this practice,  which  is called
circumcision    Pliny  has  written  a  very  amusing
chapter on the subject of the acrimony of the men-
strual discharge; he speaks very gravely of the plants
being blighted  in a  garden,  because  a menstruous
woman  one  afternoon  walked near  them.  It  has
been said, that  the  intention of the menses was for
the  nourishment of the  child; but  to this it  may be
objected,  that  there  are many animals who are with-
out  it,  which  nourish   their young  as well as  the
human  species.  Besides,  if that was the intention of
nature, why should the  quantity lost in every month
be equal, while the child for the first three months does
not weigh as  many ounces, and in the latter months its
increase of weight is much  greater than the menses
can be  supposed to afford ?
   It appears to be a discharge intended to preserve the
uterus  in a state  fitted for conception, for a girl  can-
not conceive till after the menses have appeared ; nor
does any woman  conceive after they have ceased  to
flow.  So that women only can become pregnant while
the menses continue;  and they appear to be more sus-
ceptible of conception immediately before and directly
after each period  of  menstruation, than at any other
 part of the month.   Also, in all animals there is a dis- 
12    THE LONDON PRACTICE  OF MIDWIFERT.

charge somewhat  analogous  to  it,  which  in them it
called heat.  This  state is very nearly allied to it; and
is well understood  by boys, not one  of whom, when
buying a doe rabbit, will pay half the price  for it,
if  not  in heat, as  if she is in heat: he lias nothing
to  do, but by pressing with his thumb to invert a por-
tion  of the  vagina, and  if it is  red and covered
thickly with bloodvessels,  he  knows it indicates
heat, and is what he  looks for;  but if the vagina is
smooth and white, any boy knows that he  must keep
that rabbit on bran and other expensive provision for
a month, before she will take buck.

           Sect. v.  Irregular Menstruation.

   Wherever the menstruation is in any way altered
from its natural  state, we should never neglect it, that
is  to say, we should apply some remedy, whether it is
really  necessary or not.   If a patient thinks it worth
while to  say she feels pains in the end of her finger, it
is  proper to look at it;  and if we  think  it will  do
good, to  tell her  she had better poultice it; and for
this reason alone, we should always  appear attentive,
but never careless.  So  that,  upon this  principle, in
disturbed  menstruation   we  may  always  prescribe
something, though  the  complaint be of one kind or
the other.
   Menstruation may be  diseased either by becoming
irregular in regard to the time of accession or  cessa-
tion :  irregular in its monthly  return;  or as to the
quantity  of fluid lost at each period ; or the secretion
being attended  with pain: it  may  arise too early in
life, or continue too late : instead  of the usual quan-
tity, it may be greater or  less  than it should be: and
these are all the circumstances in which  this secretion
generally becomes diseased.   The  first consideration
is, where it arises too  early in life : perhaps there if 
IRREGULAR MENSTRUATION.          13
no  such thing as menstruation beginning too early in
life, except as connected with a complaint.  It may
arise from  too great strength of constitution and vas-
cular action ; from  increased fulness of vessels de-
pending on too large a quantity of animal food, for
the wear and tear of the constitution.  There is a full
face ; a full pulse; throbbing in the head; the breasts
are full, with  a warm  imagination.   This secretion
arises properly at sixteen;  but here it begins at twelve
or thirteen.
  It arises from too much blood, therefore we should
take some away; prescribe  purges and strong exer-
cise; but  the kind  of purgative  must  be   chosen
with discretion.   Rhubarb,  jalap,  senna, colocynth,
and aloes, are not  calculated to diminish the quantity
of blood ; they only increase the peristaltic motion of
the intestines.   Saline purgatives, by producing a more
copious watery  evacuation, diminish the quantity of
circulating fluids,  and are therefore  to  be preferred.
Now, if we are bleeding with one hand, and  purging
with  the  other, the  patient  must not be  using both
hers to cram  in  food.  If   we purge once  every
second day, it is as much  as is necessary ; but she is
not satisfied if we do nothing  on the intermediate day;
therefore we may give a saline draught, which is a good
medicine.
  The other  state  of the menses is,  where their ap-
pearance is retarded:  this  is a more common thing
than the other, and  more  especially in  large  towns.
It occurs where there is too little  blood, and the uterus
is not in  a state  fit for conception.  The  pulse is
weak, the  appetite  is disordered, the countenance pale,
the constitution is below par in point of strength.  We
shall now consider  both the states just described.  Fe-
males labouring under symptoms  of plethora, as in
the first state, will be liable tosudden inflammation of
the lungs,  and a  disposition of body which predisposes
                        e 
14     THE LONDON PRACTICE OF MIDWIFERT.

to what is  called a  galloping consumption.  Those,
on the contrary, who do not  begin to menstruate at
the usual time, will generally be more or less of a scro-
fulous habit, disposed  to go  into a decline, or  slow
consumption.   Here the mode of treatment adopted
in chlorosis may be superadded to  that  for the re-
storing of health by sea-bathing,  if the  lungs are not
any way  affected, and the stomach be in good order,
but not when there is weak stomach or oppressed re-
ration.

          Sxct. vi.  Obstructed Menstruation.

  Of obstructed  menstruation  there are two kinds;
one, the  acute or accidental; the other, the  chronic.
The acute,  or  accidental arises  where there is perfect
health up  to  the time  of menstruating, which will
be, we will say, to-morrow; the woman takes cold
to-day, and, in consequence of that,  does not men-
struate at  the time she  expected.  Or we  may put
it thus:  she  began to   menstruate  yesterday,  takes
cold to-day, which stops the secretion to-morrow : this
is the acute or accidental obstruction.   When we are
consulted in this case, she will not consider the sup-
pressed discbarge as one of the symptoms, but  as the
cause, from which  she has got cold, and every  other
inconvenience she feels.
   Menstruation may be considered as a secretion  de-
noting the  state of the  health of the  woman:  while
it goes on, the  health  is generally good : but when it
does not go on, the health is usually imperfect.  Ob-
struction may be perhaps attended with  symptoms of
lever; but this does not prove it is the cause of fever,
any more than the want of perspiration becomes the
cause of fever, because it attends it.
   Obstructed   menstruation  generally  depends upon
one  grand cause,  the  application of cold:  this will 
OBSTRUCTED MENSTRUATION.
15
 produce a fever which will stop it if coming on, and
 arrest its progress,  where it has already commenced.
 In all cases where  the application of cold obstructs
 menstruation,  there js pain  in the head, back,  and
 loins,pain in the limbs, with  all the symptoms  mark-
 ing fever.  If we know of this  early, we may with
 ease give relief.   The patients will tell us that they
 are obstructed, and have  such and such  symptoms.
 There  we  always may take  blood, and clear out the
 bowels;  rhubarb i? the best to  give;  then a  saline
 draught, with  antimonials in such quantity as to come
 short of vomiting, and five or six drops of laudanum
 every six hours, with four or five grains of ipecacuanha
 every six hours.  The warm  bath is productive of ad-
 vantage where applied soon  after the  complaint has
 begun.  Where  the slipper  bath  is not at hand, the
 lower part of the body may be seated  in a volume of
 tepid water in a large tub; after which  the patient
 must be made very dry, and  put into a warm bed, and
 use the medicines before mentioned ; and the discharge
 will return, or, if not immediately, it  will ultimately
 return,  and the  health  remains unimpaired:  but,  if
 the menstruating period is passed over, it then be-
 comes a chronic obstruction,  the  symptoms attending
 which are very destructive of female health.
  Of the chronic obstruction of menstruation there are
 two  kinds,  which  have each a distinct set of  symp-
 toms of plethora, or symptoms of weakness ; and we
 have pointed out that chronic obstruction,  depending
 on plethora, may degenerate into that kind  depending
 on  weakness.   The patient  will first  be  taken with
 symptoms  which only belong to  plethora, and after
 that she  will experience those belonging to weakness.
 The young are most liable to the first  kind, in whom
 the quantity of blood is much increased beyond what
it should be, by luxurious habits, and  where too little
exercise  is  taken for the  quantity of food;  and even 
 16     THE LONDON PRACTICE OF MIDWlEFRl

 here it will not often lead to obstruction, unless  the
 occasional cause be applied by taking cold :  when thi#
 does  really happen, the  attack  of fever may be  so
 slight as  not  to be observed by the patient.  Where
 we see  all the signs of the system  being  loaded with
 blood,  we should certainly take some away :  where
 the pulse  is  hard, full, strong,  and  frequent; the skin
 dry and hot, great thirst, with pain in the  head, back,
 and loins; where, instead of an active disposition,  we
 see a desire to be  always by  the  fire, and  the girl at
 the same time liable to giddiness, it is evident there is
 more blood than there  should be, and part must be
 taken away.   Here the  pulse  is  rarely  up to  100,
 which being an increase of more  than  twenty  beats
 in every minute, the effect of such increased  action
 is,  that the  strength will be  worn  out,  and  the
 chronic obstruction from plethora  be  changed  into
 the chronic obstruction from weakness; and the  rea-
 son is this, that the  action is so powerful, that it may,
 by  continuing, exhaust  the powers of life,  the whole
 body  will be  worn out, and  would drop down ulti-
 mately ; since nothing  exhausts  the strength of the
 system  so much as increased action of the heart and
arteries; for it is not the pulsating  arteries alone  that
arc affected, but in the same  proportion is the  action
 of all the  capillary vessels in  the  body increased,  so
 that the whole extent of increased action is prodigious.
It being known that the action arising from obstructed
menstruation with  plethora  brings  on  weakness,  it
 might be  expected  that the  strength of action would
be brought gradually down to the point of health : but
that never  happens;  it sinks below it.    This sort of
obstructed menstruation, at its commencement, must
be treated by evacuation,  by  bleeding; but the foot
is  not preferable, as we  do   not  get  enough  blood
by opening the vena saphena,  unless the  foot is im-
mersed  in warm water; and if this is done, we are un 
            OBSTRUCTED MENSTRUATION.          If

able to tell the quantity we take, unless we from time
to time measure the water.  The best way, then, is to
bleed from  the  arm, and  with bleeding to use  pur-
gative medicines; the patient should  take much ex-
ercise and little sleep, and, on the  intermediate day
to those on  which we give the purgatives, we should
give a saline draught as before ordered : increased ac-
tion of the vessels will be reduced, by these means, to
the standard of health, and  the  menstrual  discharge
generally  returns.
   The other view is  that where  the patient will not
menstruate, although  brought back to  that point at
which she formerly did.  Obstructed menstruation is
divided into two cases; where it is obstructed  at its
commencement, it is called  chlorosis;  and where it
is stopped after its commencement, it is called atne-
norrhoca.  The authors who have made  this arrange-
ment, have however  made a distinction without a
difference.  In one state there is  a yellow bilious tinge
on the skin, which, blended with the blue colour of
the small veins, gives a greenish  cast to the appear-
ance; hence the Greek term of chlorosis, or green sick-
ness.   There  will be no further distinction made with
regard to these two cases, as no real distinction exists ;
the one case will, when depending on fulness of ves-
sels,  almost constantly degenerate into the other de-
pending on  weakness, and that entirely because the
continued action of vessels exhausts the strength.   The
complaint depends on improper food, living in bad air,
or want of  exercise, and, added to these, want of com-
munication between  the sexes;  for a  certain state of
the ovaria predisposes to it.  Where the complaint de-
pends on weakness, it is not weakness alone ; for how
many women are as weak  as they well can be, but are
not obstructed  in their  menstruation?  Women who
with  weakness have obstruction in their menstruation,
have a sallowness  of skin, pale complexion;  but the
                         o2 
I}}     THE LONDON PRACTICE  OF MIDWIFERY-

yellow cast of the skin is not bilious,  for  where the
bile is in the blood-vessels, the stools are like clay, of
a brown  colour, the urine high-coloured; but here
the stools  are not of  that appearance, and the urine is
pale  and  limpid.  The  next symptom in  obstructed
menstruation is, a mark round the ancle at night where
the edge of the shoe  came :  another is, a fulness and
puffiness of the face  and eyelids in the morning ; so
that, after sleep, the whole countenance looks too big;
but in the  course  of the  day, this size and appearance
goes entirely off.  These last effects are  evidently those
of oedema, because during  the day the water lodged
in the cellular substance about the face subsides, and
the cells  below are  progressively filled;   so that by
night the ancles are swelled: during the night again,
the gravitation of the fluids diffuses the appearance of
swelling over the face.
   The  upper extremities partake  at  last in this ap-
pearance, becoming swelled about the hands at night.
 In  short,  the whole skin is swoln and stretched, and
assumes a soft pappy feel.  To these symptoms there
is now  added a very great derangement of stomach :
the appetite  goes quite away;  sometimes the  patient
has  an  inclination  for  improper food, a vehement
fondness  for cinders, candles, or pipe-clay ; this docs
 not seem to belong  to any sort  of  instinctive impulse
 from nature, but depends  on a derangement of sto-
 mach alone : all these evidences are further proved by
 flatulency and a sense of weight at the stomach after
 eating; great irregularity of the intestines, sometimes
 costive, and at  other  times  lax;  vegetables undergo
 their acid fermentation,  and animal matter its putre-
 faction :  both  known by eructations,  both dependant
 on the impaired state of the stomach : to these succeed
 difficult  respiration,  either on walking or going up
 9tairs; and  this does  not arise from ordinary weak-
 ness, where a person could rest because she was tired: 
OBSTRUCTED MENSTRUATION.
19
but in chlorosis she stops because she loses her breath:
there is also palpitation at the heart ; the pulse is  fre-
quent,  small,  and  hard;  and there are  hysterical
symptoms, very often, where the obstruction  has been
of long continuance.  This complaint is most easily
cured where it has been  of short duration, and the
menstruation not permanently interrupted.
  It has  been said  that blood flowing from  any other
part of the  body was to be wished for.  It has  been
even said to cure.   Hippocrates speaks.of hemorrhage
from  the nose  during the complaint;  and some of
those  who, coming after him, copied what he said, go
yet further, and assert, that bleeding from any part of
the body will cure; intimating that haemoptoe is to be
wished  for as  much as any other : but there is little
truth in such opinions.
   When a woman dies from obstructed menstruation,
it may be by its terminating in dropsy.  There is some
ambiguity of appearance  here:  the  difficult respira-
tion has  at  times led the practitioner to bleed,  upon
the idea  of its being a complaint in the chest, and it
unfortunately happens that it actually does  relieve the
symptoms in some  degree.  But it only augments the
weakness;  while encouraged by the  relief, perhaps
 more blood is  taken, and more  weakness is the  con-
 sequence.  But  he who  is ever  guided  by a single
 symptom  will  always be  wrong.  It will sometimes
 happen  that there shall be something else besides the
obstruction ; and where  there is obstruction, and we
 find no symptom which indicates  a  change of consti-
 tution sufficient to account for it, we should not doubt
 the possibility of a woman's being  with   child,  even
 though not married; and this  we must endeavour to
 ascertain  without  our  letting  the patient  know that
 we suspect that  it is so.  A pregnant woman has her
 natural colour  on her cheek ;  and if doubts remain on
 our mind after the fourth monthly period has passed. 
20     THE LONDON PRACTICE  OF  MIDWIFERY.

we  may satisfy them,  by laying  the  hand upon  the
abdomen, or by an examination per vaginam.
  The treatmeut  will depend  on the  form which all
the symptoms take on when combined.  Though cases
of this obstruction differ from ordinary weakness,  yet
the  treatment we should pursue will  be applicable to
most cases of weakness.  Where we are  told there is
obstruction, and that from this cause arose such and
such symptoms, we must not attempt to explain  the
truth to them, it  is not  necessary ; we must  fall in
with the popular prejudices.   The patient will tell us
it has  been flying into her  head, giving  her a head-
ach; it flies into  the  bowels, causing wind;  it flies
here, and flies there;  in short  it is always flying  day
and night.   It is  right  to keep the bowels  clear, by
an occasional dose of  rhubarb, for the same  reason
that before we begin to  build  we clear away the rub-
bish,  in  order  to lay a good  foundation;  then  we
should begin the use of bitter medicines, remembering
that in proportion as the weakness is greater, the me-
dicine should be weaker; it is an error to  suppose that
the  stronger a medicine  of this  kind is, the more effi-
cacious it must be.  To imagine, for example, if  one
ounce of Columbo-root is infused in a pint  of water,
and  makes a  good  bitter,  that two ounces must
make one  doubly  good,  is false reasoning; for if it is
too strong for the stomach, it does harm.  In all casee
of weakness, we must consider the lightest bitters at
flic  most proper;  at first, a drachm of the bitter tinc-
ture to an ounce and  a half of peppermint-water; or
an ounce of the bitter infusion instead of the tincture.
But at the  same time we must recollect,  that the  sto-
mach  is still a weakened organ: the powers of di-
gestion must  be  still weak,  consequently  digestion
will not be  so quick, nor will the  food be pushed  for-
ward from the stomach so soon as it is in health ; and
the  second meal  will  be ill  digested,  because  the 
OBSTRUCTED MENSTRUATION.
21
 whole of the first  has not left the stomach;  for these
 reasons, a gentle  purgative  must be joined with the
 food.  A good  medicine is  bitter pills, formed  with
 such materials  as  will allow the stomach to act on
 them without much difficulty ;  a good form of which
 is,
          •R- Myrrh. 3ss.
             Rhei 3ss.
             Aloes Spicat. Extr. 3ss.
             Anthemid. Extr. 3j.
             Syr. q. s.  M.

 This mass, formed into moderate-sized pills, may be
 given in number sufficient to procure two or there stools
 a day ; just to produce the effect of a laxative.
  Of all medicines, bark is the worst here; it requires
a good stomach  to digest it;  it increases any  difficulty
of breathing, that  may have existed previous  to its
use.  Now and then a gentle emetic will be useful;
we  may for  that purpose give five grains of ipecacu-
anha every half hour  till it  operates.   After the bit-
ters have lost  their effects on the stomach, this gentle
action  will act as  a stimulus to  it,  and render them
as efficacious  as before:  when the stomach  is strong
 enough,  we may begin with steel,  the  best form of
 which is called  Griffiths's draught, but it  is the most
nauseous mixture that ever  was  made  -r a pleasanter
form is this :
           ft. Ferr. Sulphat.
             Potass. Subcarbon.
             Sacchar. alb. aa  3ss.
             Myrrh.  3j.
                Ft. Pil. mediocres.

 These materials may be beaten without a fluid; the
kali attracts  the moisture from the  atmosphere, and
is always soluble;  but if, instead of the  kali, we were 
22     THE LONDON PRACTICE OF MIDWIFERY.

to use the aq. kali puri, the pills might be fired through
a deal board out of a pistol, therefore would not have
much good effect  when  taken into the stomach ; they
may be taken in a dose of four twice a day, with a
bitter draught after them.   The consequence of this
treatment will be, that the last patient  will be raised
up to that  state which  is  nearest  health ;  while the
plethoric patient is lowered dowu to the same point.
These two  patients being now  brought to  that  same
point which is most  favourable to menstruation, it re-
mains to discover the best means of getting back  the
secretion.  Having brought  down  the  plethoric, or
raised the low and weak patient, so that both are on
a par,  we may  now begin with  the emmenagogue
remedies.
  All those remedies called emmenagogues are sti-
mulating;  we  must  never  use strong  stimuli where
the constitution is yet weak, or we shall only exhaust
the system ; and where there is a tendency to plethora,
we  shall produce  hcemoptoe: these,  then, must not  be
begun upon till  the  constitution is  amended.   Some
employ hellebore [helleborm niger), which  has some-
times certainly evinced its powers, for  which reason
we   may give  forty drops of the  tincture, though
most commonly the  menses will return without giv-
ing  any thing.   Madder is recommended  from  its
supposed deobstruent quality.   Instances of its won-
derful powers  are  related in  Dr.  Home's  practice.
Now and then electricity has  been useful, when the
patient all  but menstruates.   Friction of  the  lower
extremities is good as exercise.  Issues have been re-
commended ; but dancing,  air, and  exercise, are the
real, the natural,  and effectual  remedies.   It is only
necessary  to  determine to the part; we  well know
that a  mother, directly she takes the child in  her
arms,  feels the draught of the  milk come into  her
breast, even before the child is put to it. 
PROFUSE MENSTRUATION.
23
          Sect. vii.  Profuse Menstruation.

  We now proceed to consider the opposite state  to
obstructed menstruation,  which is profuse menstrua-
tion,  or  menorrhagia: this  is  where  it  returns too
often, though there may not be too much  lost in each
time; or, it may be, there is twice the quantity lost at
the regular period :  in  short, in whatever manner the
secretion is increased, so as to weaken the constitution,
it forms menorrhagia.  Whether there be too much  or
too little tone in the vessels, they may be inactive, al-
lowing their contents to escape, as they do in petechial
fever, both into the  cellular membrane and into the
urine.  Another way is that of increased secretion, as
in the nose b/eeding; so  that,  when  the  secretion is
increased, it is likewise altered : we find that in menor-
rhagia, coagula frequently escape.   In speaking of this
complaint, we must always  regard  the quantity usu-
ally separated in health.  One woman accustomed  to
lose four ounces, will  menstruate  profusely by losing
six;  while  another  accustomed  to lose the  latter
quantity,  will  not  be  said  to  menstruate profusely,
unless she lose more than seven or eight.
  Profuse menstruation n,ay depend on increased  ac-
tion of the  heart  and arteries; on too much food,
drink, or stimuli in any  shape; and  the symptoms
which will appear in the constitution from  such causes,
will be those of plethora, oppression of the chest, to-
gether with heat and  thirst;   and merely regulating
the constitutional symptoms will  remove it:  this is
the simplest sort of menorrhagia,  and requires least
discussion.   We must prohibit  the  use  of  animal
food,  and keep the bowels in a state of purging with
Epsom  salt; a  convenient  way of giving it is Inf.
Ros. fjss. with a drachm of magnesice sidph. and a little
3yrup of roses, which  may  be repeated three times
m the twenty-four  hours.   What we  want is  not a 
24     THE LONDON PRACTICE OF MIDWIFERT.

violent purging, but a gentle increased action  of the
bowels; by this we lessen the appetite, which is ano-
ther object gained :  and it does not allow the food to
remain so long in the stomach, while  part of the cir-
culating fluids is evacuated by the increased secretion
we have produced into the intestines.   By this mode
of treatment being  pursued, it  will generally happen
that menorrhagia shall be restrained; but if  it  should
not, it will be necessary to apply local remedies, such
as folded cloths dipped in equal parts  of  vinegar  and
water, cold, which  are to be applied to the  abdomen
and pubes, and renewed  very frequently, in the man-
ner  practised  with  common  fomentation.  Another
successful method  of checking the  disorder is the ap-
plication of ice to the abdomen, permitting it to dis-
solve : a small  piece of ice wrapped  in the corner of
a napkin  introduced into the  vagina, and retained
there  for  a few minutes, has been  known to succeed
most completely.
  The next state of  increased menstruation is from re-
laxation of the system.   This will sometimes arise from
increased  action, which we have remarked will often
degenerate into a weakened state ;  and the  effect of
great action is the production of great weakness.  There
is a languid pulse,  flabbiness of  muscles, with  all the
symptoms of weakness and relaxation of vessels ; and
a very small force of action in the heart will  be equal
to the  forcing of blood through an open  vessel.  All
the strengthening  medicines a3  well as  astringents
will be necessary here ; alum and bitters : and where
there is nothing of a vibrating feel  in  the pulse, steel
may be given.  But  sometimes, when  the profuse die*
charge depends on relaxation of vessels, steel will in-
crease the discharge; yet where there is no fever, it is
one of the best remedies.  Next  comes the cold bath,
and moderate exercise in a pure air.
  In regard to  steel, it must be given very gradually 
              PROFUSE MENSTRUATION.           25

at first;  the  chalybeate waters of  Tonbridge and
other places are very proper.  The stomach frequently
will not bear steel in a  less diluted form.   It is very
beneficial to recommend our patients to some mineral
spring in the  country  (chiefly with a view  to get
them out of town), where they may get up early, and
enjoy the benefit  of a  country air.  The patient goes
with  hope  and expectation of relief; her  mind  is
amused, while  in the  water there  may be no  virtue
at all.  Dr. Sydenham relates a curious tale of  a gen-
tleman who had consulted him a long time, and was
little relieved : the Doctor  told him  he really could
do no more for him ; but there was a  Dr. Robinson,
of Inverness,  who  was  wonderfully clever in such
complaints as  his; that he would give him a letter to
him,  and   he  was confident he  would  come back
cured.  The  patient  was  a  gentleman  of fortune,
therefore he was  soon  able  to  begin his journey.
When he arrived at Inverness, he found there was no
physician of that name, nor ever had been in the me-
mory of any  person there.  So this gentleman came
back,  vowing every thing  that  was hostile  to the
peace  of Dr. Sydenham.  When he arrived, he was
in a  very  ill  humour,  and told  him, he  thought  he
had used him very ill,  to send him a journey  of so
many  hundred miles for  nothing.  " YVell," says  he,
" are you   better in health ?"—" Yes, I am well now,
but no thanks to you"—" No,"  says  Dr.  S.; " but
you may thank Dr Robinson for curing you.  I wanted
to send you a journey with an object in view ;  I knew
it would do you good ; in going, you had Dr.  Robin-
son  in contemplation; and in returning, you were
equally busy in thinking of scolding me."
  We should  always give an  object; else, when  we
send a patient into the country, every  step his horse
takes  he will be anxiously considering  whether he
feels himself better  or  not; which anxiety alone is
                         D 
26     THE LONDON PRACTICE OF MlDWIFSRT.

enough to prevent his getting better.  We  may then
order our patients to Islington, if we think  that is far
enough;  or  to Hamstead, if we think it good to give
more exercise, and an object farther removed; and the
stopping the increased secretion will sometimes be the
consequence of this last measure.
  The next sort of menorrhagia does not depend on
general but local weakness ; arising from the woman
having borne a great number of children; and  the
loss of blood is owing to the weakened  state of the
uterus.  This effect is sometimes dependant on exces-
sive venery ; hence we account for the violent attacks
of menorrhagia prostitutes are very subject to.  It may
arise from blows on the abdomen.   This is a more un-
manageable case  than the  others ; because the  weak-
ness is local, and  any strengthening remedies applied,
constitutionally increase  the strength of both parts
at the same time; so that  there still is  the same dif-
ference between the system and the uterus,  in point of
tone, because they are both equally raised:  cold and
astringent solutions injected  into the vagina are the
best remedies.  Though now and then a case occurs,
where the opposite means  succeed, where every cold
application has failed, and throwing up tepid water has
put a stop to the disease.
   But it often happens that there is no clue whatever
by which  we may direct   ourselves; then we must
mind, that, whatever we do, we avoid  mischief.  If
there  is costiveness, we should  remove  it; that is
not doing harm at any rate.  The most difficult thing
is, the management  of this state of relaxed uterine
vessels.  It may  be produced by frequent child-bear-
ing;  but a much  more certain cause is frequent abor-
tion.  A woman  who has  borne  ten children  in tea
years, does more than nature intended her to do; but
the  system can  support this easier than ten miscar-
riages.  Where  this  case  exists  simply without any 
             PR0PUSE MENSTRUATION.           27

weakness  of the system, the  cure  will  be effected
by only removing the cause : but where the system is
reduced by the hemorrhage, we may endeavour to in-
crease both general  and local  tone at the same time,
by  injecting  a  decoction of the cortex granalorum,
with the addition of alum.
  The worst  state of relaxed uterine  system is,  a
great local weakness of vessels, which cannot be acted
upon through the  medium of the constitution.   Since
the  hemorrhage will  be  increased  by whatever in-
creases the strength of action  in the heart and arte-
ries, it would be more an object to  lower  the consti-
tution ; and the best measure is, to leave it altogether,
only attempting  to  stop the  hemorrhage by  local
means.  But  the  cold  application so  much  recom-
mended,  will often fail; a piece of ice has  been  in
the vagina a  whole day without stopping it.  In these
cases, the most  likely thing  to  succeed is,  to intro-
duce an injection into the uterus  itself; to do which,
a tube must be carefully passed up into the uterus, like
a male catheter.   We must withdraw the wire from
the tube, and insert the nose  of  a small syringe into
the tube, and press  forward a little  of  the astringent
injection; as soon as it  produces pain in the back,
the pipe must be taken  away, because a very little  of
the  solution  will be enough;  if there be thirty drops
in the uterus, it is quite sufficient.  In the very worst
case that has been  known to happen, this method was
completely effectual in the cure.
   We should always examine whether there may not
be a polypus :  we  cannot know  what we are about if
 we do not examine.   In uterine hemorrhage, an ho-
 rizontal posture is both useful and necessary. 
 23     THE LONDON PRACTICE OF MIDWIFERY.

          Sect. vm.  Painful Menstruation.
   Dysmenorrhoea is the name given by the Greeks to
(hat complaint, of which we  are  now to treat.   The
English name for  it is  painful menstruation.  Painful
menstruation is so unnatural a complaint, that in a
state of nature it is unknown ; but  it happens among
those  who do not  marry at the  time of life nature
intended ; for which there are many reasons: one of
the greatest objections being, the difficulty  of  main-
taining a  large  family;  consequently  women  are
thrown out  of  a  state of nature,  by not doing that
which nature intended.  The girl naturally  is  taken
■.vithout  warning,   scarcely  knowing herself unwell
but by her linen  being wet;  and  if she feels pain, it
is only very  slight in the lower  part  of the  back;
which is from the consent of certain nerves with those
of the uterus ; but in four or  five years, that becomes
established pain in the back, as bad even as grinding
pains in  labour.  Such a woman will afterwards bear
labour very well, and  declare that she would  rather
bear a child, than experience the pain of difficult men-
struation once a month.
  They go  on in  this manner, that when the time
comes at which the patient expects to menstruate, she
feels a pain  in the  back, and observes at  that time
a little stain;  the pain increases, and the menstruation
goes on very imperfectly, for some time, and when at
last it becomes  more plentiful in quantity, the pain les-
sens, and the last two days the secretion is not attended
with any pain.
  The appearance of the fluid is not that of menstru-
ation, as it usually occurs.  There are coagula of va-
rious  sizes; and if what is discharged  be  examined
carefully, flakes of coagulable lymph will be perceiv-
ed.   These are not observed by  the  women;  but if
inquiry is  made, they find themselves  liable to lose
?uch little flakes.  These being floated in water, fo im 
PAINFUL MENSTRUATION.
29
a cast of the inner surface of the uterus, proving that
the secretion takes  place from the whole  inner sur-
face.  This state arises from interruption of the func-
tions of the uterus,  and is  a situation in  which it is
much less  liable to  become  impregnated;  but if it
does, that  woman may go on menstruating without
any pain to the end of her life, or perhaps with less
than she suffered before.  This complaint is more fre-
quent in large towns than in the country.
  The first object  in regard to  the  treatment is the
removing the inflammation, for  there can be no diffi-
culty in supposing inflammation present  at the time
of  the  pain being  so violent:   one strong  proof of
which is,  the  coagulable lymph being thrown out.
The patient should  leave  off animal food entirely, if
possible, at least partially ; avoid  all liquors, and live
as simply as possible ; keeping the bowels in such a
state, that hard stools shall not be formed.
   If the patient be strong  and  plethoric, we may
bleed once;  but it is a bad principle to bleed young
people; it  lays the foundation for a  larger quantity of
blood  being formed than should be.  Between one
period and another,  the parts about  the pelvis should
occasionally be immersed in the tepid bath, and after-
wards rubbed, and immediately as the pain comes she
should  be put into a warm bath : this may  be done
the night before.  The pulvis ipecac,  comp.  should also
be given to assist perspiration, which is always an ob-
ject here.   Pursuing this  plan, the  habit will be bro-
ken, and the patieut may go  for years without  men-
struating with  pain; but when it returns, the  same
ground must be gone  over again. It is often entirely
relieved by  marriage; so that it might  sometimes be
useful to  recommend this to  the  parents' considera-
tion ; but it must be managed with great prudence.   It
often happens that  a medical man becomes the friend
and adviser, as well as the physician, in a family.
                        n 2 
JO     THE LONDON PRACTICE OF MIDWIFERY.


    Sncr. ix. Final Cessation of the Menses, and Uu
        Treatment to be pursued at that Period.

  We  now  come  to  consider the time when th<-
tnenses leave the woman, and cease  entirely, and to
speak of the best manner in which  the  woman may
be conducted through that period of her life.   It is a
work of time; a work which proceeds slowly.  Na-
ture never acts abruptly.  The discbarge, which con-
tinues from  15 to 50, first becomes irregular: it  ^
necessary  that it should be gradually stopped, to  pre-
vent the constitution being destroyed ; and it happens
that  the body is frequently injured  by this event;  in
fact, it is  one of the most dangerous periods of a  wo-
man's  life.   It not uncommonly  happens  that the
menses at this time become profuse,  producing a weak
state of the  system leading to dropsy, and the woman
Is  carried off in this  manner.  Another evil  is, that
at this period all  glandular  complaints which may
have lain dormant for many years, come forward.   A
little lump in the  breast, which has hardly been felt
for years, will now be converted  into a formidable
cancer,  which will destroy life if not removed.  Not
Hufrequently a tumour  will form  on the  os uteri,
which, if the woman is not particular, she  will allow
to be examined:  it does not come  forward, and  no-
thing of any  consequence is  done till the time that
the menses  cease, when it will  begin to give pain, en-
large, aud  be troublesome.  And why ?  Because  an
evacuation,  which  has regularly   occurred  every
month  hus  Kept  back any  tendency which might
have exi-ied in the vessels of that part, to form a new
and more solid structure; that evacuation being now
stopped, 'his fiction commences again with  greater
rapidity than e\er.  If a tumour  was forming in any
part of the body, we should expect that fifteen leeches 
         FINAL CESSATION OF THE MENSES.        31

applied to it would go a good way towards the check*
ing its progress;  this is the  case with  the menses;
and it is not wonderful that the mind3 of women are
so interested  at this period  coming on as they are.
They know it is a most important time; so much so,
that some  call it, emphatically, the turn of life ; as if
speaking of the time when life is determined.  Others
again, from the  uncertainty of the discharge, call it
the dodging time.  They have  learned, by tradition
partly, that it is the most important and the most criti-
cal time of their whole life.

            Sect. x.  Spurious Pregnancy.

   The last circumstance with regard to menstruation,
is spurious pregnancy, as it has been called, for want
of any other name.  It seems the most unaccountable
mistake in the world for a woman  to consider herself
pregnant  when she is  not  so, and  yet  it is amazing
how common a  complaint this is.  It seems a very
odd  mistake to  make ; but yet we may suppose it, for
many reasons.  The time of life most incident to  the
error we  now speak of, is that in which a  woman is
apt to indulge in  the pleasures of the  table ; this will
produce  indigestion and sickness  in the  morning,
though it  will be attended with flatulency.   The wo-
man, for  fear of  killing the child, loosens  her stays,
which has the good effect  of giving  the wind more
room to  ramble  and stir, which is again  obstinately
mistaken  for the motion of the child.  From her tak-
ing largely the enjoyments of the table,  she increases
in size, and her breasts participate  of the general ful-
ness : this is explained  to be milk coming into them.
   We must  always recollect, that  whenever we  are
consulted by a woman in this situation, we must ne-
ver  tell her  the  truth,  but  throw a shade  over each
symptom.  We  may say,  No doubt  but she is  with 
32      THE LONDON PRACTICE OF MIDWIFERY.

child, but we have some doubt with regard to her
reckoning on her confinement.  We may ask, If she
has been sick in the morning, all the time from that
she first reckoned ?  She will say, " No, certainly ;
but do you  doubt my  being with  child?"—"O no,
there is  little doubt of that;  but stomach complaints
will at times arise in a very strange way.  You have
felt the  motion of the child, 1 suppose ?"—" O yes
very often."—" But have you ever felt a limb coining
up, or a knee pressing, as if H would come  through
your side ?"—" Why no, not so plain  as that, cer-
tainly : but I have  felt it move bo often, that there can
be no doubt."—" Ay,  but are you sure it might not
be wind?"—"• Why, dear  me, Sir,you never doubted
it  before ?"—" Oh, I do  not doubt it now; but  wind
will do this, and feel a  good deal  like a child.   Pray
are you always sick in the morning 1   Because I once
knew a  young  lady who was mistaken  on this point,
and she had seven children  afterwards."
  We should always convey a meaning to that effect ;
it will reconcile  her wonderfully.  Some  women would
sooner forgive us for supposing they had taken a false
step, than for thinking that they could  not  have chil-
dren ; so that we must be exceedingly careful to avoid
any hints which they can construe as  implying that.
All these cases requiring great care, we should break
them very  slowly.  The woman  cannot  bear, the
husband cannot bear, nor can even the friends hear, to
hear that it is no such thing.   The  treatment of such
cases will by gentle purges,  which will at the  same
time have the good  effect of increasing the appetite:
if the complaint, as it generally does, depend on flatu-
lency, it will in this way be taken off, and the size will,
diminish gradually.*

  • According to  the following epigram, the size sometimes di-
minishes suddenly; in this instance the woman straining hard 
SPURIOUS PREGNANCT.
33
 Lucinam geminans) quater  pepedit; and se ended  her  preg-*
nancy:
          Venter cum tumuisset Acciellse,
          Septem mensibus et novem diebus;
          Caepissetque lien parum dolere ;
          Acciri jubet illico obstetricem,
          Quaeri fasciolas, et apparari :
          Sperato, puerum editura, partu.
          Mox, inter medias manus ministrae,
          Laxo poplite, cruribus levatis,
          Lucinam geminans, quater pepedit. 
34
                    CHAP.  II.

        DISEASES OF THE  FEMALE PARTS OF
                   GENERATION.

            Sect. i. Enlarged Nympha.

^Ve  now come to consider  those  diseases  to  which
the parts  of  generation in  females  are particularly
liable.  Nothing will be said of those complaints to
which they are subject in common  with other parts of
the body, but mention  will  be  made only  of those
more particularly incident to these parts ; and first, of
the enlarged  nymphoz.  The nymphce, in the natural
state, are small folds of skin, which, from  their situ-
ation, are vwy red and  vascular.   These are liable to
be enlarged,  becoming  so  long  that they may inter-
fere  with  the patient's  sitting  down, and  give  her
great  pain.   It is  nothing more than a troublesome
complaint; but will sometimes require removal, which
is the only cure for them : in the operation, scissars are
preferable to the knife. The enlargement of the nym-
phce generally depends on the deposition of  new mat-
ter ; but sometimes  may arise  as part of a diseased
labium.

      Sect. ii. Hymen imperforate, and diseased
                   Labia Pudendi.

  There are two states of the hymen requiring our at-
tention—imperforation and rigidity.  Where the hy-
men is  imperforate, the fluid  collected behind may be
evacuated by a trocar  passed through it.  Where we
are obliged to divide the hymen, for  certain reasons,
it is better not to lay  the  whole  completely  open;
there is no  occasion for it.   Where there is contrao 
HTMEN IMPERFORATE,
35
tion of the vagina, it will be very useful to pass, in
the way  of bougie, a portion  of wax candle, kept in
its  situation by the T bandage.  Where the contrac-
tion is longitudinal, there is no remedy.   The labia are
subject to  inflammation, and its consequences,  from
any cold, fever, or the application of extraneous irri-
tation.  It often arises from the  bad effects  of a hard
labour, or  the unskilful management of instruments.
All the consequences  of inflammation  must  be here
treated as when they happen in any other part  of the
body.  In opening any collection  of matter, a very
small puncture is best, giving  the parts time to con-
tract upon  the contents, and lessen the size of the ca-
vity.   Bark and  wine must be given with all possible
expedition  where a tendency to erysipelatous inflam-
mation and sloughing appears ; and where a  slough
does form on the vagina, we should take care to keep
the part distended by a wax candle  or large  bougie, in
order to preserve a passage for the menstruous fluid.
   CEdematous swellings of the labia are often the ef-
fects  of  uterine pressure in the  latter months of preg-
nancy ; they sometimes become so large as to prevent
the woman from  walking.   If this occur two months
before labour, we may scarify  ; but if it happens near
the time of delivery, we had better do nothing.  Where
arising from mechanical pressure, we  should treat  it
by recommending a reclined  posture ; where  it de-
pends on a disposition to  anasarca, scarifying  would
do no good.  Where the parts are affected by venereal
 chancre, it is better to treat the  parts locally, as well
 as constitutionally ; the evil is, there is no measure to
 the effects  of mercury :  after giving it, we can only
 say,  we think we  have  cured the disease : we don't
 know that there may  not arise a second set of  symp-
 toms a long time after.   As  a rule in practice, we
 should generally continue the exhibition of the medi-
 cine for a fortnight after  the  sores have healed.  A 
 36     THE I0WD9N PRACTICE OF MIDWIFERY.

 good local application is about a drachm of calomel
 mixed  with  half  an ounce  of spermaceti,  or  wax
 ointment.

            Sect. hi. Itching of the Parts.

   Itching of the parts is a common complaint with fe-
 males ; one  most frequent cause is, when, from care-
 lessness the girl has never been taught to wash regu-
 larly.   There are  a great number who  do it  only
 after  being  unwell; this is  not  often  enough.   It
 sometimes  arises from irritation of ascarides;   when
 this happens, the treatment must be adapted to the
 primary affection.
   A case now and then occurs where  the itching and
 excoriation depend on a  scorbutic  taint;  particularly
 in those women  in whom accidental cold in the head
 produces such an acrid discharge from the nose,  as to
 excoriate the parts over which it passes : an affection of
 this kind has nothing to do with the venereal desire;
 yet the itching is  so  violent, that  they will rub till the
 parts bleed.  In  such cases, a single  bleeding from
 the arm is  useful, and a purge with senna and  salts,
 abstaining from  animal food and spices.   The bowels
 afterwards may be kept lax by oily and  mild purga-
 tives, not by the saline medicines.   The best local ap-
 plication is the tepid bath, but patients are not  satis-
 fied of its efficacy unless it is medicated.   If this alone
 should not be effectual, a part  of a wax bougie may be
 retained by a  proper bandage, so that, by  its introduc-
 tion, the parts may be preserved from the increased
 heat and inflammation that attends their being; in con-
 tact.  This complaint has been  confounded  with fu-
 ror uterinus, a disease in which the patient is wuilty of
 every possible indecency.   It is, however, in its uature
 perfectly  distinct from it.  The excoriation and itch-
 ing are to be chiefly cured by local means, while furor
tderintis is  only remediable  by attention to  the diet 
ITCHING OF THE PARTS.
37
 fend regimen, or non-naturals, as  they have been call-
 ed ; remembering  that in this, as  in  all other species
 of madness, the patient is never well until she allows
 herself to have been mad.

         Sect. iv.   Fluor Albus, or Leucorrhcea.

   Another very  common  complaint is fiuor  albus.
 Most women conclude this leads to disease, and some
 are much alarmed at its appearance.  In  procidentia
 uteri,  it arises mechanically ;  for its cure  which is
 sometimes very tedious, the cold water bath is the best
 remedy of any that we know of: cold water may be
 injected into the  vagina, and if that  is not sufficient,
 an astringent may be  added, as zinci sulphat.  3ss. ad
 3j. to a pint.  This complaint  is  most unmanageable,
 when arising at the cessation of  the  menses: here it
 often precedes disease of the uterus, and should  be
 treated as if in expectation  of scirrhus ; recommend-
 ing a careful abstinence from wine and spirits ; animal
 food to be quite left off, if  the constitution will bear
 it; together with  which, no  exercise of any  conse^-
 quence should be  allowed.   An occasional  purge
 should also be given, the tepid injection and bath be
 fng used regularly.

             Sect.  v.  Procidentia  Uteri.

  The uterus is connected  laterally to the pelvis, by
 the broad ligaments, and anteriorly by the  round Jiga*
 ments.  When these parts have lost their  tone, they
 allow the uterus to fall through the vagina, so that the
 menstrual discharge has been frequently seen coming
 from the lowest part of  the tumour, the os uteri.   The
 most frequent causes are, rising too soon  after deli-
 very or after abortion.  Next to fiuor albus,  it is the
Wjost common  complaint that is met  with.  There  is
                       K 
38     THF. LONDON PRACTICE OF MIDWIFERY.

a dragging feel in the back, and uneasiness  about the
hips, arising from the broad ligaments: there is also a
pain in the  groin, and the uneasiness these sensations
produce is extremely distressing, though  not amount-
ing  to  pain.  It will at last interfere  with the passing
the  stools and urine, and it is pushed down  at those
times, when  the  woman tells us she feels something
like an egg; this gradually increases, till at last  it  is
altogether out of the body, producing  pain,  and per-
haps ulceration of the os uteri, from the contact of the
clothes; and  the bladder, by its connexion with the
uterus, being dragged down, makes an angle with itself,
which  stops  the passage through  the urethra.   Now,
while there are these powers acting in  the bringing it
down,  there  are no muscles to  bring it backj and
where gravitation leaves it, there disease finds it.  The
only sure relief for procidentia uteri is from  the use of
pessaries ; the best are of an oval form, flatted on both
sides;  the outer edge must be left broad and rounded
off, as it is in close contact with the soft parts round
it;  but towards the hole in the middle it may be made
thinner, and this will diminish  the bulk  and  weight:
these are to be  kept of  different sizes.   The best are
of wood;  the cork  pessaries  cannot  be kept clean.
They were formerly made round : but this is more in-
convenient,  and obstructs the passage of  the urine
and faeces; they also  used to be made with very large
holes,  this  was  dangerous;  the os uteri  has become
strangulated  by getting  into it; when this  has hap-
pened, a pair of pliars may be so  introduced, as to
break  down the ring, so as to enable us to get it out.
In introducing this instrument, it is smeared with cerat.
retaceum, and passed edgewise ; it is to be laid acros6
the pelvis in such a manner as that  the largest diam-
eter is from one ischium to that on the opposite side.
If the woman  is married, we  had better explain  to 
PROCIDENTIA UTERI.
39
her how she may replace it, in case it slips away.   A
very convenient form for a pessary,  where a woman
is a widow, and has ceased to menstruate, is that of a
globe; it is  less apt to  be displaced than  any other
shape; but here we imj*t always have air holes.   This
disease is curable in early life by long-continued hori-
zontal posture, the repeated use of astringent solutions,
and diminishing the size of the pessary.

           Sect.  vi. Polypous Tumours.

  Polypous tumours are found to arise from different
cavities of the body, as the nose, the ears, and the ure-
thra : the female vagina, uterus, and rectum, are  all
liable to this fungous disease.  A polypus does not
appear to be regularly organized like a'natural part of
the body ; it most probably arises in this way: a blood-
vessel  is ruptured, the  blood  from   it  coagulates,
and  into this various vessels shoot, and there, as living
matter,  it  may  grow by  powers of  its own.  There
being no nerves in such parts, no  symptoms are felt.
Perhaps  the woman, in menstruating,  first observes
that  she loses rather more than common, the  quantity
increasing  each period;  and  the blood,  remaining
round the tumour within, putrefies, bringing on a very
offensive discharge.  The disease in general proves
fatal by the  body  being  drained  of its blood.  The
best means of extirpating these tumours is to intro-
duce a ligature upon an instrument made for that pur-
pose ; but though the disease may be cured, the woman
may die before it is cured, or after it,  from the volume
of blood lost during its  continuance.
   The first step towards  acting in this  disease, is, an
attentive examination, tracing it to its neck, and then
we are certain what it is ;  or, if we are able to move
it  as on a pivot,  it is equally evident. The instru
ment for carrying  the ligature round,  is to be  intro- 
 40      THE LONDON PRACTICE OF  MIDWIFERY.

 duced and carried entirely round its  neck, so that the
 ligature  will be  laid round its root;  we  should then
 bring  the  instrument  away, leaving  the  ligature en-
 circling  the  neck  of the polypus,  its end hanging
 down: the ends  of the ligature are then to  be put
 through a canula, to be  passed up over the ligatures
 till it is also in  contact with the  disease;  we then
 have only to draw the ligature  tighter every  two or
 three days, till it  has separated.

           Sect. vii. Tubercle of the Uterus.

   The  fleshy tubercle of the uterus is a disease dis-
 tinguished  by this name  from scirrhus ; the  cause we
 know  nothing, of, nor  do we  know of any  ill effects
 it ever produces: it only grows to an enormous size,
 and, towards the latter end  of life, may  produce in-
 convenience from pressure.  They are mere tumours
 possessing the power of growth;  they are  not capa-
 ble of becoming cancerous, or of ulcerating.   It is
 never worth while to do  any  thing for this complaint,
 as it is productive of no  evil; and  it  is very comfort-
 able to know, that it is  not  every tumour about the
 uterus  that is  cancerous in its  nature; and  though
 these tumours never go away, they are not dangerous.
 If the pressure falls at  last on the bladder and urethra.
 the water must be drawn off.

             Sect, vni-  Scirrhous Uterus.

   Of all diseases  to which the body is liable, none is
 so formidable  as  scirrhus, nor any so  frequent.  It is
 often hereditary;  but  it  is disputed  amongst  practi-
 tioners, whether  it is  the disease  itself,  or  the pre-
disposition, which is inherited.  In the schirrhous state,
the uterus may remain a  great length  of time without
ulcerating.  The  period  which  generally  brings this 
                SCIRRHOUS UTERUS.              41

disease forwards is that of the cessation of the menses.
Then it will  inflame and form  matter;  and when
schirrous tumours once inflame,  they  very soon ul-
cerate :  these  tumours  always  begin  in the cervix
uleri. probably from its more glandular texture :  they
never begin at the upper part:  and it has been as-
serted, that a division by ligature, passed in time round
the os uleri, would bring away the disease.
  The  first alteration taking place, is in the os uleii.
which becomes a  little more open before  the inflam-
mation  has  existed for  any considerable time ; and
when ulceration has taken place, we shall  know it by
examining   the  discharge.  Ulceration  having once
commenced, must and  will go  on, for it cannot be
stopped by any means we  know  of.  It spreads ruin
around it in every direction ;  lays the rectum and the
bladder into one  mass with itself, so tiiat urine, fgeces.
and discharge,  are  all coming from the  same  mass.
From the moment ulceration has  begun, nothing can
be expected fjr the cure of the  disease ; but something
may still be done ; we  may diminish  pain, we  may
diminish the quantity  of discharge,  and lessen the
footer of that discharge: and this is not all; we  may
fake off accidental hemorrhage ;  where there is  he-
morrhage, that mu=t first be atteuded to;  though an\
woman  might pray to be let alone, in order to be re-
leased  by any means from  so much  pain : death is
rather to be wished for, than deplored, by the, patient.
But our duty obliges us to consider how we can lessen
the disease ; and  not whether the woman would  wish
to go out of the world or not.  We should then throw
up cold water and astringents; and when  the hemor-
rhage is restrained, act in such  a manner as shall
make the  disease go on as quietly as  possible to the
patient.  The means to be recommended  are  these:
let her sit  in a tepid bath, and throw  up tepid water
frequently into the vagina and if there is  a tendency
                  '     K  2 
J2      THE LONDON PRACTICE OF MIDWIFERY.

to hemorrhage,  astringents  must be  injected.  The
nature of cancerous virus is  not that  of being offen-
sive ;  but  it kills as it  goes,  and that causes the of-
fensive  smell; while all  this may be from time  to
time washed away, so as to render the room and the
patient as inoffensive  as in any other disease :  there
can be no objection to  the  throwing  up of opium, in
the form of a clyster, into the rectum.  But we should
avoid  the  use of laudanum given into the stomach;
it must be kept  as a last resource :  solid opium, by
being  less sudden in  its effects,  leaves  less debility
than  laudanum.   Emollient  injections may  be  ne-
cessary to get rid of the faeces, and to act as internal
fomentations; by these means we  may render  life
more  comfortable while it  lasts.   As the cause of the
constantly  fatal  determination of the disease is  its
coming forward; if by any  means  we can prevent
that coming forward, we shall do  the greatest  good
for the patient that can  possibly be rendered her.  In-
flammation seems to  be the sine qua non for the con-
version of scirrhus into cancer.  Now, to check local
inflammation, we may expect the application of thirty
leeches will go a great  way.   Menstruation produces
the same  effects; not  that inflammation  was com-
menced before each period: but  the recurrence of the
discharge  keeps the system free from  that state of
plethora which eventually produces the inflammation :
at all events, if we prevent  the inflammation,  we
suspend the  disease;   and if there is no proof of a
breach of substance, the patient may live many years.
  In  order  to the plan of cure  and necessary absti-
nence being attended  to, it is  necessary that  the
woman should  know  the consequence of neglect;
this is a very delicate point: the best way to manage
which,  is not to  tell  her it is a  cancer, but that  her
complaint  already is of such a  nature, that the least
imprudence on her part may change it into a cancer 
               SCHIRRHOUS UTERUS.              43

If we bring cancer in any  how, it does not matter,
she will recollect it.  We may  bleed, and purge  al-
ways with the  neutral  salts;  abstain  from  animal
food, fermented liquors, and spices, letting the whole
diet  consist of vegetables cooling and unstimulating.
Yet, another injunction should be attended to, which
requires great resolution in the woman, which is the
constant observance  of an  horizontal posture.   After
this plan  has been continued some time, the  patient
may begin a course of m^curials of calomel and an-
timony ;  the  decoction  of  sarsaparilla  being drank.
Superadded to all this, great advantage will arise  from
the  application of  leeches, or the cupping-glass,  to
the  lower belly, whenever she says she  feels  as if
there was a rushing kind of  heat within  her, which is
as if a fire was burning, or embers glowing  within :
she does not  express it, as if productive of any  pain,
but  on  the contrary a  most agreeable sensation of
warmth; here also the injection of tepid water, and
its iir-e as a bath, are productive of great advantage.

          Sect. ix.  Dropsy of the Ovarium.

   Dropsy of the ovarium is not an uncommon disease ;
all encysted  tumors of these parts are called dropsy.
though this term is inaccurate ; but it does not  signify,
Sometimes tumours will  arise in the broad ligaments ;
they may also arise in the Fallopian tubes; but where
watery collections arise in the uterus, they are always
encysted,  or  in the  form  of one or more hydatids.
The first symptoms of these complaints are generally
mechanical, only pressure on the bladder or rectum ,
they may also affect the  nerves and absorbents.  But
they are  so long before they produce any real illness,
(bat the water has sometimes been drawn off for several
months before any other complaints were felt.  From
one tumour forty-nine pints have been evacuated; and 
14     THE  L0.ND0N PRACTICE OF MIDWH'ERT.

in a few days afterwards, from another tumour in the
same patient, nine pints more.   There is a case men-
tioned ty  Bonetus,  where 112 pint3 were drawn oft'.
The fluid in these cases is not serous, but gelatinous
and glairy; and there has been  fat and hair fouud in
these tumours,  and even  teeth;   this  will happen
where  there has been  no impregnation.   A subject
was breught from the dissecting-room to lecture upon
by Dr. Hunter, where a swelling of the ovarium was
observed, and to his great astonishment, upon cutting
into it, both teeth  and  hair were  discovered, where
the woman was not impregnated.   This  is a disease
which  may be borne  a long  time: in  one patient,
who had it from the year 1770 till 1798, the tumour
was tapped  as  often  as eighty-four times.  In the
records of a public institution, a woman is mentioned,
who had it from the age of thirty  to that of eighty.
It always begins on one side, and  gradually spreads
over the other.   As to  treatment, none in the way of
medicine has  been  known  to  have  the least  effect
upon  this complaint.   Tapping will not always  he
quite   successful;  therefore,  the  patient should  be
warned of the probability of there being more cyM-
fban one.

       Sect. x.  Supposed Dropsy of the Ultras.

  Another complaint  has been called  dropsy  of tiic
a'ems; but  for many  reasons, no such disease cai
exist.   Cases  mentioned of this  disease have most
probably been hydatids in the  uterus.   It  is a slight
complaint which cures itself.  A lady with a tumuii:
of fhis kind went into a pastry-eook's shop, and sal
down in the parlour;  the wet, which  she  felt,  i.i
creased, till the whole shop  was deluged, aud  very
unpleasant conjectures  were the  consequence.   In
another case, the lady  was riding in  a coach, which 
         SUPPOSED DROPSY OF THE UTERUS.      45

driving over rough pavement, caused  the weak mem-
brane to give way, and the whole  fluid  escaped.
Instead  of a single  hytadid, there  may  be  some
thousands hanging in  clusters  of  all sizes.  There
will be no symptoms but the woman getting larger,
with occasional discharges of water; and, when the
uterus does contract, nothing will come away but the
water and hydatids.  We  may  always prognosticate
the event;  and  though nothing can  be done, we
shall get some credit, and possess great satisfaction, in
knowing what the complaint certainly  is. 
46
                   CHAP.  III.

                 ON CONCEPTION.

         Sect. i. Preliminary Observations.

Xhe human subject is the only  animal whose  uk
rus is fleshy; in all other animals  it is  membranous ,
there are numberless proofs  besides its appearance to
satisfy us of its not being membranous.  It is subject
to all  the diseases  incident  to fleshy  parts, among
which are, scrofula, schirrhus, and  cancerd  We  find
women are most apt to conceive immediately before
and  after  menstruating;  and observe, that women
falling with child do not menstruate ; nor do women
who suckle menstruate, at least they should not.
  Two processes,  important in  themselves,  never
go on well in the same system at the same time.  If
a woman has a child at her breast, and another in
her uterus, either  one or the other  will be  neglected
by nature.  This law of the animal economy is dif-
ficult of explanation; and has much engaged the at-
tention of physiologists.  It is difficult,  and that is the
strongest argument in favour of its being attended to ;
for it requires  no  skill to  explain  that which is ex-
plained every day. Yet,  this law of nature is not
more inexplicable than  any of the rest; they are all
involved in difficulty, and none capable of  being ex-
plained ; except some few chemical and  mechanical
rules, which  perhaps may be supposed laws.  When
man was formed, the Creator, by bestowing on him
the faculty  of observation, gave  him the power of
adding to  his stock of present comforts and conv< 
CONCEPTION.
47
niencies, and even pleasures: by observation he learns
that such causes will always produce such effects ; by
this he is informed that fire always burns.  He may
possess some knowledge in mechanics ;  and, if he is
attentive to cause and  effect, he may obtain the means
leading to great knowledge in mechanics.  But, such
and no more is given to man.   Added to this  ability
for observing, man must be  enabled to  retain in his
mind all the knowledge he thus acquires by observa-
tion.   This is the province  of memory;  without
which  he might put his  hand a second time into  boil-
ing water, or walk into the river.
   Every day proves to us how little we know of  mus-
cular motion; our knowledge in that part of physi-
ology is  the  next remove from nothing.  We know
that muscle is an arrangement of parallel fibres, gene-
rally of a red colour, containing a power by which
they contract when the stimulus of mind or matter is
applied.    We know that they will  lift weights by
their contraction; and a  weight proportioned to the
number of fibres  composing each muscle.  We know
all this by looking on the muscle  after the  skin  is
dissected off;  therefore no  reasoning  is  necessary.
We find, by suspending weights to muscles  after
 death, that the power of attraction  becomes  greater
 than that of cohesion: a muscle that would with  ease
 raise a weight while alive, will be  torn asunder by
 the same after death :  but all this has  nothing to do
 with reason, for any  person  might  see it.   Another
 kind of  knowledge regards  mechanical  motion  : this
 teaches us, that a  muscle  acts with greater or less
 advantage according  to its insertion.  If the insertion
 of the biceps flexor of the arm had been  nearer  the
 wrist, it would have been further from the centre of
 motion,  and consequently  would  have acted   with
 more advantage; but we see that nature chose rather
 to increase the strength  of  the muscles', than to de- 
48
THE LONDON PRACTICE OF MIDWIFERY.
form the arm by  the shape which the tendon, being
so placed, would have  given the limb.   Even  this,
although calculated  to display the wisdom of nature
yet has nothing at all to do  with the physiology of
the muscle itself.  Why are  we not able  to perforin
by  tendon, all  that we  do by  muscle.   We do not
know.   Do we know any  thing ?  Yes, this we cer-
tainly  know,  that  every  man, who forms a  new
theory,  begins  by  knocking all down before him:
every opinion  which has  been delivered before his
time is alike wrong,  away it goes.   It is easy enough
to clear away  the  rubbish; the next step  being to
raise  his own, which,  after  he had  supported  for a
time, is in its  turn  knocked down also.  One  says,
the particles or fibres composing the muscle, are of a
lozenge  shape;  while  another  proves  them to be
tubes.   One man tells us, that muscles contract  from
the presence of nervous fluid ; another,  that the  prin-
ciple in question is  the electric  fluid; and  the third,
as  arduously as any of the  rest, supports the proba-
bility of its being galvanism.
   It is the same with regard  to  the knowledge which
we possess (or rather want) of the  functions of the
brain and  nerves;  about which all that we know
is that the bony case between the shoulders contains a
pulpy mass  with many  strings  attached to  it, which
are dispersed to all parts of the body: which strings,
we  know  while  we  remain in  health,  convey im-
pressions from  without,  and  volition from within.
These  things  we know; but  this is not explaining
the nervous  influence.   What  is the reason that the
nerves alone are capable of conveying impressions ?—
what is the state of the nerve while passing the im-
pression along itself? These questions oblige us to call
fn the assistance of the vibrations, oscillations,  elec-
trifications,  and many  other things,  about  which we
are net better  satisfied  than  we are with nervous in' 
CONCEPTION.
19
fluence.  It is the  same, regarding respiration ; all
our knowledge  of  which process lies  in this  small
compass ; that, while a man breathes freely, he lives ;
but when he dies, it is for want of breath.
  We have theories wisely  built enough ; one  of
which says, that respiration is for the purpose of cool-
ing the  blood ; another says, it is to warm the blood.
Now  this  proves, what?—why,  that  we know  no-
thing  at all about the matter.  And let  us not be dis-
satisfied on being told this, as in time to come we may
know more.  We know that these things only  take
place  in animals and vegetables; never in minerals.
No pebble  ever grew,  nor  did we ever hear of  one
putrefying; but, from  the  structure  of animal  and
vegetable matter, it is all liable  to putrefaction  and
destruction.  So that the Divine Author of nature has
wisely established a process in animal and vegetable
matter,  by which it is  capable  of continuing  itself.
Upon this  curious and interesting  subject, much use-
ful information and  excellent reasoning is to be found
in Dr. Paley's Natural  Theology, a book which can-
not be too generally perused.  The object of this rea-
soning is to prove,  how  difficult  it is  to account for
the means by which many of the  functions in a  living
animal body are performed; and no one is  involved
in greater  obscurity than the  subject of the present
chapter.

      Sect. i?.   Different Theories of Generation.

  It was an  ancient opinion, that  generation is the
effect of fermentation ;  we know, however, that pu-
trefaction and  warmth  are  only  favourable circum
stances  with regard to generation in some animals ;
and that fermentation in vacuo does not produce ge-
neration even in those animals.
                       K 
•50     THE LONDON PRACTICE OF MIDWIFERY.

  Most vegetables,  and some  few animals, may be
propagated by  division or cutting.   It is very easy
to procure as many myrtles (for instance) as are de-
sired, by cutting off slips,  and setting them in the
earth.  Some animals have the extraordinary power
of producing  coiisiderable  organs  after they have
been lopped off.  The  water-newt  will  produce its
legs as complete as ever, after they  have been cut
off.   In the more perfect animals, no new  member
can be regenerated after being once destroyed.   If
two inches of the fibula or  tibia, are cut  away, such
space will fill up, although the quantity of bony matter
required  is great; but, if one of the  sesamoid bones
is taken  away, it will not  be reproduced, though in
weight not the tenth part of the  other bone.  A por-
tion of the gastrocnemius muscle being cut away, may
be reproduced ; but a whole muscle, be it ever so
small, when removed, can never be regenerated.
  Propagation goes  on in animals by sexual contact.
In vegetables, both sexes are in general found growing
on the same individual plant, as they  are incapable of
loco-motion ; and the parts subservient to this process
in vegetables are curiously placed, and so beautifully
arranged as to  be certain of success.  If the flower
is upright,  the male and female parts are contigu-
ous ; and if both  sexes  reside in the same  cup, the
male  is,above the  female; so that  the  fecundating
du-4 has only to fall down, as the breezes brush it off.
Where, on the  contrary, the flower  is pendulous, as
in  the  digitalis  purpurea, we find the  female is the
longest:  that the intention of nature  may be still ful-
filled by the same means.  This i3 universally the case
in animals: but where both sexes are  on one body,
ihat body is  not capable of propagating  on itself.
The hermaphrodite worms are not able to impregnate
themselves.  Some  vegetables have different sexes on
different plants,  of which description the palm is  a 
        DIFFERENT THEORIES OF  GENERATION.     51

specimen :  these, therefore, do not propagate, unless
the male and female are  placed  in favourable  situa-
tions, both  with regard to each other, and the prevail-
ing winds.   We sometimes ingraft with the same view
to propagation.
  In animals we find, that where one sex is more rare
than the other, that of which there are fewest indi-
viduals, is almost always the most salacious.   Animals
will not intermix their different  species; and  this is
said by Haller, to be for the  convenience of  the great
Author of nature, that he may know the animals which
he has created.  This opinion of Haller is, however,
very derogatory from the wisdom  and  power of the
Supreme Being, and from the general tenets of piety,
which  that  physiologist was always known to incul-
cate ; and whether he  uttered it,  or whether it  has
been put into his mouth by  his  pretended friends, it
is equally absurd and contemptible.  Varieties of  the
same  species of animals, however, will intermix : a
horse and an ass will produce a mule, which  creature
never existed till then.   Those  who  breed  canary-
birds well know, that the mule bird  will never pro-
pagate.
  It was the opinion  of Haller, that  in all animals
there  must  be  a coitus  before  generation could  be
complete :  but it is certain,  there can be no  coitus in
fish of the  bivalve  kind ; they not being able to quit
their shells,  cannot be in actual  contact.  The  whole
creation should be considered as an immense chain of
existences;  euch link  of which,  either on the right
hand or the left, still  bears a'strong resemblance to
the next, and to each other.   In some animals there is
a coitus, in  others there is none.  In  some,  as in the
newt, there  is  somewhat resembling a coitus,  which
is deficient by the  male having  no  penis.   The  ova
are then impregnated out of the female.
  Another gradation is seen in fish, where they go
into still waters to deposit their spawn  ; antl the pike 
 &2     THE LONDON PRACTICE OF MIDWIFERY

 also chooses shallow water.  Some principle acluatt*
 the male to follow the female ;  in this instance he doe;
 so ; and the ova  are impregnated by the mule  fish
 while  they are  in the water.  The experiments  of
 Spallanzani on frogs, prove the  possibility of ova being
 fecundated out of the body  of the female.  So that
 we come to this conclusion, that the  propagation of
 animals is  either by a coitus, without a coitus, or with
 a partial coitus : the length of which  is of very  dif-
 ferent duration; being in some exceedingly short, as
 in most birds, witness the common fowl and the spar-
 row, &c.; in some animals longer,  as the  dog ; in
 others very long: and Spallanzani instances one species
 of frog in  which the coitus lasts forty days.  The
 effect  of the coitus, on the part of the male, is, the
 imparting  of a fecundating fluid, which is  capable of
 giving life  to the matter  from the female, with which
 it comes into contact.  The female frog forms all the
 eggs within her own belly, they only  wait the prin-
 ciple of animation.   These cges are not impregnated,
 and are subject to  all the laws of matter; but after
 impregnation, they become subject to different laws,
 being regulated by those  only which regard animation.
 The unimpregnated egg  could  neither assist in pre-
 serving its own heat, uor  resist putrefaction, or  freez-
 ing, so long as  the  other can.   All animal animated
 matter is capable  of maintaining a certain tempera-
 lure, and  resisting putrefaction :  and that is a prin-
 cipal distinction between living and dead matter.
   Mr.  Hunter took  an  impregnated  and  an unim
 pregnated egg, in  an atmosphere below the tempera
 lure of living matter;  and found,  by a thermometer;
 that the egg which possessed the principles  of anima
 tion preserved its own heat three degrees above that
of the  air  round it; which  did not   happen in the
other.  He took others,  and set them in a freezing
 mixture, and found  that  the impregnated egg took 
         DIFFERENT THEORIES OF GENERATION.     53

 seven minutes and a half longer in freezing than that
 which was unimpregnated ; and there is not a scullion
 but knows, that a pullet's egg  will not keep near so
 long as a hen's egg.
   It appears  that only a small quantity of seminal
 fluid is necessary for  the purposes  of impregnation.
 Spallanzani says, that three grains of the seminal fluid
 of the  frog were taken, and  diluted with eighteen
 ounces of water;  and that  such  a drop of this,  as
 stood on the point of a needle,  was quite sufficient to
 impregnate an ovum  taken  out  of the  body of  a
 female frog.   There can be  no doubt that the neces-
 sary quantity  of seminal  fluid  for impregnation may
 be very small; but the truth of the calculation, which
 Spallanzani brings forward  from  the  last-mentioned
 experiment, is not very  evident.  He says, that  the
 quantity needful for a single ovum  is the 164777777th
 part  of a grain of male semen. Indeed,  such a cal-
 culation sets reasoning aside.
   With  regard to  the effect of the coitus upon the
 female, in whom the ovaria correspond with the testes
 in the male; the ovaria, at the time of coitus, are em-
 braced by the  fimbriated  extremities of the Fallopian
 tubes.  The Fallopian  tubes are hollow, and have one
 end open into the  abdomen, and  the other into the
 uterus.   The coitus affects the tubes, by causing them
 to  turn towards  the ovaria,  and embrace them with
 their fimbriated extremities; hence, probably, they
 have derived  their name morsus  diaboli, the devil's
 bite.   The peritoneal coat of the ovarium  swells, and
 becomes  more vascular; it  at last  bursts; and the
 ovum, which  caused these effects, is grasped by the
fimbriae- of the tube, through which tube it is con-
 veyed into the uterus by  a peristaltic motion, which
 the  tube  is capable of.   The  truth  of this  is now
 known, but it has not always been so well  understood.
 Now, it is supposed at this time  by most physiolo- 
oi     THE LONDON PRACTICE  OF MIDWIFERY.

gist?,  that  the semen  of the male must first  be re-
ceived into the uterus  as a previous step to that of the
ovarium giving out its  ovu7n.  This has been doubted,
and that by men who  had the  best means of informa-
tion on this subject.  Harvey has doubted it, in his book
on generation, which  is the best  book he has written,
containing  more  wisdom than  all  his  other works,
none of which, however,  are contemptible.   His op-
portunities  for acquiring knowledge from nature were
superior to  what ha3 ever  been enjoyed  by  any other
physiologist.  King Charles gave him the  liberty of
killing as many deer  as he pleased during the rutting
scasou; and he says, he never  found the least particle
of seminal fluid in any  one  instance in the  uterus.
lie does not think that a single drop  ever gets to the
uterus&t all; however, it is now proved otherwise.
  Haller had a peculiar  method of procuring his in-
formation : he would take pains to discover the favour-
ite pursuits of a  student,  and then  desired to make
extracts from his observations  for  his  perusal ; by
this means he acquired much information  with little
comparative trouble:  though this was sometimes pro-
ductive of  error;  for,  having extracts from magazines
and even newspapers, a great deal of nonsense gained
admission into  Haller's library.   In one instance, in
particular, he had got an extract from  a newspaper,
relating to some  uncommon diseases  among seamen,
which was taken  from Robinson Crusoe; a  history
which never existed  any where  but  in  the  brain of
Daniel De Foe.   It had  been  read  and copied, no
doubt, by a person of no very extensive reading, who
believed all that he read.
   Mr. Hunter made an experiment upon a bitch, which
proved very satisfactory to his  inquiry ; he sa.w the
seminal  fluid thrown into the  cavity  of  the  cornu
uteri.  To prove the  necessity  of actual contact of
fluids to  impregnation, Mr. Hunter took some male
semen of a frog, and placed it m a  watch-glass, over 
       DIFFERENT THEORIES OF GENERATION.      £5

which were suspended the ova of the female, to see if
it would  operate this way ; but though it was almost
close to the semen, which was placed in a gentle heat
to evaporate, yet  the  parts which  flew  off were  un-
equal to the task of impregnating ;  nothing but actual
contact did it.
  Before  generation can  take place, there  must be
certain conditions  in the animal.   The animal must
have attained the time of puberty :  the testicles in the
male, and the ovaria in the female, must each be per-
fect.  In the human subject,  this  period is  charac-
terized in the female by the commencement of men-
struation ; and in the male, by the secretion of seminal
fluid.  There is also an alteration in the trachea, by
which the  tone of the voice  changes, from  the treble
to an alto, counter-tenor,  or  tenor;  and there never
yet vva3 a person capable of keeping his voice without
this change.  The reason why is not  known.  We
know of something similar to it in mumps,  where the
glands of the neck being swelled, frequently are ac-
companied by a sympathetic  pain and swelling of the
testicles.   We see the  same  thing in birds, some of
which only whistle during the pairing season: black-
birds never sing in winter; at which time, if they are
opened, the testicles will not be found, having shrunk
away to  nothing:  if opened  when in full song,  the
testicles will be found of the size of large peas.
  Out of all these facts have been formed the different
theories of generation ;  to enumerate all the varieties
of which  would be fruitless.   Almost every system
of natural history contains some extravagance or other
upon this head.  Not a physiologist, from Aristotle to
Darwin,  but has amused himself,  and perplexed his
readers, .by some  new  and  wonderful  theory  upon
generation, equally ingenious ami unintelligible; and
we are now just as well informed upon the subject »s
were our  learned forefathers in the  days of Galen. 
5§    THE LONDON PRACTICE OF MIDWIFERV.

   Speaking generally  we have three opinions upon
generation: either the father and mother assist in the
producing  the child;  or the father alone, or the  mo-
ther alone, forms it.   The oldest authors were  of the
first  opinion,  and  it  is the  most natural;  it  is
the  opinion most likely to be received  by common
understandings; for  we Bee a  child  like its father or
mother; and  frequently  it  resembles both parents.
We  see that if  the parents  are black and  white, the
offspring is party-coloured.   We see  that two animals
are mutually employed in the production of  the third;
and it is from this very natural to conclude, that both
must have  had a share  in its production.   We also
know that diseases are hereditary.   This, in part, laid
the  foundation for an opinion  entertained  by the an-
cients,  that the  semen  from the right  testicle  and
ovarium combined to produce  male  children, and
that from  the  left side, female  children.  If these
men had meant to arrive  at  the  truth, they might
easily have discovered it, by castrating a dog of one
side; for if then he  produced pups of both genders,
it  must be  a very good  proof that their conjectures
were wrong.
   As that,  however,  was  too  great an exertion in
those days,  the opinion has been universally believed
for  many   centuries.   The most beautiful theory,
though  equally untrue with the rest, is that of the
celebrated natural historian Buffon.   It  is  the most
ingenious doctrine that ever has been held forth ; and
it  certainly is  all but  true.  He  supposes there  are
certain  incorruptible  particles  of  matter, capable of
originally forming, and  afterwards nourishing, animals
and  vegetables, and that the arrangement constitutes
(he only difference between a lion and  a cabbage.   lie
explains that this peculiar sort of matter is confined
to animals and vegetables; that is to say, a man can
not subsist upon pebbles, nor will a vegetable be uou- 
       DIFFERENT THEORIES OF GENERATION.      57

rished  by being placed among stones only.  Buffon
assures  us, that the same number of these particles
exist now that ever  have been in existence and ever
will  be: he says, if  seed is sown in mineral matter
alone, it will not grow; but take animal and vegetable
matter, as dung, and  mix with  the soil, the seed sown
in that will thrive.   This is from some of these par-
ticles being, as it were, presented to the plant, which it
is capable of joining in its own structure, and thereby
it grows.
  But what matter is this ?   It is capable of being con-
verted into the nature of the seed it nourishes ?  If it
is, we sec strange  metamorphoses.   The cabbage is
then literally  turned into a lamb,  not  only into  his
body, but his substance; and  the man who eats this
lamb, turns the cabbage a second  time, by which it
forms human flesh.   Now if this happen to be devour-
ed by  a wild beast, suppose a young  lion, then  the
particles of the cabbage will enter  into the composi-
tion of this lion; which lion, by dying, turns into ma-
nure to nourish potatoes; which being eat again by a
man,  brings  round the  cabbage again, only  in  the
shape of potatoes ; so  that the  eabbage is turned into
a lamb, the lamb  into a man, the man into *a lion,  the
lion into a mess of potatoes, and they into a man again.
When  nature sets  her  fingers  on a  young  animal, it
stops growing, and that  in the age of puberty.  The re-
dundant particles  are kept after this in the testicles,
and are governed by the modulus interior ; they join
each other, and form that resemblance  of the parents
which is observed in some children.  The redundant
particles in children  are  not employed  in generation,
being employed  in the  purposes  of growth ;  and in
eunuchs the particles are not  wanting; but there  be-
ing none employed in generation, is the reason all such
people are very subject to fatness.   When old age  ap-
pears, the time comes when there is no redundancy of. 
58      THE LONDON PRACTICE OF MIDWIFERY.

particles;  but, on the contrary, a deficiency must be
expected.
  Buffon also says, that where there are more particles
than enough, a monster will be produced that has some
redundancy of  growth: an  additional  arm, leg, or
head, perhaps.   If there is a great deal more matter
than is necessary to make one child, the matter may
be then moulded into two.   This is a most ingenious
theory certainly ; it has every merit except that of
truth.  There  may be many objections made to it;
for, in  the  first place, all  children are not like  their
parents, and where the parent may be imperfect, the
child shall be perfect.  Besides, children have  parts
when they are born which the parents have not at the
time the child was conceived, as the thymus gland,
placenta, ductus arteriosus, &cc.
  The last opinion worthy of notice is that of the che-
mists,  who supposed  that  the foetus was  formed by
the same principle of attraction  which in chemistry
forms a neutral salt, upon  the mixing of an acid and
an alkali.   Some will have it depend on  a fermenta-
tion  or decomposition of the seminal fluid, and that it
forms new combinations in the uterus, accounting for
the formation  of a child upon the same principle as
governs the manufacturing  a barrel  of ale.  Certain
books, said  to be  written  by Paracelsus, actually re-
late, that he thought he should be able to make lob-
sters in a retort and receivers; but though he almost
succeeded, yet, when he came to separate  his appara-
tus, he found himself  very much disappointed—there
was not one lobster to  be found.
  A supposition with some people has been, that the
child was the  offspring of the  father only; and that
the mother was  only  as the ground, in which it re-
ceived nourishment for a time.
  These hypothesis had each their advocates  till the
time of Leeuwenhoek, who was the great improver of 
       DIFFERENT THEORIES OF GENERATION.      09

microscopes, and applied himself to make discoveries
by their assistance.   He certainly did discover a great
deal that is true, and much more ; which, supposing
it was true, no man would ever be able to  find out.
He discovered the globules in the blood.  Well know-
ing the blood to be composed of  different fluids, he
imagined those globules were the basis from which all
other fluids arise.  He said, that the globules of the
blood were each formed of six globules of coagulable
lymph, and these  again of six of serum.   Having
satisfied himself of the truth of these  discoveries, he
next examined the seminal fluid, in full expectation of
finding  something  wonderful  there  too, and  sure
enough  he did. He there saw the molecules in the
seminal fluid, and imagined that these little bits of ani-
mation might, by uniting, form a fibre, and so on, till
an animal was finished.   The next  fine day he exam-
ined these  merry little fellows again, and  found they
were exactly like tadpoles in a pond.
  If the  opinion is  true, that  the father  is  the sole
author of the child, why  does  the  stallion, by engen-
dering with an ass, produce a mule ?  For, if the ass
merely nourishes the foetus in  her  belly, it would be
an inconsistency to suppose that any thing like an ass
should he produced.  Besides, supposing, against rea-
son, for a moment,  that this  was the  truth,  what an
immense number of animals would be produced in the
year, when the 164777777th part  of a grain is suffi-
cient for the purpose !
  The theory which at present is received is just the
opposite; it supposes the child to  be the offspring of
the mother only ; so that,  by this doctrine, the most
virtuous women are with child before marriage.
  It is  said, that  the ovum  undergoes no  material
change  after impregnation.  Haller proves  that the
seminal  fluid is, in quantity,  sufficient  only  to  act
as a stimulus.   May we then say that the seminal fluid 
60     THE LONDON PRACTICE OF MIDWIFF.RV

is a specific stimulus ? The best way of examining  all
difficult questions, is to separate them into parts, and
then we stand a better  chance of finding the truth.
We certainly are not able to see any alteration of parts
produced by impregnation ; but why disbelieve it  on
that  account  alone ? Do we not see the alteration
produced on the eggs of other animals, in  the impreg-
nated egg being able to preserve itself and  its heat lon-
ger than the unimpregnated egg ? It does  not follow,
that  because  any  two things are put together, they
must have  been coeval.  When the hand is scalded
badly, if not taken care of, the fingers will  grow toge-
ther, and require division  by  the  knife ; it would  be
absurd  to  say, that nature intended  this  to  happen.
The objection  made, that the particles of semen are
so small as to be  incapable of combining  with the
ovum,  is of no weight.   Do those who  propose  it
know the size  of the particles of the sulphuric acid,
which enables it to  combine  with an alkali to form a
neutral salt ? And this question is alike answered  by
every body, that they know nothing about it. So all that
we know of generation is, that, in consequence of coi-
tion, the sexes are able to produce the lertium quid.
   The seminal fluid either is,  or  is not,  a stimulus ;
specific implies something that we do not  understand.
Supposing  that a specific  stimulus signifies a stimulus
which alone is capable of producing the action, even
then it does more, for it makes the ass's embryo grow
to a  mule,  if this  stimulus was applied  by a stallion.
   How can this be accounted for by any supposed sti-
mulus only ? Ought not the child of a black woman to
be black ?  Nothing can  be  more clear than that  it
should.   Yet  if a white man  is the  father, the  whole
is altered, and  the  rele mucosum  of the skin  of that
child, instead of being black, will be brown.  We may
conclude, then, after all the  ingenious  opinions that
have been advanced upon this prolific subject, that the 
        DIFFERENT THEOR.'F.S OF GENERATION.      (J 1

 irue theory of generation is neither more nor less, than
 that the seminal fluid of the male unites with that of
 the female, and out of this union of the two arises the
foetus.

         Sect. hi.  Ovum and Corpus Luieum.

   When the ovum has  left the ovarium, and passed
 down into the uterus the point in the  peritoneal  coat
 of the ovarium through which  it passed,  and which
 was consequently wounded, communicates with the
 cavity  of the ovarium  behind it, where a substitute i*
 provided, which is of  a spherical figure,  called  the
 corpus  luieum named  from the colour it has before
 being injected.  It is  exceedingly vascular, which vas-
 cularity we discover only by injecting : and a curious-
 circumstance is observed,  that the injection leaves  a
 small central space, into which  no vessels  shoot; so
 that the highly vascular corpus luieum incloses a speck
 in its centre that is not  at all vascular.  The  opinion
entertained  of this corpus  luieum by Dr. Hunter,  ap
pears to be the most rational of any ; it is, that nature
intended these corpora  lutea not  only to  repair  the
injury done to, or the loss  sustained by the ovarium.
but, by their situation and action, to form a new ovum
in place of that which was lost:  if we inspect  that
part of the peritoneal coat of  the ovarium  through
which  the  ovum passed  a month  after  delivery,
we find the surface extremely vascular, much more so
than might have been expected to arise from so natii;
ral a change.
                        G 
t',2      THE LONDON PRACTICE OF MIDWIFERY'

               Sect. iv. Membranes.

  The ovum may  be considered in  two  different
states; first, as  it comes down from  the  ovarium;
next, as to what  it  acquires  by  being  permanently
fixed in the  uterus.   When it comes  forth from the
ovarium into the Fallopian  tube, it  consists  of two
membranes, the chorion and amnion.   The  chorion is
so called  from its  numerous  vessels.  It is  derived
from a Greek word, signifying number, and in musi-
cal language its sense is preserved by  chorus.   There
are vessels  in all possible points of this membrane,
proceeding as from the centre of a  sphere.   As the
ovum increases in size, we see the vascularity of the
chorion gradually  diminish, till in  the latter  months it
is found to be a transparent,  smooth, polished mem-
brane, except  at  that point where it forms  the at-
tachment  of the placenta.  The excessive vascularity
of this membrane, when it is passing  forward  into the
uterus, is probably for the purpose of containing oxy-
gen sufficient for its  own purposes, till it has finished
its journey through  the tube, and  is fixed in  its local
habitation, the uterus.
   Within  the chorion is another  membrane attached
closely to the chorion externally, by a condensed cel-
lular membrane.  This is called  the amnion,  and is
found in all quadrupeds, all  birds, and all  fishes; no
creature is without  it.  In the human subject it is per-
fectly transparent, there are no red vessels either to be
seen or injected.  The amnion is reflected over the fu-
nis umlrilicalis, so as to cover entirely the fcetal  cord.
The internal surface of the amnion is quite smooth in
every  part.  The amnion of other animals possesses
fed vessels most evidently, as in  the cow; and why
diould  we  not  suppose that in  like manner vessels
exist in the amnion of the human species,  although
we cannot discover them ? 
LIQUOR AMNII.
63
               Sect. v.  Liquor Amnii.

  This inner membrane of the ovum contains a fluid
called the waters of the foetus, together with the foetus*
itself; which fluid, in its purest state, is found to be
common  water,  containing a  small  mixture of sea-
salt.*  This fluid is  named the liquor amnii;  and in
delivery,  when  it comes away, is called the waters.
and  escapes  in  consequence  of the  breaking  of
the membranes which are stretched across the os uteri.
The  nature  of this  fluid is known  by examination
after the ovum is expelled by a miscarriage.  In deli-
very, it is very frequently coagulable, because  at that
time  extraneous matters both  from  the foetus and
membranes may become mixed with it.  It has been
supposed coagulable by its own constituent quality ;
this  supposition has also been strengthened by  the
ehild's  body being  generally found  covered  with a
substance like white paint,  which immediately after
delivery will not come off, as if it was a precipitation
of the coagulable matter.   This is, however, a muci
laginous  matter, and,  if  dependant on the  liquor
amnii,  the funis and inner surface of the amnion
should also be covered with it.
  There have been great  disputes as to the  source
whence  the liquor   amnii  comes.   The most  pro-
bable one is, that it is secreted by the inner surface of

  * The following is the  analysis of liquor amnii, as given by Dr
Bostock of Liverpool, in the 4th vol. of the Medico-chirurgical
Transactions, viz.
               Water........... 98.34
               Albumen ........    16
               rncoagulablc matter    1
               Salts............  1.4
100.00 
  «>4     THE LONDON  PRACTICE  OF MIDWIFERT.

  the  amnion.  The proportion of it, with regard to
  quantity, also agrees with this belief.  Some suppose
  it to be the urine of the foetus; others imagine  it is
  the sweat;  some, the saliva; and others  combine al!
  these fluids  together in  the composition of the liquor
  amnii.   Now we may venture to take it for granted,
  that no  one will contend for saliva where there is no
  head; and as children have been produced which had
  the waters round them, though they had no head, we
  may safely  give  up this  opinion.  Neither will the
  urine be contended, for where there is an impervious
 urethra; and though there are no monsters without
  skin,  yet we  find  the quantity of  this  fluid is
 smallest when the surface of the skin is largest, and
 largest where the child is  the smallest; and  this is
 a strong argument against the probability of perspira-
 tion being the producing cause.
   It has also been supposed to be a secretion from the
 uterus,  which, by soaking  through the membranes,
 was found on the inside; but we know of no transu-
 dation taking place in the living body.  Haller states,
 <hat he  has seen the liquor  amnii of a strong saffron
 colour,  from a woman who had taken a great deal of
 saffron;  and Baudelocque says, that this fluid from a
 woman  who  had been  salivated, was so strongly  im-
 pregnated with mercury, that it changed the colour
 of brass and copper.  Now, if this was the case, all
 the chamber-vases in the Lock  Hospital would  be
 amalgamated in a  short time.   It does not appear to
 be at all probable.
   There has  been a difference of opinion again, as to
 the use  of the liquor amnii: it  has been supposed to
 be for nourishing the foetus.   As the yolk of an egg is
known to be  swallowed by the chick before the shell
is broken; so also the child was supposed to swallow
and digest the liquor amnii.  But this is untrue :
many quadrupeds have  been  born without  heads. 
LIQUOR AMNII.
65
 which  nevertheless  were  perfectly  nourished.  The
 liquor  amnii answers  two purposes:  in the  early
 months it defends the foelus from coming into contact
 with the sides of the uterus too abruptly ; it is per-
 fectly capable of checking its motion when calculated
 to do harm: and  for that reason it  is,  that  the pro-
 portion of this fluid is  larger in  the  early than in the
 latter months.   In the advanced  stage of pregnancy,
 instead  of defending the foetus  from the ulerut,  it
 protects the  uterus from the foetus; for the child  is
 able to kick and thrust, while the uterus cannot move:
 besides, it serves to  protect the child from  the con-
 tractions of the uterus, which  are  sometimes very
 powerful; for, while the waters remain, the child can-
 not be acted upon so strongly, it  being a known law
 in hydrostatics,  that  fluids  press  on all sides equally.
 It is of  great use in  the latter months of pregnancy,
 and becomes the foundation of the child's being deli-
 vered alive.  A child that is alive at the  beginning of
 labour is sure of being alive at the end of it, provided
 the membranes  are not  broken; but when they are-
ruptured too early, it  will happen that the child will
 be  born dead, either from  the  pressure upon some
 part of  the child's body, or, as is most common, pres-
 sure upon some part of the cord, by which the  circu
 lation is interrupted, and tiie child dies strangled.
  Next to the chorion  and amnion, are the  decidua,
 and the decidua rejlexa,  which membranes  are fur-
nished by the iderus after  the ovum has come  down
into  it.  That it is composed of two membranes was
 discovered by  Dr.  Hunter; he  demonstrated  it as
 formed  in due uterus, a  membrane quite distinct from
 the chorion and amnion.  It may be distinguished as
 clearly as the pericardium or any other membrane.
                       a 2 
lid
THE LONDON PRACTHE OF MIDW1FERT.
       Sect. vi.  Placenta and Funis Umbilicalis.

   The foetus, as suspended in the middle of the mem-
 branes, is attached to the maternal placenta, by the
 continuation of the  umbilical cord.  The placenta ib
 a mass formed  by the chorion and amnion, and forms
 the after-burthen, as borne by women after the child
 is born.  It is called secundines, from its being the se-
 cond birth,  or  that which remains after  the  delivery
 of the child.  The placenta is so  called from its resem
 blance  to   a cake,  and is of  various dimensions.
 Where  it spreads to a large extent,  the thickness is
 generally less  considerable than in a placenta whose
 surface is small.
   That  passage  leading from the  umbilicus to the
 placenta has actually been  found not more than Bix
 inches  in length; and in some instances it has been
 near  four feet  in  length.  This tube consists of two
 arteries  and a  vein, which  are  twisted round  each
 other, covered with a  sheath from  the amnion, and
 involved within the sheath in a  gelatinous substance.
 The cord does  not contain nerves, as it neither causes
 pain  to  the  mother or  child   in  division.   No ab-
 sorbents exist,  at least they  have never been found.
 The  placenta,  when examined  in  a fresh state, is a
 thick viscus, but thin at the edges, and from  near
 the centre  of  it  the  cord  generally  rises.   Every
foetus has its own placenta  and membranes; and  if
 there are twenty  children in the uterus, each will be
 involved in  its  own bag.  Sometimes in the  case of
 twins, the placentae unite,  where the  edge  of each
 lies  against the other.   The two arteries and vein*
 give  off no  branches  till  they  get to  the placenta,
 where they are thrown off and  ramify; and then dip
 down to that surface of the placenta next the mater-
 nal part of the cake,  and  ramify very   minutely in 
         PLACENTA AND FUNIS UMBILICALIS.       g^

twigs, which are supported by the parenchymatous part
of the cake.
   One circumstance peculiar to the cord is, its being
sometimes tied in a knot:  it is the accidental effect
of a certain position of  the cord with regard to the
child, while the fetus is yet in utero.  Before explain-
ing the nature of the human placenta, it will be proper
to say a few words relating to its  structure in other
animals.   In the  cow, there is a certain part of the
uterus  to which  the placenta is always attached, pre-
pared by nature for that purpose in  a very curious
manner.  There are a number of depressions, cavities,
or sulci, which receive corresponding projecting parts
from the foetal placenta; by  which  means  the  circu-
lation is  established between the parent and the young
animal.  The peculiar nature of this apparatus gave  it
the Greek name cotyledons ; of which, in delivery,
only the  fcetal part comes away ; so that we find the
foetal circulation in the human species and in the cow
differs, by being brought about by different means. In
the cow there are little lobes forming the cotyledon?,
while in the human subject there is for the  same pur-
pose a single cake, the placenta.   The maternal part is
made up  of decidua and membranes.  If in the uterus
of a cow the cotyledons were to be cut away, there
would doubtless be a hemorrhage; but the same parts
separating from each other in the gradual manner na-
ture intended  them, prevents the  possibility  of he-
morrhage;* three never was an instance  heard of,
where a cow has died in  consequence of hemorrhage
lfom  these parts.  But in the human  species, the
maternal part coming away, leave the vessels  un-
supported  and open,  which is the only  difference
in  this  respect between  the woman and the female

  * This opinion seems to be asserted rather too strongly.
Wand onhumna anilcornparai;rc Parturition. 
 t>3     THE LONDON FRAeTICE OF MIDWIFERY.

 quadruped.  The  circulation  in the  foetal  placenta
 pours the blood into the veins ; but there is  no com-
 munication of vessels immediately with the mother.
   The fcetal placenta is easily understood ;  the diffi.
 culty is in understanding the mechanism of the mater-
 nal  placenta.  The maternal  part consists  of cells,
 which are constantly filled with blood by the sperma-
 tic and hypogastic arteries, which is taken up by  the
 corresponding veins, like what happens in the corpora
 cavernosa penis.   The fcetal vessels open into  the cells,
 and are immersed in the arterial blood  from  the mo-
 ther. There can be no difficulty, therefore, in seeing
 why hemorrhage must frequently happen in the  hu-
 mans ubject, while it never occurs in other animals. Be-
 fore we  treat of the uses of the placenta, the following
 propositions should be attended to, that  the same ends
 are always obtained by the same means, ami that the
 same compound must consist of the same parts.  These
 being established  as axioms, it may be proved that
 animal matter is formed of the same  elements, though
 variously applied,  in all animals ;  that  every animal
 lives in a fluid medium, more or less dense, either in the
 open air, a fluid that is  of small specific gravity, or in
 water, a fluid which is more dense, and of greater
 specific  gravity than air ;  but whether the medium in
 which the animal lives  be rare or dense, it is  neces-
 sary  that it be capable of exposing the blood to the  in-
 fluence of the air.
  Those animals which  live in the water have a pecu-
 liar apparatus called gills.   Where the animal  is ca-
pable of locomotion, these gills are so placed behind the
head, that there is a constant stream  of  water passing
 through  them : and through these gills the  whole vo-
 lume of blood circulates, so that it may extract the ne-
 cessary principle from it.   It is for this purpose we see
 a fish is  continually opening its  mouth,  the water  by
 that means getting into the gills.  Of  the truth of this 
          PLACENTA AND FUNIS UMB1LICALIS.       69

there can be  no doubt; and if the extremities of the
gills are  tied, though the circulation might go  on to
nourish,  yet the fish i3  as completely suffocated as a
dog is when hanged;. so that a fish,  no more than a
quadruped,  can live, unless  ttiere is a contrivance for
the exposure  of the  blood in the lungs to the contact
of air.  The beard of the oyster is of the same  utility
as the gills to  a fish, it being  the contrivance by  which
the whole of the circulating fluid is exposed to the
water.  The heart of a fish is of a peculiar character:
it has only a single auricle and  ventricle instead of a
double one; there is no right ventricle nor left auricle,
as pulmonary vessels, which there  are in us.  The
ventricle sends out the aorta, corresponding to our left
ventricle.  The  right ventricle  and  the  left auricle
being subservient to the pulmonary circulation,  where
there are no lungs wanted, it is plain that  these parts
may be dispensed with.  Then seeing that these parts
are unnecessary, if the animal  does not breathe,  there
can be no occasion for them; and we see that fishes
do not breathe,  therefore they have no lungs, but the
blood is oxygenized by air contained in the water rush-
ing through  the gills.
  Having taken it in this point of view, the next thing
to be observed is, that in fish the bronchial artery goes
to the gills,  the  blood being  returned by the bronchia!
vein into the auricle.  The fazlus in utero may be con-
sidered to all intents and purposes as a fish, and this it
is  not difficult  to prove.  In the first place, what is a
fish, but an animal living in the water? and  does not
the  child both  live and swim in wafer ?  In  fish, the
same structure of heart exists as in the foetus.   In the
fish, we  know that the heart  contains but two  cavities,
and that  of  the Jtetus has no more ; which being estab-
lished, will sufficiently prove, that the circulation in the
foetus and in the fish is exactly similar.
  First, tlien;  flic heart has two cavities, an-auricle and 
 70     THE LONDON PRACTICE OF MIDWIFT.Rk

 a ventricle.   We know that  in the adult human heart
 there are four  cavities,  the right and left auricles,
 and the right and left  ventricles.   Now,   both auri-
 cles in  the foetus are thrown into  one cavity  by an
 aperture called the foramen  ovale,  by which commu-
 nication the blood passes freely from the right  to  the
 left side of the heart, so that the  distinct action of  the
 auricles is not so perfect.   With regard to the ven-
 tricles, there *i3 not so direct  a communication  as  be-
 tween the auricles;  but there is something equivalent
 to it: the  ductus arteriosus throws the blood with  full
 energy  into  the aorta, and is so large in the foetal
 state,  that it is frequently  by students mistaken for
 the pulmonary artery, so  that here both the ventricles
 contract at the same instant,  and for exactly the same
 purpose, that of pressing forward  the  blood  in  the
 aorta.   Let us for a moment suppose one room to be
 filled with ink, and another with  milk:  an engine hav-
 ing a pipe  with two branches,  one being placed to
 draw up the fluid from each  room,  what  fluid  would
 be forced up through this engine ? Surely both the  ink
 and milk mixed together ; for, though the pipe has two
terminations,  it is still a  single apparatus; and in the
fcetal state it is exactly  the same : the  end could  not
 be better attained if  the heart had been actually form-
 ed for two spaces. The ductus arteriosus looks like the
 aorta in size,  and  passes over to join the  blood from
 the left side of the heart; so that it is pretty clear, that
 the situation  of the  fcetal heart  is exactly that of  the
 fish, there being but one auricle in fact, and one ven-
 tricle in effect.   It  has been before said,  that  in  fish
 the bronchial artery  was a branch of the aorta; and,
 in the foetus,  the hypogastric artery going to the  na-
 vel,  and a branch of the  large vein from the placenta,
 going immediately  to the liver to get sooner to  the
 heart, without having to travel first through the  body,
 is exactly on the same plan  that  we find in the cod' 
         FLACENTA AND FUNIS  UMBILICALIS.        71

fish, or any other fish.  It now remains to be proved,
that the placenta is similar to the gills.
  It is certain that air  is  contained in all water, yet
(he blood  of the foetus is not corrected by its floating
in water: it is not in this respect exactly  furnished
with gills as a fish ; but what amounts to the same thing
is, its having a placenta, which is  capable of bringing
away the arterial blood of the mother into the system
of the child, which blood is capable of undergoing all
the changes of animalization, and has received  the
benefit of the air, though what that benefit may be we
know not.   It is something which the blood is capable
of extracting through the fine coats  of the vessels,
in which it either circulates or is  exposed.   It is  the
same quality that fish obtain by the water passing con-
stantly through the  gills; and it is  generally agreed  to
be something, and that the blood  obtains this some-
thing,  while passing through its vessels.   During la-
bour, if  by accident the circulation in the cord is in
the least retarded by a little pressure only for  a  mo-
ment, the child is weakened ; and if it is suspended for
a minute the child dies, because the blood cannot pass
to the gills, or cannot  circulate through  the placenta.
It does not at all signify whether the blood is kept from
the air,  or the air from the blood; the effect will  be
equally fatal.

Sf.ct. vii.   Changes that take place, in the Child immediately
                    after it is born.

   The Author of nature never intended that in labour
there should be any risk of death  to the  child ; there-
fore we  find,  that in natural labour the child's head  is
born before the  navel-string is in the pelvis:  a  very
wise  provision, and a reason for the umbilical cord be-
ing attached so low on the abdomen.
   The moment the child  is  born, the foramen ovale 
72     THE LONDON PRACTICE OF MIDWIFERT.

closes.  In  the foetal  state, the  blood passes through
the ventricle, the lungs not being yet pervious.   But it
rs very extraordinary,  that the  first act  of breathing
becomes the efficient cause of all these openings clos-
ing: upon the child's drawing in  breath, the lungs be-
come larger and more capacious than they were dur-
ing the fcetal state, when little blood could pass round
the left auricle:  but  now the  case  is altered :  the
blood upon the lungs being filled,  rushes into the left
auricle, and closes the  valve of the foramen ovale;
and the constant pressure that is afterwards  made on
both sides of it, makes the closing of it unavoidable.
When  the  child breathes, that moment is the current
and quantity of blood  increased in the aorta ; the con-
sequence of which is,  that the blood which passes the
ductus arteriosus must be checked;  it is soon  quite
stopped,  and  the blood coagulating, the sides of the
vessels afterwards  collapse,  and this part is always
found in a ligamentous  state after birth.  When the
child is born,  the circulation  fails in  the hypogastric
vessels, because it is distributed elsewhere on account
of the lungs being active.
  The circulation  is  not carried on in the placenta
after birth, for this reason; before birth,  the  heart  is
in effect single ; both ventricles and  both auricles are
employed in forcing the blood along the aorta and its
branches; the  contraction of  the left ventricle is felt
in the superior  partolNqe aorta,  that part from which
the subclavian  and carotids pass off.   The power
exerted by the  right ventricle is, as  it were, kept  in
reserve;  for the ductus  arteriosus does  not enter the
aorta  till it begins to descend,  when  it assists very
much in propelling the blood through the cord, which
nevertheless requires a great  force.  When the lungs
are beginning  to  play,  instead  of both sides of the
heart  acting as one force, each part now acts in its
own proper place ; the right side of the  heart  forcing 
     CHANGES THAT TAKE PLACE IN THE CHILD.    73

the blood through the lungs, while the left ventricle
is all that remains to press the column of blood for-
ward in the arteries; and to prove the truth of this,
we have only to attend to the child  for the first hour
or  two after delivery, till  the action of the  lungs is
fully established.  This may be easily done ; instead
of dividing  the  cord as soon as we otherwise should,
we  may let it remain rather longer  than usual;  and,
as the action of the lungs increases, the pulsation in the
cord will gradually  lessen, till we shall only feel the
pulse vibrate to a shorter  and still shorter distance
from the belly: and when Ihe circulation is perfectly
poised, the pulse cannot be felt beyond  the navel; it
will perfectly cease in the  cord.  The part from which
the cord drops  away  will be  weak  for 3ome  days,
therefore it  must  be supported  by bandage to avoid
any risk of rupture,  or  other violence, which  may
happen from crying, till  the  parts are  strengthened.
It was probably upon this  foundation that the Jews
never circumcised their children till  the eighth  day
when the navel had acquired strength.

    Sect. vhi.  Consequences of Pressure upon the
                   Navel-string.

  It has been sufficiently proved, that the child before
birth  lives  through  the  navel-string,  a3  fishes do
through  the gills: when born, the state  of  a child
is at once changed from  that just  described, to that
of a quadruped.  All pressure upon the cord should
be  very carefully avoided; such  an accident would
occasion much mischief.  For this reason, the mem-
branes should never  be broken till the  last moment,
as the  possibility of the funis passing down is by this
circumstance afforded.  From accidental  rupture of
the membranes,  the whole of the  waters may be dis-
charged  prematurely,  which will  of itself produce
                       a 
74     THE LONDON PRACTICE OF  MIDWIFERY.

much inconvenience  in  the  progress of the labour,
and much pain  to the woman, as well a3  additional
pressure  to the child; and  if care is not  taken,  the
foetus may be destroyed before its birth.
  From  accidental pressure  the  circulation  through
the navel-string may  be arrested, whether the delivery
is not advanced, or is nearly over.  Where, from  any
cause during  labour,  the passage of the blood through
the cord  is interrupted,  the effect upon the child  will
be the same as it would in a man,  if from accident
(or otherwise) he should chance to have a rope draivn
tight round his neck.  The fcetal life is destroyed be-
fore  the  quadruped's life  has commenced.

    Sect. ix.  Different States of the Child when born.

   It sometimes  happens  that  children are born not
perfectly alive to all the purposes of  the  open air, hut
yet perfectly alive as relates to the fcetal life.  A very
successful way of remedying this, when  the*' trachea
happens to be blocked up with mucus, is,  to pass the
finger as far down the child's throat as possible, clear
ing away the slime ; after which the child will  some-
times  breathe  immediately.  Or,*it may be from a
want of stimulus: in which  case it should be drawn
from under the bed clothes into the  open air, and the
 skin and  muscles be generally  stimulated by a few
 smart raps on the glutei muscles,  and the muscles  of
 respiration will in some instances begin their action in
 this way.
   Now  and  then the child is born aud breathes, and
 yet does not live.  This can only be the effect of mal-
 formation : and  though it cannot be remedied, it is
 right that we  should be aware  of every thing that
 may happen.   In horses it is known very  properly by
 a definition  of  the disease broken-winded, or broken
 m the wind; in which case many of the cells in the 
   DIFFERENT STATES OF THE CHILD  WHEN BORN. 75

lungs are broken down into one, and there is not the
same surface for oxygenation as in health ;  on which
account such horses never breathe  well, until  by ex-
ercise the circulation is increased  so much, that the
blood is forced through in spite of them.
  Sometimes a child will  be  apparently  dead, no
mark of the fcetal circulation remaining.  Here all the
other means that reason suggests must be tried.  As
the child has  lost the fcetal air, another means of sup-
porting life by inflating the lungs must be substituted ;
this may most conveniently be done by a cloth being ••
placed over the child's mouth,  and some person, ap-
plying his own to it, and stopping the nostrils at the
same time, blowing air into the lungs ; by this means
the blood may sometimes be made to circulate.  No
time must be lost before this operation is begun, as the
child will have a more slender  chance for  recovery
for  every minute of delay.  The  child must be se-
paratedlfrom  its mother, and immersed in hot water,
and the lungs should be inflated if possible while in
the bath ;  but sometimes the air will escape by passing
down the oesophagus, which may frequently be known
by the bubbles coming from the rectum up through
the  water : when this  happens, the trachea should be
gently pressed aside, and then, with a finger or thumb,
any more may easily be prevented escaping, though
it is  of no further consequence than as a matter of
inconvenience.
  Besides  inflating the lungs, care  should  be taken
that  the child does not lose its heat: it will on this
account be necessary to lay it in a  bath  of warm wa-
ter, or, while that is preparing, wrapping it in warm
flannels is the best application ; for holding it to the
fire is not only objectionable a3 a very  partial applica-
tion, but sometimes, in very cold weather, vesications
have been produced ; and though these would not ter-
minate  in  the death  of the child,  there is  yet no 
   T6     THE LONDON PRACTICE OF MIDWIFERY.

   reason why it should be  done, when it may  as  well
   be dispensed with.  This, and the endeavouring to ex
   cite respiration,  may be perhaps at last effectual; and
   when the child  begins to  gasp,  there is good  reason
   to expect it will recover.   Some volatile alkali  should
   then be ready prepared to be held to the nose the in-
   stant  that the  ribs  vibrate, which is a  preparatory
   action to an inspiration.  If  this last application is
   successful, it will  produce four  or  five  inspirations
   instead  of one; and if this  treatment is  persisted in,
^ it will often succeed after a great length  of time.  A
   medical gentleman sent for Dr. Clarke to a  breech
   case; when he came the head was not delivered, and
   the  child  was  apparently dead : the gentleman in-
   formed him, that he was sure the child had not  been
   dead  above half a minute.   Dr. Clarke delivered the
   head  as soon as possible, and was endeavouring to in-
   flate  the lungs from  five  till  eight in the morning,
   before it was able to breathe  for itself properljp when
   he completely succeeded,  the child perfectly  recov-
   ering, though its body was of a dark purple.  Now if
   this poor child had fallen into the hands of a midwife,
   she would have shaken hpr head, and cried," Ah, poor
   little  thing, 'tis  dead ! ! !" She  would have  cut the
   navel-string,  laid  the child in a pan, pushed it under
   the bed, and there  would have been an end to the
   business.
     In  another  instance, a breech  case, and  to  all ap-
   pearance  still-born,  the  practitioner had  in  vain
   tried  to recover the child, and after a long space he
   gave  over, and the child, wrapped up in  the  flannel
   was laid in the  basket, and  placed  in a  closet.   He
   went away ;  and in the evening calling to see  the mo-
   ther, he saw the nurse with a young child by the fire .
   he reprimanded her, saying,  It was not right to bring
   a young child into the room in the situation her  mis-
   tress  was in.  " Why, Sir," says the nurse,  " this is 
    DIFFERENT STATE OP THE  CHILD WHEN BORN. 7"7

my mistress's child; about an hour after you  was
gone, we heard a  bustle in the  closet; some china
cups fell down,  and I supposing the cat might  have
got to the child, opened the   closet,  where, to my
astonishment, I saw the child   in the flannel kicking
every thing about him."  The fact is, the gentleman
had recovered him, but had not continued  his appli-
cations quite long  enough.  If the dark colour of the
skin changes to a  lighter and more  natural colour,
there is  ground  enough  to encourage us  to go on.
The blood receives the benefit of the lungs in respir-
ation before we can perceive any  pulse at  the wrist.
Whether the fcetal life is extinguished or not, the im-
mersion in warm water will be  equally proper.
   It will sometimes happen that the circulation  will
be  excited, and  the heart  will beat,  as  long as the
lungs are artificially worked ;   but  as soon  as all as-
sistance i3 withdrawn, the lung3  remain passive; the
heart at the same time ceasing  to move.   In this  way
the child may be sometimes kept half alive for a  long
time.  The limbs  of a child in thi3 situation should
be moved and rubbed carefully, to assist in restoring
the circulation.   This will do  something towards the
recovery of the child.   Volatile alkali and spirits all
assist ; but the inflation  of  the lungs is the remedy,
without which  every thing  else will fail.*  It is also
said, that electricity  i3 useful,  and perhaps in some
cases it may ; but it often happens that an electrical
apparatus cannot be procured in sufficient readiness.

  * Removing the child into a colder room, or letting the fresh
air  blow  upon it from aa open window, will sometimes, in such
a case as this, be of service.
H 2 
78      THE LONDON PRACTICE OF MIDWIFERT.
    Sect. x.  Changes of the Uterus in consequence of
                   Impregnation.

   The  consequence  of pregnancy is  the  uterus in-
 creasing in size : and this it does by assuming a pyri-
 form shape,  convex on the  upper and lower sides,
 flattened before and behind.  The uterus in pregnancy
 is never full; by which is meant, that it is not full in
 the  same sense  that a bladder would  be full  when
 distended with air.  It is not  ever quite  full,   but
 grows larger as the fozlus within increases in size.   It
 is commonly said, that the uterus is distended during
 pregnancy ; this is not the case; if it increased its size
 from distensiou,  it must grow thinner  ; we know it
 never does, but on the contrary increases in thieknes?
 in the same proportion as in size.   This is the effect
 of additional new matter being laid down in its struc-
 ture, and not the consequence of stretching.  The
 size of this part, in  the various pregnancies of  the
 same woman, frequently and  generally  differs, being
 dependant entirely on the volume of its contents ;  the
 bulk of the  child, the number of  children, and  the
 quantity of the liquor amnii being very various.
  The uterus in  pregnancy  is the most anterior of
 all the abdominal viscera.   The reason of which is
 obvious: the intestines are tied  behind  to  the  back
by the mesentery ; and the uterus is fixed laterally by
 the broad ligaments,  but not  being  checked by any
 attachment behind, it naturally will incline forward.
The uterus constantly  performs a variety of different
functions, and is necessarily a complicated  structure,
possessing those parts which most other viscera of  tin;
body are found  to have ; as  arteries, veins,  nerves.
absorbents, and a peculiar structure for the secretion
of a  mucous fluid, capable of preventing the sides of
the uterus from cohering ; by which apparatus its  uv 
CHANGES OF THE UTERUS.
79
ternal  membrane is  liable to those diseases  which
affect glandular parts.  And  further,  the menstrual
discharge from the uterus  serves as a nidus in which
the ovum is nourished ; and does not, as Harvey sup-
posed and familiarly expressed it, form the ovum, just
as an artist forms a figure of plaster.   It  is certain,
that the uterus possesses no such specific power; for
the ovum will grow both in the Fallopian tube and
ovarium; although the uterus, from its having an ex-
ternal opening, from its  power of expelling the foetus,
and  from its  strength, is  the only part  designed by
nature to nourish the ovum.   When we see that, after
birth, the uterus is capable of shortening  itself from
the scrobiculus cordis to the navel, we must be aware
the only way in which  this  can happen is from the
presence of  muscular fibres;  and if it contracts also
from side to side, we know that, being subject to the
same laws as muscular fibres, it is reasonable to infer
their existence.  The muscular  fibres  of the  uterus
are very useful in expelling  the child  and placenta,
but most of all for the prevention  of hemorrhage ;
and  it is provident  that this set of fibres  act inde-
pendently of  the will, for,  if a woman  had the power
of suspending the progress of the labour, after two or
three pains she would perhaps think  she  had suffered
enough and would be unwilling to go  on.  We are
not able  to perceive any difference upon dissecting a
voluntary and an involuntary muscle.  What difference
can be perceived in the appearance of the fibres of the
intercostal and pectoral muscles ?  And yet the one can
be called into action when we please, while the other
will not stop at  pleasure, but  continue  to perform
(heir action during sleep.
   Haller first says it is as much voluntary as the in-
testines; then he  thought  again for a moment,  and
added, the  action of the uterus  is voluntary and de*
pendant  upon the will; but the  will  causes it  to con* 
80     THE LONDON PRACTICE OF MIPWIFERT.

tract  by a pain which it cannot  resist.  That  it is
involuntary there can  be no doubt;  it is  often not
felt at  the commencement of its contraction.   The
difference between  the action of the  uterus and that
of other muscles, is that other muscles almost always
act without pain, this  hardly ever : but as to the de-
gree of pain,  it is very various.   The reason is this,
that, while other muscular fibres in contracting rarely
meet  with much resistance, this always does.  If as
much resistance be felt in any other part of the body,
the muscle will give  as  much pain.  If a person
wants  to  bend  the  foot  downwards,  the muscles
forming the  calf of his leg contract  without  giving
pain; but if they endeavour to contract beyond that
part which the motion of the ancle-joint admits, then
there  is a violent pain which is called cramp : so that
pain,  when  attending  muscular contraction,  is  not
peculiar to one muscle or another  muscle.  It never
happens but  when  resistance is made to  the further
contraction of the muscle.  So that if the pelvis were
wide enough to admit of the child's immediate passage
without any  resistance, there would,  comparatively,
be no pains.  A lady of great respectability, the  wife
of a peer of  the realm, was actually delivered once
in her  sleep;  she immediately awaked her husband,
being a little alarmed at finding one more in bed than
was before.   The placenta did not come away at the
same time, but soon afterwards.   The next pregnancy
she was awakened by a slight  twitch  of pain,  and
she observed  to her husband then,  "  You remember
how oddly 1 was taken the hist time.  Oh dear, there's
another twitch;  ah, and here's  the  child."   This
last delivery was almost as much without pain as the
one before.  But such a formed  pelvis as this  lady's
is not found once in  ten thousand,  perhaps  in a hun-
dred thousand women.   A  woman does not feel the
pain till we by  the  touch  perceive the membranes 
             CHANGES  OF THE UTERUS.            81

tightened.  After the membranes are broken, the pain
is direct, because the resistance is direct.   The uterusi
in  its action, sympathizes with that of the other invo-
luntary parts of the body.  Anger will in some people
make the heart  jump  almost through the ribs; while
fear will at times empty the bladder.  Rage increases,
while fear diminishes, the action of  the heart and arte-
ries.  Hope and confidence increase the action of  the
uterus} while fear and dread retard it. 
82
                   CHAP. IV.

 US THE  SIGNS OP CONCEPTION, AND THE DISEASES
                  OF PREGNANCY.

            Sect. i. Signs of Conception.

Most women are desirous of knowing whether they
are with child, and some are very anxious; those be-
ing most so, who should  not be  with child.   There
are also  other descriptions of patients  particularly
anxious,  much more desirous  of knowing than any
other ladies ; those who are too  old to become preg-
nant.  The reason is this; they know themselves to
be  getting beyond the meridian of life, which it is
their wish to conceal; this they endeavour to  do by
all  the airs  they can  give  themselves;  but are well
aware nothing  will be  so satisfactory as their being
able to raise a family with  as much apparent ease as
at eighteen.   When a girl is at eighteen, we  all sec
that to  be her age; but when  a woman at six-and-
thirty still wishes to be thought eighteen,  and  endea-
vours by every means to impose on those around, she
deceives herself very much with regard to the proba-
bility of  being pregnant.
   Pregnancy produces a great  number of changes in
the  constitution,  dependant  upon  the uterus  as the
great centre of sympathy; as the stomach is in men.
Hence the strong hysterical fits which sometimes oc-
cur in pregnancy.   Though  some of these changes in
a state of nature are not so great as in the state of art,
which prevails in most parts  of Europe, pregnancy
frequently will produce a continual tendency to fever ; 
SIGNS OP CONCEPTION.
83
the pulse increased; the palms flushed; and even
sometimes a small degree of emaciation: alteration
in the constituent principles of the blood also gene-
rally arises, giving the buffy appearance to the  blood j
and if from any complaint fever arises, this buff will
be greater in quantity than at any other time it would
have been ; the face  will grow thinner, the  fat  be-
ing gradually absorbed.  There are also  other symp-
toms  of the hectic state, but the changes in the coun-
tenance are most observable.  The little fever some-
times occasions a  great churlishness of  temper;  a
woman in such circumstances can hardly bear speak-
ing to, and it frequently creates a degree of fretfulness
unknown before.
   Another sign of pregnancy is, pain and tumefaction
in the  breast, which is  only a part of the uterine sys-
tem,  and is affected  from  the  same  cause  with the
uterus.   The areola becomes darker and broader than
before;  the rete mucosum  is sometimes so  altered,
that it is as dark as that of a mulatto, while the skin
generally is as fair as alabaster  (when the  child h
weaned, the darkness of the areola will  diminish and
disappear :) the breasts  enlarge, and will not bear the
pressure of clothes so  well as before; the  woman
will not  be able  to  lie  on one side with her  usual
 ease:  this  proceeds  from the skin not increasing in
 proportion to the secretion of the glands.
   The  next part  that  sympathizes with the uterus is
the stomach ; this is generally perceived in the morn-
 ing ; for though occasionally it  is affected the whole
 day, it  is  generally  felt on first being erect in  the
 morning.   The morning sickness in the progress of
 pregnancy  is closely  connected  with the growth  of
 the child :  so much so, that it has sometimes been a
 rule to judge that where this ceases the child  is dead.
   Pregnant women  have  antipathies  and longings;
 and this desire is in some for the most strange things,. 
34      THE LONDON PRACTICE OF  MIDWIFERV.

as is well known to almost every medical practitioner.
These irregularities  are often increased, and very fre-
quently altogether affected, by many women, who use
them as an artful way of obtaining what they want.
They may long for cherries at Christmas,  and the
husband will rather get  them, if possible,  than have
the child, as the  woman persuades him it will be,
covered with  cherries.   If they  are  about longing,
(hey might as  well  long for a new  gown, and no
doubt they often do j  but they have too much wit  to
mention it.

      Sect. ii. Suppression- of the Menses during
                    Pregnancy.

  No woman can be  with  child if she menstruates;
this  is  the sine qua  non of pregnancy; for  though
there may be sometimes an appearance of blood, there
is not that regular appearance  of uncoagulating fluid
which constitutes  the menses; even  in Hippocrates
we may see this.   If in  a young woman, between the
age of fifteen and thirty-two, the breasts shoot and are
very  painful, and  she i3 not regular; if the  areola
are enlarged and dark, and she has morning sickness :
there is little doubt but  that she  is with child.   It is
not likely that all these things should by any accident-
al cause be present at the same time,  though^ any  of
them may arise.

   Sect. hi. Peculiar Symptoms that sometimes attend
                    Pregnancy.

f There are peculiar  symptoms attending  the preg:
naucy of particular  women, as a cough,  toothach,
headach.  Dr. Clarke used to relate an instance of a
person being as completely salivated during a certain
period of her pregnancy, as ever was a patient in the 
       SYMPTOMS  THAT ATTEND PREGNANCY.      8j

Lock Hospital.  When  these symptoms  occur, they
mark a peculiar idiosyncrasy in the constitution, and
are the surest possible indications.
  There are many women who, at an advanced pe-
riod  of life, either imagine themselves to  be pregnant,
or wish that they  were so; they  know the usual signs
of pregnancy, and often perplex a practitioner by their
questions.  If he answers them in  the negative, they
are offended; and if he complies  entirely with then
wishes, they afterwards doubt his skill.  The only way
to proceed in such cases  is, to imitate the  celebrated
oracles of old, and to pronounce judgment in a man-
ner that shall be perfectly unintelligible.
   The uterus being the great centre of sympathy, the
diseases of pregnancy are so many sympathies ; and,
considered as such, there are no parts which may not
become affected  by its  influence.  Not uncommonly
there is a continual state of low fever;  and yet preg-
nancy prevents the coming on of many diseases ; but
though it prevents many, it produces  some which are
serious.
   Attempts have been made to divide pregnancy into
three spaces, giving  three months to  each: this may
be good, considered in some point  of view, but it
does not suit the human body.  Again, they have
divided the complaints by arranging all those before
quickening, or  in the early period,  together; and all
those after quickening, or in the latter period, together
also.  This is bad, because all that occur immediately
before, and directly  after, this time, are of the same
character.  A  very  good division will be into those
depending on irritation or pressure;  for all the com-
plaints from irritation are worse in the  early months,
on account  of the nature of  irritation;  all irritations
being more powerful as stimuli  when  first applied
A man going first into a glass-house, shall be so af-
fected by the light and heat as to  have violent inflam- 
b*6     THE LONDON PRACTICE OF MIDWIFERY.
 inationof his eyes, which none of the workmen incur.
 A person living in a mill, is not even kept awake by a
 noise which might deprive any people unaccustomed
 to it of their wits in less than an hour.

     Sect. iv.  Sickness, Vomiting, and Heartburn.

  The diseases of  irritation arise in  the earliest pe-
 riods of  pregnancy, ceasing just  before the time of
 quickening, and  not occurring again till just before
 labour;  in the latter  months, the  complaints from
 pressure  produce sickness,  vomiting, and  heartburn.
 When these arise in the morning in women who are
 with child, they  are taught not to mind them ; they
 do not mind them ; they frequently  bear  them with
 great patience, and there is an end of it: we  never
 hear  any  thing of them :  but where the stomach
 continually rejects  whatever food  is taken ;  where
 there is a continual vomiting of bile as well as food,
 and  this lasts morning,  noon,  and  night; the poor
 woman,  become  emaciated  and a skeleton, alarms
her friends and herself.  Then it is a medical man
is consulted, for the alleviating  of that in  a vio-
lent  degree, which  when  more  moderate  is  unat-
 tended to.
  There  is no barm in giving aperient medicines.
 All those medicines which generally  allay vomiting
and sickness, do  nothing here.  The saline draughts,
 and  opiates, are quite  ineffectual.  The most  effec-
tual  remedy is,  to  take  aw.iy about six ounces of
 blood, which may, if necessary, be repeated  in three
or four days time.  This will not  affect the  strength.
 The sickness  here  depends on continual  irritation:
 and to attempt giving the usual remedies to cure com-
plaints of the stomach, is as ridiculous as it  would he 
COSTIVENESS.
87
 to treat the pain  in the shoulder, by  local remedies,
 for affections of the  liver, in which it is always felt.

                Sect. v.  Costiveness.

  Women are very apt to have costiveness as  an at-
 tendant on the pregnant state; which is indeed a very
 common complaint at all times.  It seems to be a part
 of female education  to teach  children to hold  urine
 and excrements, as  much as even dancing and music.
 The fact  is, that women very often go to stool from
 necessity, unless they have  taken  medicine.   This i^
 bad at any time, but  worse in pregnancy than at any
 other  period.   Add  the  pregnancy  to  the acquired
 habit  of costiveness, and  it is.  sure to cause a large
 collection  of  hard feces.  The pressure not unfre-
 quently produces such a tenesmus  as to provoke mis-
 carriage  or abortion.   This often  happens at a  time
 when the woman thinks herself  loose in  her bowels.
 The fact is, the thin  stools pass  by the sajbala or
 hardened balls  of faeces,  and  this  it 13 which  pro-
duces such frequent mistakes as  are often made with
 regard to the real nature of the  complaint.   To pre
vent  which,  it  is  always  proper to ask when the
 patient last had a costive stool  ?  and inquire what sort
 of stools those  are,   which  generally   are  voided
 She  may say, she has not had a costive stool for a
month; but has  had a loose one every three or four
 days.  By the most  diligent  inquiry alone  can the
 truth be ascertained.
  A  similar state in  other  animals requires  what  is
 called raking; that i3,  the  owleech passes  his  arm
 oiled up the  rectum,  and  so brings  away  the faeces.
 In like manner must the patient  be raked, by passing
 the shank of  a spoon  up,  and breaking down the
 consistence of that  bulk next the  sphincter, which  is
 easily washed away  by  the  warm water injection;
 after which an injection with  lj. of soft soap to Ibj. 
oft      THE LONDON PRACTICE OF MIDWIFERY.

of water, will act very readily  upon  the  intestines
then  the Infus. of Senna will  be very proper:  and it
■'* to be  hoped that, after this,  the woman nerself will
be on her guard against costiveness.

         Sect. vi.  Hemorrhoids and Diarrhaa.

  The piles  is a  very common complaint  of preg-
nancy,  and more so about the time  of  quickening
than at any other.  Sulphur and  manna are excellent
aperients in this case :  the throwing up of cold water
is very  successful, so it is when applied  to  varicose
veins.   When the piles are external,  the best appli-
cation is leeches,  and the  irritations may be  lessened
by  preparations of plumbi  superacetas.   Ten  grains
dissolved in four or six ounces of rose-water forms a
good lotion, with  which the part may  be washed fre-
quently.
  Diarrhoea in pregnancy is of great consequence to
attend  to,  as the  tenesmus accompanying  it will
sometimes bring  on  miscarriage.  Diarrhoea in preg-
nant women should  be treated just  as at any other
time ; astringents  may be used after the stomach and
intestines are cleared,  provided  there  is no  fever; if
any fever is present, that  must  be first removed, as
the diarrhoea is the less evil of the two.
  With these there may be different affections of the
bladder: if there is  incontinence of urine, it cannot.
be removed but by delivery; the patients mind should
in the mean time  be soothed as much as possible.

    Sect. vii.  Inflammation about the Neck of the
          Bladder, and Suppression of Urine.

  Inflammation about the neck of the  bladder  is no!
an  unfxequent complaint in  pregnancy.   This may
arise from causes  perfectly independent of the state of 
SUPPRESSION OF URINE.
89
breeding, which causes would produce it at any lime,
as the application of blisters, or the accidental use of
cantharides.. It frequently will arise from cold ; from
its sympathy with the uterus; it may arise from the
pressure of the uterus upon the  neck of the bladder.
This complaint may become important by a continual
desire of making  water; and frequently  this  shall be
totally  prevented  by  the neck of the  bladder  being
much swollen; and whenever  suppression  of urine
happens during the  state of child-bearing or  preg-
nancy,  it is always serious ;  so that all the means we
know of must be tried.  Women, in general,  under
these circumstances, will bear losing six or  eight
ounces of blood;  which will do the  most good of any
means that can be employed.  The bowels must be
kept gently open.    But it  is not  indifferent  what
medicine  is ordered for  this  purpose.   If saline pur-
gatives are given in  inflammations of  mucous  mem-
branes,  a  chemical composition  takes place  in the
bowels, the products of  which are by  circulation
conveyed  to  the  inflamed  surface;  they can then
only be  productive  of mischief;  and  we  find, for
that reason, as frequently as such medicines are used
in complaints of  the bladder,  the  patient always is
worse.   The medicine for removing costiveness here
must be of  the  demulcent kind:  cassia] fistularis
will  do very well: solutions with the ol. ricin.   The
more copiously the  patient drinks of  thick barley-
water,  or  gruel made of grits, the  better.  Infusion
of linseed, or the  lac  amygdal and all oily and mu-
cilaginous fluids, are  to be advised.  They relieve
these cases, though the way in which they act  is not
known.  They were once  said to obtund and  rub
down the sharp spicules of the salts in the urine; a
most fantastical idea.   The truth is, we have no way
of learning the precise manner in which these things
act.  No  person  can  see, a priori,  why cinchonn
                       . 2 
1)0     TIIF LONDON PRACTICE OF MIDWIFERY

should cure the ague.  No one can explain why tar -
tarized antimony should produce vomiting, any more
than Glauber's salt.  Ipecacuanha vomits,  and rhu-
barb  purges; these effects we  know they produce,
but know nothing  farther than this: we know not
why  ipecacuanha  should  vomit instead of purge, or
why rhubarb  should  not  vomit as  well as purge.
Every one is aware, that  in  cough all mucilaginous
fluids are  good; but why  ?   We  do not spit these
drinks back again  in coughing,  we spit the same
mucus or phlegm as we did before: but we  all know,
nevertheless,  that the straining and cough  is eased.
If, therefore,  this mode of treatment is  pursued, we
may prevent the strangury  from getting head, and also
suppression of urine : but if the latter comes  on, the
water must be drawn off, and after this it must again
be done;  and so repeated regularly  to  prevent the
il 1 effects of the retention.

           Sect. viii.  JRetroverted Uterus.

   The  subject of  the  following section,  the retro-
verted uterus, wa3 first spoken of here  in the year
1746.  Monsieur Gregoire taught the history of it in
the medical  lectures he  then gave in  Paris.  At that
time it happened that six  English  students attended,
and only one out of the six, on returning to England,
recollected that particular complaint being mentioned.
In the first case  he  met with in London, he did not
succeed in the attempts that  he made toward reduc-
tion ;  therefore  he  sent  for Dr. Hunter:  but the
woman died : and Dr.  Hunter made  a public dissec-
tion, and read a lecture upon  the  disease over the
body.  After this time, the attention of all  medical
men  was  directed to this complaint more  than any
other incident to pregnancy; and  so much practical
 information was derived from it, that, iu a short time. 
RETROVERTED UTERUS,
91
the English practitioners knew more of it than the
French,  who  did  not believe one  half  of what the
former wrote ; saying, it was impossible that it should
be so common here without their knowing any thing
about it.   In  retroversio uteri, the fundus is turned
downward and backward; while the cervix is  directed
upwards  and forwards, and is sometimes even above
the symphysis pubis.   As this is  the situation  of parts
in the disease, it is easily understood  that it will be
more likely to  happen, and less likely to be  relieved,
if the pelvis is too  large or rather too small; either of
which states of pelvis implies a considerable concavity
in the sacrum, and a  projecting angle  above.   In a
large and in a  deformed pelvis,  the projecting angle
above is  thrown too forward, which will prevent the
return of the  uterus to  its  proper  situation  after it
has once been retroverted.  Now, in  describing the
contents  of the  pelvis, and  more particularly  the
appendages of the uterus, it must be recollected, that
the uterus is connected with the sides of the pelvis by
the broad ligaments;  at its anterior part by the round
ligaments which come off from the abdomen, some-
thing like the spermatic chord in men.  It has no
connexion behind, but lies smoothly upon the rectum.
The consequence  of which  connexion  is, that if the
uterus is misplaced, it must be  downwards and back-
wards, because the os uteri is  tied forwards to the
meatus urinarius ;  and there is no communication be-
hind  by  which it is held to  the rectum, but anteriorly
it i« connected with the neck of the bladder  by close
cellular  substance.  Therefore  whatever  raises the
'•ladder,  will  raise the cervix  uteri;  and whatever
raises the cervix uteri, must at  the same time depress
(he fundus.   So  that, in retroversion of the uterus,
the urethra is  drawn close  up  behind the  symphysis
pubis; and, in the case now under  consideration, the
bladder gets up, and draws up the os uteri with it. 
 92      THE LONDON PRACTICE OF  MIDWIFERY.

   When first the  disease  was  known, it was said to
 arise from fright and other things of that kind.   Thi=
 is not the case.   There are no muscles attached to
 the uterus, nor is it capable of moving  itself by  any
 influence of mind upon it.  The only true cause  for
 this  change of position  iu it, is  quite mechanical.
 There is frequently great fulness of the bladder, and
 if it is very much  distended,  the retroversion  will
 happen in  consequence.  The only period in which it
 can happen lasts but for four weeks, between the end
 of the third month and the end of the fourth.*   For
 iu the  early months of pregnancy, the uterus, in length
 from the fundus to the cervix, is not so great as to fill
 the space  between the sacrum  and  the neck of the
 bladder, and cannot for that reason produce suppres-
 sion,  which  alone constitutes  the  disease.  This ap-
 plies to  all situations of the uterus in unimpregnated
 women, and women who  are with  child till  the close
 of the  fourth month of pregnancy; after  which, the
 uterus eannot  be  made  to go down  into the pelvis.
 When the uterus has  once  fairly  mounted into the
 abdomen it is impossible for it to return into the pelvis,
 until  its volume  has been diminished by  delivery or
 abortion.
   The retroversio uteri happens thus: the  bladder
 becomes full, and  rises into the cavity of the abdomen :

  * The Author is certainly in'an error in "supposing that  the
 occurrence of this accident  is limited to the period of four weeks.
 Of retroversion much earlier proofs may be adduced,  but the fol-
 lowing will suffice.   Mrs. W. 42 years ot  age, thought she had
 symptoms of early pregnancy, but as she had  not been in the
family way tor upwards of fourteen years, was unwilling to give
 credit to her feelings.  She consulted her accoucheur, stating
 that if it were so, she could not be more than two months ad-
vanced.  The day after this  consultation her uterus became retro-
verted, and she was cured by the usual means.  This happened
 on the 20th of July, and on the 5th of  the following February
 she was put to bed. 
               RETE.0VERTED UTERUS.             93

the neck of the bladder in rising draws up the os uteri
with it, which drawing up of the os uteri is assisted by
the fundus of the bladder pressing down that  of the
uterus, and, in nineteen cases out of twenty, the blad-
der in this way becomes the occasional cause of com-
plaint;  and when  the complaint is formed, the sup-
pression of urine is the only material object to  attend
to.   For  the  uterus  being  retroverted,  the woman
cannot  make  water;* therefore, it must be drawn off
by the catheter.   As  to the uterus, it either gets right
again,  or it doe3 not.  Now it can hardly get right of
itself before bail  symptoms are produced; and if they
do arise, it is  not to the  uterus ; for  if the uterus be
impregnated, the pregnancy either goes on, or it does
not go  on.  If it does go on, nothing happens ; if it
does not  go on, abortion takes  place; the ovum and
waters are expelled, and that becomes the cause of the
return  of  the  uterus to its  proper situation, from its
bulk going down.    If, on the contrary,  pregnancy
does go on, the increasing size of the uterus  will in
time bring it out of the pelvis.   But this being accom-
plished  by time  alone, it  may not be convenient  that
the practitioner's attendance be  prolonged  to  three
weeks or  more,  so that attempts may be made towards
the reduction, but they should not be persisted in if
unsuccessful.
  Case i. A young  woman, maid-servant in  a very
respectable family, was detained upon some household

  B Writers on retroversion of the uterus have insisted much
 too strongly, on the fact of the patient not making any water,
which has led to many errori in practice ;. for, if the woman passes
some urine, thepractitioner immediately concludes that tbe utend
is not retroverted.   There is an instance in Van-Doeveren, of a
woman  who had a retroversion of the uterus, and died of a rup-
tured bladder, though  she every day passed urine ; and in Mr.
Croft'? case (London Medical Journal, vol. ii. page 381) a small
quantity of urine  occasionally flowed involuntarily.  It is ot
great importance to remember this. 
94     THE LONDON PRACTICE OP MIDWIFERY.

business  so  long,  that,  though she wanted to  make
water when  first she came  into the room where  she
was  at work,  when she  went out again,  found  she
could not pass any ;  she was in great pain, and begged
her mistress would let her go home to her friends.  A
young gentleman who attended her family came to an
eminent practitioner, wishing him  to see her ; while
going along, he  said there was some swelling  in the
abdomen, and great pain as well  as  suppression of
urine.  The practitioner asserted  that  she was with
child, and not  only so, but that she was three or four
months gone : and the  event proved the truth of hi?
assertion.   Upon examining this girl, the fundus uteri
was  found lying  in the hollow of the sacrum, while the
cervix uleri was up above the pufjes.
  Case ii. A  lady in the country, the first time she
met  with this accident, was at church, and on coming
home, found  herself unable to pass  any water.  It
had happened  in this instance, as it usually does, that
it arose from allowing  the  bladder to  be too much
swelled by its contents.   This lady  had been fomented
and  plied with diuretics to make her secrete plenty of
water while she was unable to pass a drop, and the
bladder was too full already.  The medical  man who
attended  her wrote  to  a celebrated  practitioner in
London,   and  described her  symptoms ; his  answer
reached him in time to  save her life ; and though her
misery must have continued pretty long considering
all things, yet he relieved  her upon knowing what ii
was.  This same  lady was about two  years  ago iu
London, and had the very same occurrence take place,
and  in church again.  The  fact  is, the full bladder
may always produce it.
  The disease in this country is very common ; for as
the child  learns to  speak, it is taught never to say a
word about any  want of that kind  : if a word  should
escape, the company is no sooner dispersed, than the 
RETROVERTED UTERUS.
95
poor child is whipped, so that  they  are completely
educated to it.
   The  moment this complaint found  a  name,  the
public prints were so full of accounts of various cases,
that the French believed none of them.  The danger
arising  from this  complaint is  a  single danger, it is
fulness of the bladder alone : it is this which ought to
be attended to; the water must  be drawn off, and it
is necessary to attend to  the  curve in  the catheter,
which curve is given by holding the instrument in one
hand, and pressing the thumb of the  other hand  on
one side,  while  it is gently drawn through the hand.
In passing the catheter, the point must be dexterously
introduced close behind  the pubes ; for if some dex-
terity is not used, it frequently will not pass into the
bladder.
  When  the  water has been once drawn off, it will
be necessary to  pass the catheter twice  a day, till the
uterus, by a gradual enlargement, recovers its natural
situation.   As it  increases in  size it will  gradually
rise j but  as  it may not be convenient for  a medical
practitioner to call twice a day for some weeks, it  is
sometimes advisable to attempt the  reducing of it;
which is done by the patient placing  herself on  her
hands  and knees,  and the  two fingers of one hand
should be passed into the vagina, and a finger of the
other into the rectum, by which means it is sometimes
possible to succeed.   Where the event is left to time,
the iderus is sure to recover its proper  situation j for
which reason it is  preferable to leave  it, especially as
force used to replace  the iderus has not unfrequently
brought on abortion.

      Sect. ix.  Cramp, and Pain, in the lower
                    Extremities.

   Cramp and pain in the lower extremities are not
uncommon attendants on pregnancy ;  these are most 
96      THE LONDON  PRACTICE OF MIDWIFERY.

liable to happen just before quickening ; and again a
little  before delivery.   At the time  of quickening,
this arises from  the  pressure of the ischiatic  nerve;
and again, just before labour, it arises from the pres-
sure of the uterus also.  The cramp and pain in the
leg is sometimes so  bad as to be attended with para-
lysis.   This evil  cannot be remedied ; but as it is  al-
ways better to do something than  nothing, any harm-
less  thing  may  be  given; and the success of  the
medicine may be prognosticated  before  it is taken,
since we are acquainted with  the  necessary rising of
the iderus, which the woman is  not.  But wherever
it happens at a late period of pregnancy, and  the pain
is  great, there is still  no way of relieving  it.  The
only way is to   wait  patiently till the labour shall
remove the cause.   It is very rarely fatal   In one  in-
stance, that however proved so, there was a mortifi-
cation in the integuments over the sacrum,  and the
nerves coming out through the foramina of the sacrum
were as clearly dissected by the disease as they could
have  been by the knife: this, however, is almost the
only fatal case upon  record ;  therefore  iu general it is
not to be considered  as serious.
  Sect. x.  Varicose  Veins, (Edema, and febrile Stale.
  Varicose  veins, and swelling of  the lower extremi-
ties, frequently  occur in  pregnancy.  The  varicose
swelling will at  times burst,  and cause a great deal of
trouble; a quart of blood will sometimes be lost  by
the bursting of one vein; but it is  only serious when
it continues between the pregnancies.
  (Edematous swellings of the lower extremities will
sometimes require scarification;  but the treatment of
most of the attendant complaint? should be the same
as when they arise from causes independent of preg-
nancy.   (Edema may exist in one or both labia ; this
will be best removed by scarifying; it is often neces; 
       AFFECTIONS OF  THE HEAD A!>n CHEST.     97

jaiy to do something here, as the labia pudendi are so
stretched as to deprive the patient of the use of her
limbs.
  Women in pregnancy are sometimes  affecled with
the febrile state,  characterized by  flushings  of the
hands and face, being restless and hot  at  night.  We
may almost always succeed in removing this  unplea-
sant state by taking a  little  blood, and  giving  saline
draughts.

      Sect. xi.  Affections of the Head and Chest.

  There are two local diseases whiGh reqnire noticing,
affections of the chest and affections of the head.  Af-
fections of the chest are very  apt to occur in. preg-
nancy.  Peripneumony is very common, though pleu--
risy does not happen more commonly than when the
woman is not pregnant.  It seems to  depend on  the
pressure of the uterus  interrupting the circulation in
the  lower part  of  the  aorta; and  the circulation
through the lungs is  not so free as it should be.   It is
hereof infinite  importance to bleed to the greatest ex-
tent.  It affords the only chance tbe woman  can ob-
tain for her recovery ; and in this, and in all violent
affections of the breast, the general rule  should be to
bleed, and bleed, and  bleed again,  till  the patient  is
cured ; for if taken in  labour while the disease is upon
her, or if during labour an hozmoploe comes on, there
is no probable  event but death.
   The other local complaint  is, over-fulness  of the
 vessels of the head, which state will  be known by its
 being attended  with  giddiness, throbbing, fulness^
 headach, dancing before the eyes.  Now, when these
 symptoms appear, we immediately reduce the mode
 of living ; the  patient must altogether  lay aside the
 use of wine and animal food, she must  be bled, and
 be  kept in a continual state of purging, by which we
                        K 
93     THE LONDON PRACTICE OF MIDWIFERY.

may prevent that state of body which would terminate
in puerperal convulsions.

Sect. xii.  Soreness  and Cracking of the Skin covering
                   the Abdomen.

  In the latter months  of pregnancy the abdomen
will  sometimes become  cracked and sore, the  skin
seeming to suffer from over-distension :  in this  case
nothing is so useful as a frequent use of warm oil,
which, to  be effectual, must smell  of camphor, or oil
of cloves,  or a little oil  of sassafras ; or it must be
coloured; for, unless it has either  taste  or smell, no
patient will trouble  herself to rub  on  simple  oil, the
nature of which is so well known.

                Sect. xiii.  Abortion.

  At any time after the ovum is  formed,  an expulsion
of the contents of the uterus may take place, and thia
effect is expressed  by  tbe  terms abortion, premature
labour, and labour.   It is called abortion at any period
before six  months.  The  nosologists  express  it in
Latin abortus  ; and it is commonly  known  by  the
term miscarriage.   This is one of the most common
complaints of pregnancy, therefore it is of more  con-
sequence that every practitioner should  well  under-
stand it.
  Abortion is not peculiar  to the human  species, al-
though they are more subject to it than other animals
because  they lead more  unnatural lives.  We eee,
agreeably to  this  rule,  (hat  the  domestic  animals
more frequently abort than those  that  are wild.  In
the  human  species  the  greatest number of miscar-
riages are between the eighth and  twelfth  week :
perhaps there are more at the tenth week than at any
Other time of pregnancy ; but why this shonld happen 
                    ABORTION.                  Q9

at (hat time more frequently than at any other, we are
ignorant.
   There are two kinds of constitutions very liable to
miscarriage;  the  most strong  and  the most weak:
the most strong, because there are some causes which
act upon  the  vascular system;  the  most weak,  be-
cause many causes act through an irritability of the
nervous system.  As  a proof of the  latter, we may
mention hysteria; the character of which  is a dispo-
sition in the body to act on slight occasions.   A habit
of miscarrying has  been much falked about.  The
existence of such a habit however is doubtful; though
a woman who has once miscarried will be very apt to
miscarry again.  But there is another consideration—
what made  her  miscarry the  first  time;  where
Was  the habit then ?   We can only say it depends on
habit after that time.   A  better explanation of  it,
than its dependance on  an acquired  habit, may cer-
tainly be given, thus: the general cause of miscarriage
is  either too  great strength, or  too great weakness:
and  with  regard  to the  occasional  causes, we may
mention sj'mpathy;  this has such an effect with  other
animals, that there is not a shepherd but knows if one
sheep  aborts,  others almost always abort too.   If a
sheep lambs, the shepherd always separates that animal
from the flock, to prevent the other ewes lambing  be-
fore  their  time.  One animal is thrown into action,
because the other animal is acting.  Consents, also, arc
common in animals as well as sympathies.   Certain
parts of the body are  connected in disease ; the nose
with the rectum in ascarides, and the shoulder with the
liver.  Crying is known to produce tears in many be-
holders.   If a man goes  into a  theatre, the people all
laughing at some joke (he actor  has just spoken, he
will  grin too, without  almost wishing to inquire why.
If a person is seized with a fit of gaping,  those  who
are near will spontaneously follow the example. 
 tOO     THE LONDON PRACTICE OF MIDWIl ERY.

   These are so many  instances of this disposition lo
 imitate, that it  proves the  impropriety  of a pregnant
 woman being ever in the room with one who has been
 miscarrying; and perhaps the  true cause of abortion
 is an indisposition in the  uterus to grow  after  it has
 reached a certain size;  and when arrived  to (hat size,
 contractions begin, labour pains also  succeed,£and
 these  being a< companied  wifh the expulsion of the
 ovum, constitute miscarriage: whether this happens
 at the second, (hird, fourth, or fifth month, it is still
 abortion.
   The first time abortion  happens, it surely "13 not to
 be explained by habit.  The iderus is in some degree
 of the same nature  with  other parts.   In  various
 people we  know (he bladder, without inconvenience,
 contains a  different quantity of urine; in  one person
 it will not,  without his feeling uncomfortable, contain
 more than  six ounces ; but that is not  as much as it
 will hold, because it  will, if necessity  urges, contain
 four times  that quantity;  proving  (hat i( can dilate.
 Every person may have observed (hat at one time the
 quantity which he  retains with convenience will vary
 from that which he retains  at another time.   It is the
 same with  the uterus, which may be apt to  increase
 to a certain magnitude and no further, by which (he
 ovum attains a particular size only before it excites the
 involuntary action of (he uterus by which (he whole
 is expelled.  That  the disposition exists, and that it
is that  alone,  appears  from this circumstance, that
many women go to the usual time of  miscarriage, and
feel  all the signs of disposition to  abort,  and yet, if
 they keep  quiet; for a sufficient length of time, (hey
will  recover, and go to (he full  (ime of pregnancy.
This is accounted for by (he disposition in the uterus
to contract at a certain period of gestation.  Tumours
may cause  it from  pressure : constipation  acts in this
way,  producing exactly the same effect  that other 
ABORTION.
101
substances would.   All  causes, which by  increasing
the circulation,  keep up too great a velocity in the
motion of the blood,  will produce miscarriage,  as
violent exercise; it will,  by the increased momen-
tum of (he blood, separate a portion of the placenta
from (he uterus,  which is very easy (o conceive; for
a certain  force, being applied to the cells of the ma-
ternal part of the placenta, will be  sufficient to rup-
ture them; and (he  cells giving  way, the blood will
make its  escape  between the surface  of the placenta
and membranes,  so as to form hemorrhage.  Where
(he flow  of blood from  the ruptured part is consider-
able, and it finds  a different course between  the mem-
branes leading to the os  uteri, it will produce profuse
hemorrhage.  Violent bleeding  will also sometimes
arise from the use of spirits in  too  large proportion.
Now and then accidental injuries  done to other  parts
of  the body will  cause a partial separation of the pla-
centa from the uterus.  Acute diseases of the mother;
pleurisy,   acute rheumatism, continued fever,  small-
pox, scarlatina,  may either of them produce miscar-
riage.  There  is no disease in  which abortion is  so
dangerous as  in the  small-pox;  passions of the mind
will frequently cause it; and none so  surely as those
which increase the action of the heart and  arteries.
Rage may separate the placenta from  the uterus very
soon.  It is not essentially necessary that the force of
action of the heart  and arteries in general  should be
increased, because increased local  action of the part
is quite sufficient; therefore,  the  union of  the  sexes
often causes women  to abort: and  where the dispo-
sition  is known to  exist, the best way is, to separate
(he wife from her husband, until the period of quick-
ening is  past,  when there is less  danger of this occur-
rence.
   Another  set of passions  of  the mind, which  may
produce  abortion, are those  in which  there is pr««
                      e 2 
 102    THE LONDON PRACTICE OF MIDWIFERY.

 duced a sudden  contraction of the involuntary mus-
 cles : the paleness attendant on fear is a proof of the
 contraction of (he small vessels of (he skin ; and it \i
 not the skin  alone which is  contracted, the  internal
 parts are affected in exactly the same manner.  When
 an army  is marching into the field of battle, many a
 soldier falls into  the  rear to empty his  bladder; and
 many a man, who is not a coward, feels a regard for
 his  own  safety; but the  idea which would  prompt
 him to seek it, being a consciousness of  shame, over-
 comes it.  The  king of Prussia  said, " Give me the
 man who  will run and rally."  However, there is no
 doubt of the bladder being frequently emptied by the
 influence of fear ; and where the soldier has  not an
 opportunity of falling into  the rear, he will let it find
 its own way out at  the knees.  The bowels are af-
 fected in the same way as the bladder in fear, that is.
 (hey contract so Hpon their  contents, that these art
 frequently forced out.
  Instances have been  known of abortion so quick,
 that the ovum was expelled within half  an hour. A
 pregnant woman  heard a  child  scream out, and
 thought (he poor thing had  fallen  down stairs ;  she
 ran (o (he  child,  who  was not hurl, her own pains
came  ou,  and the  ovum  was expelled.  There  are
certain parts with which (he uterus  sympathizes,  such
are (he bladder and rectum; hence tenesmus, stran-
gury, and diarrhcea produce it.
  Besides these complaints,  there are others which
may,  perhaps, be said to arise from medicines taken
for  the procuring of abortion; but  medicines have
very little  effect  iu these  cases.  Hippocrates used to
make his students take  an oath that they would never
attempt to procure abortion.  We see advertisements
in every day's paper for this  purpose; which though
worded artfully  enough, are perfectly understood bj
those who are interested in them : (hey say, " Femak 
ABORTION.
103
 obstructions removed, upon whatever cause they may
 depend."  And (hough (hey will not always succeed
 in making (he woman miscarry, yet  they gain (he at-
 tendance  of  them when they lie in, having private
 apartments for those who wish for concealment.
   With regard to the signs of approaching abortion,
 (he first  and most obvious  change is the  absence of
 the morning sickness, which sickness is always a sign
 of  health in  the foetus,  and  goes  away when  (he
foetus die3.  So  that to-day  this sickness may be, as
 usual, troublesome, and  to-morrow  it shall  be quite
 gone away.   Another symptom  preceding a miscar-
 riage is, a subsidence of the swelling of the breasts ;
 from being hard they become flaccid : by these signs
 will any  woman, but particularly  if she has miscar-
 ried before, know the approach of (his state.  There
 are also  pain3 about the abdomen  and back, which
 are so  many  evidences that (be uterus  has (aken on
 this action.   Hemorrhage  in  general,  also, attends
 these symploms, (hough sometimes a miscarriage may
 happen wi(h very little loss of blood.
  Women miscarry  in various ways, wilh  regard (o
 (he progress of (he  abortion.  In some, the ovum is
 expelled, and in  others it  will come away in pieces.
 The ovum and its  membranes  may be  thrown  off
 first, while the decidua does  not  appear  till  after'
 wards :  sometimes the  ovum  will come away in a
 clot of  blood, and it will not be known as an  ovwn,
 if the coagulated  mass were  not broken down and
 examined : at other times the membranes break very
 early, and the foetus  will come first.  In some abor-
 tions there  is great  pain;  (he grinding  pains  will
 sometimes equal those of labour;  while iu  others
 there is very  little, the ovum appearing to drop  off
 from its connexion with the uterus,  upon the os uteri
 being relaxed, just as premature fruit  drops from a
 free. 
104    THE LONDON PRACTICE OF MIDWIFERr.

  As to the prognosis in miscarriage, it should be re-
gulated by the state of the constitution : if it depends
upon the  contraction of the uterus alone,  the pains
will go on as in  labour,  till the whole ovum is ex-
pelled ; and it is the most picturesque appearance in
the  world, to  see  the foetus  through the membranes
perfectly alive and  moving, for  the placenta contains
sufficient oxygen  from the  air  to  keep up (he  cir-
culation for sometime.   But where the miscarriage
depends on some cause acting on  the circulation, the
woman loses a large quautity of blood, becomes cold,
faints, and the blood stops.   In  fainting and cold,
it is natural to  endeavour  to  restore tbe balance by
giving strength and warmth ; accordingly,  she is put
into warm clothes, and has a little  brandy and water
given her,  which is sure to bring on a return of the
bleeding.   The friends give a little more of (he grand
restorer of nature;  she  again  recovers,  and faints
again.  This may as repeatedly happen as the people
around her please to apply the stimuli.   The warmth
of clothes and the stimulus of spirits are hurtful, by
increasing  the  circulation, which  soon removes  any
coagulated film which might have served to  stop (he
moutiis of the  bleeding  vessels ; while, if time  was
allowed for the blood to jelly, the woman  might not
only  recover the  breach of continuity  made in  the
placenta, but  go her full time of pregnancy.   But we
are  not,  in  general,  to  expect such  a favourable
event.
  There  is very little immediate danger in abortion,
generally  speaking, when it  occurs in the  five  first
months of pregnancy.  We may  say,  that, provided
the consti(u(ion be good, there is  no danger before
the fourth month ;  not but that it may kill; but there
is no necessity to suggest any existing  danger to  the
friends, even  if there should  be  considerable hemor-
rhage.  If it comes from small vessels, there is no im- 
ABORTION.
105
mediate demand made upon the heart for a large sup-
ply of blood in this way.  A woman will sustain the
loss of a quantity of blood which ha3 soaked through
the whole  of  the bed-linen and three mattresses ;  al-
though  if but half the quantity  had been  suddenly
withdrawn  from a  large vessel, the life of the per-
son would  have certainly come with it.   So (hat the
safety or danger of the patient will depend upon the
proportional size of the vessels from which the blood
is  lost, together with the time  in which it is lost.
But if it is  continual, though not  from  large vessels,
it may at length kill, either  immediately, or by over-
powering (he constitution.  A child may  be  bled to
death by leeches, and an infant has been known to
die under the operation of a single leech ;  a woman
who does  not  die while the  blood is  flowing, may
die in consequence of dropsy caused by the loss of
blood.  The danger  of miscarriage is  not to be con-
sidered as regarding that which is  now felt; we must
calculate its probable returns.  When a woman mis-
carries one year after another for several years suc-
cessively, there is no time for the constitution to  re-
cover itself.
  Abortion never ends at once in death, but  it pro-
duces  weakness and dropsy. All miscarriages  are
more  dangerous while the woman  has  an acute dis-
ease,  and  most so  with the  small-pox.   A  small
crop of pustules  is  known  to produce more  danger
in  pregnancy than at  another time.   The principle
upon  which they die is from  weakness: that  period
of time,  when  tbe  small-pox is  accompanied with
diarrhoea from the patient's  having eaten any thing
improper,  may be fatal ; or if accidental  bleeding
from  the nose should arise, it may produce the  death
of the patient.  There is a  certain period,  when, if
(he whole  strength is not  applied to the supporting
the action  on the  surface, the patient  will sink and 
 106     THE LONDON FRACTICH OP MIDWIFERY.

 die directly.  Whenever  the  patient's  life  hangs on
 such a thread as this, it is  very necessary to let  the
 friends  know the extent  of the danger, which it is
 our duty to do,  and will  not  cause  us to relax in
 our endeavours for her preservation ;  and it will be
 extremely distressing, if the case should  turn out  un-
 fortunate  without  the  friends  having  been prepared
 for the event.
   When  hemorrhage  happens  before abortion, it
 does not follow that the  ovum must be destroyed ;
 enough of  the placenta may still remain attached to
 the uterus to carry on all the  purposes of life, and
 the pregnancy  may  go  on.   The  constitution, if
 good, will generally permit us  to  bleed ;  if the ori-
 ginal strength had been  pretty considerable, ^xij is
 not too much ; or, as  much should be  taken  as  the
 patient can  bear,  for twelve ounces at once  will be
 more effectual than sixteen ounces at  twice  in  re-
 storing the balance in the  system.   After which a sa-
 line draught may be given every six hours, with about
six drops  of laudanum : it is  rarely useful or neces*
 sary to press the opiates beyond that quantity ; a large
dose of opium  will frequently  increase  the  force  of
action  in the heart and  arteries,  while a small one
will  keep  it in the state desired.  The bowels must
be relaxed  by  small doses of  the purgative neutral
 salts ;  the  patient must  at the same  time remain
 quiet, with little or no animal  food ; farinaceous  de-
 coctions, with vegetables, is all that should be taken
 while this state exists,  as these  do not add to the force
 of the circulation.
  If the  abortion, instead of arising from  these
 causes, and being attended with  these  symptoms,
 depends  only  ou the disposition  to  contract in the
 uterus, this disposition in the uterus to act may arise
 from passions  of the  mind, or a relaxed state in  (be
 os uteri.  Now the plan  to  be adopted here is  th< 
            TREATMENT OF ABORTION.           1Q7

use of opium and the quantity must be considerable ;
if it is  small  it will do  nothing;  but if large, the
pains in the back and uterus will be  relieved, and the
abortion effectually  prevented.  When the habit of
miscarrying is  acquired,  the  woman  will know the
period  at which it  happens; and  before  that  time
comes on, the  use  of laudanum should be  had re-
course  to, from ten to  fifteen drops, increasing it
gradually till the time of danger is entirely past.
  The  next occurrence demanding attention is the
hemorrhage: we see clearly that fainting is  nature's
method of restraining a flow of blood.  In faintness
we know  (he  small vessels are constricted  by the
whiteness of the skin; we also know that cold is re-
markably effectual in stopping a flow  of blood  from
any part,  but  especially  from  the uterus: not only
cold air, but cold  water, and even  ice, should be ap-
plied to the back, belly, and  parts themselves ; every
thing should be taken cold, and  congealed if pos-
sible ; ice-creams, juices of fruit, seeds, &c. ; all the
body should be cold  both externally and  internally.
Considerable benefit is derived from  ice being  intro-
duced into  the  vagina, and replaced  every  two or
three  hours:  this  will restrain uterine hemorrhage
more frequently than any thing else;  and if it does
not stop it, the constitution will  still be secured  from
the effects which a  more profuse hemorrhage would
have incurred, and the patient is  preserved from the
excessive weakness  which would have been the con-
sequence of it; so that this treatment is good at any
time ; for, if the ovum is dead, and must come away,
(he patient is  still  preserved from excessive loss of
blood, and there  is no reason  why her strength also
should not be  saved.  If the  ovum  has not lost its
Jiving  principle and dependance  on the uterus, there
 is a great  chance of preserving the lives of both by
tfils  (reatinent.   The  horizontal  position  day and 
108   THE LONDON PRACTICE OF  MIDWIFERY.

night,  for several weeks after the  hemorrhage is stop-
ped, will  be  a powerful  auxiliary in  preventing  the
exclusion  of  the ovum from (he uterus, and ought to
be insisted on by (he medical attendant with  scrupu-
lous exactness, because in  such position of the body
(he weight of the ovum presses laterally, bnt  in  the
uprighl pos(ure its  bearing  is  towards  the  os uteri,
which causes a continuation and increase of the pains.
Where there is pain without hemorrhage, there is no
necessity  for being very anxious; for in (hat  sort of
abortion (he  pains will gradually increase  as in  la-
bour, and  the ovum will be thrown off; after which
(he pains  will  gradually cease again,  and  abortion
must  take place here before the pains can subside.'
But it sometimes happens  (hat  there  is great pain
with the loss of  blood,  and (hough  it may be (hat
nothing good can be done to restrain (he hemorrhage
directly, yet assistance may be given in emptying the
uterus ; for, after the ovum has separated, sometimes
it will not  come away:  in  this  case the finger of ei-
ther hand may be  introduced, and  some  part  got
away; and if it should not be  practicable just in that
way, it is sometimes possible  to get in two fingers,
and by this  contrivance pass  them  through the os
uteri,  and thus an hemorrhage  is  sometimes  re-
strained,  which,  if  serious, it  is worth  while  to
endeavour to remove by any means which promise
success.
  It i3 not usual to institute an examination in mis-
carriage, but it may be  prefaced by explaining  the
intention of so  doing.  Should  it so happen that the
ovum  cannot be  got away entire,  the membranes
should never  be  broken, unless, after  (he  fifth
month, the child can be felt   through  (hem  before
tearing (hem, in which case it will be possible to get
hold of a part  of  (he foetus, and  deliver,  relieving
the woman  from  that danger;  for  though  in  (he 
             TREATMENT OF  ABORTION.          | 09

early months abortion is not  dangerous,  the  danger
increases  every day,  and  when it  admits of being
treated like premature labour, it always should be, as
that treatment ensures absolute safety to the woman :
but if the membrane3 are ruptured in  an early abor
(ion, or before  twelve  weeks, it  is   probable   that
there will  be  no more pains, for  the  waters,  which
formed the bulk of the ovmn,  having escaped, no-
thing but the thin skins remain behind, and these are
so small,  that ihey  will  not  stimulate the uterus to
act, and yet the vessels will continue to bleed.
  Abortion is  prevented in the first place, if by ob-
servation and knowledge of the patient's life wo know
her  to have  been  subject to  miscarriages; we may
then be able to prevent a repetition of  tbe same thing
by her being careful to avoid the causes  which had
before produced it.   If in former  pregnancies she
has  met with some circumstances by which the ac-
tion of the heart and arteries  has been so increased as
(o produce miscarriage, it will be  necessary (o take
care that this does not occur, even if the cause should
be applied, and this is best  effected by  bleeding or
opening the bowels.   But  when,  from the  urgency
of symptoms, there is sudden occasion to act imme-
diately, evacuating the intestinal  canal  is not  sufti
cieut to ensure  safety, and it will then be necessary to
take a little blood also.  If, on  the contrary, there is
reason to believe that the woman  miscarried  from
weakness,  wo  may  prevent  a  recurrence of it  by
strengthening her by  good diet, and the use of bit-
ters  and  tonics.  There are  women who  appear to
miscarry  regularly from the state of the  uterus being
that which is  unfavourable  to growth beyond  a cer-
tain extent; iu  this  state abortion is frequently pre-
vented by immersion in  the warm bath ; it lessens
the disposition of the  uterus to contract.   If there dp
                        l 
UO   THE LONDON PRACTICE OF MIDWIFER1.

any reason to expect great weakness in the uterus and
uterine vessels, from knowing the history of (he wo-
man from her having been liable  to profuse menstru
ation, and to  all the other  symptoms of weakness,
the application of cold  will be of great  advantage in
siring the proper tone to the vessels. 
Ill
                    CHAP. V.

              ON UTERO-GESTATION.

       Sect. i.  Situation of the Foetus in Utero.

It  was the opinion of  the ancients,  that the child
sat  in the womb,  with its  face  looking in the same
direction as its mother's; the spine towards  the mo-
ther's spine;  and so placed as if  looking  through a
little  window in front;  and it  is even now a belief
with many  women, that,  when a pregnant  womau
has the  heartburn,  it is  a proof that the child has a
great deal of hair on its head, believing the complaint
to arise from  the  little  one  brushing his  wig against
(he stomach, and so causing the uneasiness.   This be-
lief arose from the supposition, that, if the child was
to remain for nine months  with  its head downwards,
it would»certainly die of apoplexy.  The question then
was, how did it  happen  that  the  child  was so con-
stantly born with  its  head first ?  This however was
satisfactorily answered, by  making the child turn  it-
self  a little before  labour.  The impossibility of this
being true is now fully ascertained, and the real situ-
ation of  the foetus in utero known to be with  its head
downwards.  Now, some will say  that this cannot  be,
because the child must of necessity  have apoplexy if
the  head is always downwards, but experience  has
proved  that this does not  happen.  It lies then with
its  head  lowermost all (he time  of pregnancy; and
the foetus in utero  is so placed, that it fits (he  uterus in
the best  possible  manner, lying with its head  down-
wards, the long  and short  diameter of the head cor-
responding with  those  of the pelvis; and next, it  it 
J12    THE LONDON PRACTICE OF MIDWIFERY.

not only the head which is placed in Hub manner, but
(he limbs, which are all of them disposed in the most
favourable and easy posture.
  There are two opinions as to (he reason of (his: one is,
that (he child hangs by the navel-string, and that the
head, being the heaviest  part, gravitates: this is  im-
possible, the supposition of the fetus being suspended
is  quite erroneous :  the  cord being a  yard in length,
how  can  (he child hang from  it ? besides, was that the
intention, the placenta should be  always attached to
thefund-us uteri; whereas it is as often found attach-
ed to the &ide  of  the womb.  Another  supposition
has been,  that the head gravitated in  the  same way,
or by the  influence of the  same cause, which turns (he
head of a shuttlecock downward when it has described
a certain parabola.   Now, from (he  fondness which
the authors of  such theories display   for  gravily, it
leads (o  the  supposition that their own  heads were
strongly influenced by this law of matter; the wisdom
of (heir ideas is certainly  too profound for  common
understandings.  The skuation of (he child depends
entirely upon  (he shape  of (he  uterus;  (he  same
woman has been  delivered six  times with  (he same
preternatural  presentations:  (his could  not  arise
from accident, at least it is not likely ; it is  no doubf
dependant on some peculiarity of shape in the uterus.
  The next observation is that the fetus always takes
(he easiest, form, the most convenient disposition  of
parts:  it  is neither flexion  nor  extension;  it is at
once that which is most  easy, and that which occu-
pies the least space.   Harvey, in his book De Genera
Hone  Jlnimalrum, attributes  (he position  of  (he  child
in utero to (he same cause tha( John Hunter does, who
wrote  so long  after, and yet  has all the merit of ori-
ginality,  as John Hunter  did not read Latin.   They
both speak of a living  principle, exactly  what  Mr
Hunter calls the life of the blood. 
PERIOD OF UTERO-GESTATION.       H3
         Sect. ii.  Period of Utero-gestation.

   The next object of discussion is the period of utero-
gestation.  In all other animals the  period of utero-
gestation is very constant.  Haller states that the time
of going with young is  very  regular in animals,  but
(hat it is  not so regular in women ; he gives  us  the
references by which we read of a woman going ten,
eleven,  twelve,  thirteen, and even  fourteen months.
Hippocrates says, that  " he  can allow the  possibility
of a child being born at ten  months, but no  later."
Among the Romans, Livy mentions a case being tried
while Lucius Papirius was censor, where a young man
claimed the estates of the father,  being born eleven
months after the father's death ; the  judge told him,
that if the father had died only ten months before.
he should have had the estates,  but eleven  month;
was longer than they could allow. The former system
in France allowed ten  months : but it is  difficult  to
know what term the republican laws may  fix upon.
In England the time is  not settled by  law.
   A very frequent question is, what  time  will labour
come on ? Now, the period should be calculated from
the menstruating time,  taking a medium  between  the
last menstruating period and  the next following  the
time when conception  took place :  this  is  the  best
mode of forming  the  opinion :  we  are always near
the mark in this way of counting.   It is better to ap-
point the day  rather before  than after the time when
we  really  expect the  woman  will   fall into labour.
There are two little varieties which  it is  proper just
to notice : one of which is,  where the death  of  the
husband will prove so  grievous iu its consequences to
the poor widow, (hat it shall  put off her labour  for
two or three weeks. A melancholy  instance  of this
happened in one of our settlements : a lady, the wife
                      l 2 
 J14    THE LONDON PRACTICE OF MIDWIFERi",

 of an  officer of high rank, was left disconsolate : a.
 friend  of her husband's, a very kind-hearted man, un-
 dertook to take care of her home ;  and certainly took
 every  care in the world of her : bu( she was brought to
 bed rather later than (he nine months; and (his from
 (he pure effec(s  of her grief.   The reverse of such a
 case happens where (he patient is  in labour with  her
 first child, and (he fear of (he labour  has brought it
 on too soon : and in some of these premature labours.
 it is remarkable what powers the constitution evinces ;
 for we sometimes  see as fine a child at seven  and
 even at six  months, as if it  bad been  growing  the
 whole  nine ; and though it is impossible that (he  lady
 could have been with child till after marriage, yet the
foetus certainly grows uncommonly quick in some of
 these cases.!
   The usual time  of uicro-ge&talion, when these little
 accidents do not occur, is forty weeks, or nine calendar
 mouths.

            Sect. in.  Causes of Labour.

   Supposing, (hen, lha( pregnancy goes on (ill (he end
 of (he  ninth month, and tha( labour  takes place ;  why
 (his should happen  (here  seems (o be  some  doubt
 There have been many opinions advanced upon  this
 It has  been supposed (o  depend on  (he child ;  on (he
 mother and child too ; or on (he mother alone.   The
 opinion of i(s dependancc on (he child was laken up
 from (he. supposed  analogy  between  oviparous  and
 viviparous  animals.  We know that  if the eggs  of a
 hen are placed under a duck, they will hatch at exactly
 the same period thai they  would have  done had  Ihev
 been under  the. hen; and no( on (he day at which
 the eggs of a duck  become  ducklings.  So (hat  tin
 time does not depend upon the warmth given, but the
 nature of  (he bird contained within the shell: from 
CAUSES OF LABOUR.             ]]5
Ibis, (hen, by analogy, has (he period of labour been
supposed to depend  on  the foetus.   It has  been be-
lieved,  that (he foetus finds sustenance in the womb
for nine months, and then comes into the world to
get  something  more palatable (o eat.  It has been
supposed that nature has enabled the foetus  to exist
for nine months in (he heat of the body,  which is
about ninety-six; but that at  (he expiration of (ha(
lime it gets (oo  hot.  It has been  supposed that at the
end of nine months the meconium becomes acrid, and
the child comes into (he world  (o have  a stool.  It
has been said that the child  rushes itself into life, be
cause it wishes  to  breathe, finding itself  weary of a
fish's life  sustained for  nine  months.  The beauty of
an  hypothesis  is to drive straight forward, turning
neither to (he one hand nor (o (he o(her, never stop-
ping to  compare facts.  But we know that dead chil-
dren are brought into (he world  by (he  same means
and  in (he same manner as living.  If we suppose (he
navel-string to have become twisted or pressed, or an}
cause to  have  been applied,  by which the  child if
killed inutero ;  can we believe it likely that (hat child;
being dead, will find itself hungry and come to eat 1
Will a dead child fancy  itself too hot, and  come kick-
ing into the world to cool ?   Will any dead child feel
itself seized with a  looseness, and come scrambling
into  the world to have a stool ?  Or, will a dead chiki
find  it  wants to breathe, and so  come  into the  world
in hopes of recovering its life ?  Or is it probable that
a  dead child should show  a degree of impatience at
being in an uneasy posture ?  And another query may-
be urged, how is a child dead or alive, while yet in the
womb,  to know that it 6hall be born in the pantry or
larder?
   Otiiers very wisely do not attribute (he birth of the
child (o either  (he parent or the child alone, but to
Hoth (ogether;  those are (he trimming physiologists. 
116    THE  LONDON  PRACTICE OF MIDWIFERY.

who are ready to take up either side of the question,
or both, as occasion may require.   It has been said to
be  from  the  menstrual  fluid  being  retained  nine
months.   It has been said to arise  from  the uterus
being so stretched, that at last it is stimulated to throw
off its contents.  The truth  is,  the uterus never  is
stretched.  Some have asserted,  that  there are  two
layers of muscular fibres  on  the uterus;  that a circu-
lar set govern and contract for nine months ;  and at
that  time  the  longitudinal  set  rise up in  judgment
against them, and, contracting with all their might, at
last overcome  them.  There is another  pretty fancy,
a continual intestine  war, which, for our  comfort, we
know does  not exist,  for  this reason ; if there  were
continual  contraction, there  must be  continual pain.
which is not the case.  Haller says, that the muscular
fibres of the iderus  have nothing at all to do with de-
livery ; he says, (he longitudinal fibres defend the child
against the circular ones.   Labour he thinks is formed
by all the symptoms of pregnancy  being increased,
and that the woman  throws herself into labour. Now.
how can this be, when  the  labour-pains commence
while the  woman is asleep  ?  What is  it then ?  It is
said to be the weight and  bulk of the child.   Why
(hen are small weakly children delivered as quickly as
large strong bulky children ?  Surely no better reason
for it can be given,  than that it  is a  law  of nature ;
and the laws  of nature we  know  nothing  about.
This  we know, that it is expelled as soon as the ninth
month is finished, whether dead or alive no matter ;
and never was there a woman who went longer than
nine months, at which time the  uterus begins to con-
tract upon its  contents, or is thrown  into  the action
that constitutes labour.   The universality of this law
in nature is so  great, that in the  instances of extra-
uterine foetus  with  which  we  are  furnished, tin-
labour-pains  come  on at  this  period, and  last fo< 
CAUSES OF LABOUR.
117
days  too; and gradually subsiding, the woman sup-
poses she  must have been  mistaken,  till an abscess
forms in her  side, through which bones, &cc. are dis-
charged.
  A foetus may be expelled from the uterus before the
third  month, but never is retained beyond the ninth,
May it not receive a stimidus at the  time of concep-
tion, which at the  end of the ninth month produces
labour?  else why contract when there is no contained
foetus ; when the foetus is lodged in  some parts of the
abdomen ? 
118
CHAP. VI.
ON LABOUR.
            Sect. i.  Division of Labours.

Labour is  intended to expel the child and its mem-
branes, and, being  various, has  been distinguished
into different kinds.  It may properly be divided into
four kinds :  natural, difficult, preternatural, and com-
plex.   The  first two kinds include all  labours  where
the head  presents;  preternatural, includes all other
presentations ; and the complex, all accidental and in-
tervening; circumstances.  They may be thus defined :
a natural labour is over within twenty-four hours, and
Is  unattended with  difficulty or  danger; a  difficult
labour is  not over in twenty-four hours,  and is at-
tended with some difficulty and danger.  Of this divi-
sion three  degrees  of difficulty may  be  made:  one,
where the labour goes on beyond twenty-four hours,
yet it is accomplished by nature; another, is not a com-
plex labour, and yet is compatible with the life both of
mother and  child.   The last division of difficult la-
bours includes those which are not  compatible with
(he life of mother  and child.   The  next division ot
labours, preternatural, comprehends  all presentations
without the head, or the head with an upper or lower
extremity.  The last division of labours  includes  all
which  are  complicated; including five  species  not
naturally connected with each other—presentations of
the navel-string,  twin  cases, flooding,  convulsions.
and, lastly, rupture of the iderus. 
SIGNS OF LABOUR.
119
           Sect.  ii. Signs of Labour.

  Now this process of labour it is natural to  divide
with regard to the constitution of women.  Some cir-
cumstances depend on the  erect pos(ure of (he wo-
men, while others happen to  them in common with
other animals.  One  of the changes preceding labour,
which is peculiar  to  women, arising from the erect
posture, is the subsidence  of the abdominal tumour
between  the  last  three  weeks and  fortnight  before
delivery.  The cervix uteri gives way just before la-
bour ;  and the head of  the  child within the mem
branes comes into contact with the os lincce.  The
vagina dilates so as to allow the uterus  to fall into it
in part.
  There  are  other circumstances which  arise from
this descent of the uterus ; an inclination to go to stool
and to avoid the  urine ;  both which arise from  the
pressure of (be lower segment  of  the  uterus.  In
quadrupeds we see a protrusion of the external parts
in labour, which is attended with a sort  of fiuor albus.
which  discharge is also found  in women.   They  de-
scribe  it, that they feel as if every thing was dropping
through them, which depeuds on the  supports  of the
uterus  giving  way.  The  mucous  coagulum, that
closed the os tincoz, also comes away in a solid form..
involved in the mucus of (he  vagina,  which is less
consistent.  There is a relaxed state  of the  bones  Of
the pelvis (which may be frequently observed in large
animals); they walk with a kind of vacillatory  mo-
tion, and  do not step so firmly as at other times; have
a sense of uneasiness in (he  ligaments  of the pelvis ..-
and will lay hold of any (hing for a support in walking,
when they are not aware of it.
   Another circumstance which demands notice at (hi- 
 J20    T1*E LONDON PRACTICE OF MIDWIFERY.

 time is, the preparation  made  by animals for theii
 young, which is (he effect of instinct.  The bird can-
 not know (hat it has eggs in the oviducts ; it  cannot
 know what sort  of eggs it will lay, or what number;
 and  yet the nest  is formed, and  that in a manner
 beautiful beyond  our imitation.  We see something
 which points at  the same invisible hand in women.
 Suppose they have the  baby-linen  all ready in their
 box, and even locked up with an inventory, they still
 will be looking i( over again to see  (hat it is all right.
 which they must and will do, and will not suffer any
 other person to do it  for  them.  The  same thing
 holds with  regard to the  nurse ; the  patient likes  to
 see her, and have a little conversation with her, be-
 fore the time of wanting her, that she  may be certain
 that she will suit her ; and for exactly  the  same
 reason, the accoucheur sometimes experiences an act
 of civility not known at any other time.  The lady
 will send and beg (o know  how he does, hoping that
 he has got  quite rid of his cold,  and will be very glad
 to see him if he comes (hat way.
  When a woman approaches very close to thai hour
 when labour commences, she will be  subject lo re-
 peated  inclinations to  make water  and go to  stool.
 and occasionally feels a touch of (he pains of labour
and bearing down.

       Sect.  hi.  Examination  per Vaginam.

  The examination per vaginam may appear a trifling
 operation, and not  (o  require any explanation ; but
 (hough  it seems simple, it demands great  address  to
 be done as it should be.   An examination per vaginam
 h the way in which medical men express it to each
other, but it must never be mentioned in (his way  to
 a woman ;  to her it must  always be called trying  or
 faking a pain : this is at once suggesting (he occasion 
             EXAMINATION PER VAGINAM.        1 2 I

of the examination and the relief it will procure iu
taking (he pain away.
   A medical practitioner should always be extremely
careful neither to say nor to do any  thing which may
hurt his patient's feelings ; and if this is necessary with
regard to the general practitioner, it is more especially
so to him who  practises midwifery.   The conduct of
an  accoucheur upon  such  an occasion as this will
generally either establish  or lower  him in  the good
opinion of his patient.  She cannot sit down and exa-
mine him as to his skill in physic,  and if  she  could
he would not submit to it; but upon this subject  she
and her friends can judge, and upon  (his  (heir opi-
nion  of his character will  be  formed.  In (he first
place he should recoiled, that in whatever regards (he
practice  of midwifery, every thing must be done as
decently as the nature of circumstances admits.  The
sitting down and passing the finger  up the vagina is
not the most delicate operation ; but it is more or less
decent, according to the manner in  which it is done
If a woman be laid down on a bed in her clothes, and
then the  examination  commenced, the  act is an inde-
cent one; and that because it is done in an indcceni
manner.  It is necessary always to recoiled, (hat the
counterpane should be laid over her, and if the nurse
is in (he room, she  should be desired to place it pro-
perly.  Many women would rather have  their hus-
band in the room ; and this has nothing the least im-
proper in it, for  some men have an idea, that in labour
their wives are entirely exposed.  Now the  husband
sees immediately that it is quite otherwise, and he win
always remember  the  practitioner's tenderness and
care on this  point; many disagreeable impressions
which might otherwise have  perhaps been  made on
him, on account of a man's  having attended, will be
removed.   There is no occasion to expose the patient
for a moment.  If it be even necessary to  apply  the
                        M 
 /22     THE LONDON PRACTICE OF MIDWIFERY.

 forceps, it may still be managed decently ; some of
 the women should be sent out of the room ; and if it
 is necessary  to have the assistance of the nurse to hold
 up the  bed-clothes, she should  be desired  to be care-
 ful  not to expose her  mistress, and it  will be very
 seldom necessary for her to be  exposed.
   A professional man never should seem to know any
 thing about the parts of generation,  further than that
 (here is  an  orifice near (he rectum, leading (o an os
 tincae.  He must ever avoid exposing (he par(s ; he
 will do every Ihing  better under  the clothes; and if
 there be  occasion to examine the fluid coming away,
 to know if it is meconium,  or any thing else, it may
 be done with the greatest  propriety : but there is no
 reason why  such clothes should be held  up to (he ob-
 servation of  (hose around ; it can be seen as well by
 allowing it to remain below near the parts themselves.
 Before examining per vaginam, the practitioner should
 ask  for a cloth or two, and leave one,  after  he has
 finished,  lying decently over the parts  ; and in the
 next place, be should look to proper delicacy in exa-
 mining the parts themselves, so as not to be rough or
 rude, but tender.  Perhaps the parts  have been exco-
 riated  by a discharge  of many  days  continuance;
 but if not, he must  still anoint the  hand with hog's
 lard, which is preferable to oil,  as it does  not  grow
 rancid ; and  to pomatum, as it is not loaded with for-
 eign matters  and scents.
  The  way  then,  ia,   to  introduce the fore-finger
slowly,  having previously  been very careful to  pare
the nail close, and pressing with some degree of firm-
ness on  one side of the  vagina, which will give much
Jess  pain than if it  is done more  timidly,  as  in the
latter case (here will be more tickling and  irritation
(ban in (he former ;  we must endeavour to find the os
rxternum directly, and (his is essential if we would do
the operation dexterously,  and not have a good many 
EXAMINATION
PER VAGINAM.
123
hits before we find it.   The mode is,  to introduce the
hand under the bed-clothes between the  thighs,  past-
ing it up to the nates; then inclining  it forwards, the
os externum will be easily found.  Though this may ap-
pear tedious and not the readiest way, it is the  best,
and appears to the patient to be one  continued opera-
tion, and she does not know  but that it may all be
necessary.  The best way is always to examine close
to the edge of Ihe bed, wi(h (he woman  oh her  side,
except  in prolapsus or  procidentia  uleri,  when she
must be set on her knees, that  we may ascertain the
state of the  parts more correctly.  In examining, all
other positions have nothing to  recommend them but
their indecency.   In  some countries, as Holland and
Germany, it is usual  to deliver in a chair, out of the
middle of which a piece is cut to give  room to the
parts which are in action.  The back is contrived to
vary the elevation, as may be convenient.
   The finger then being once passed up,  we should
never desist (ill we are satisfied of whaf we wished to
know.   It  is  not  consistent  with propriety  to  say,
" Why really I could  not feel the os lincce;" or, " I
declare I am not satisfied what  part  it is which pre-
sents."   We had  beUer  have saved (he woman the
pain, and ourselves the  trouble.  Whatever we  sit
down to do, that  we  should accomplish,  and  suffer
nothing to preven( our finishing what we have begun :
this should be an invariable rule of conduct.
   The objects of an examination per vaginam are va-
rious.   One is, the ascertaining whether a woman 1*5
pregnant which is not to be  known  by an examina-
tion till the  third  month  is  complete. It is said (hat
before  (hat period we find the os lincce shorter; this
is true ; but shorter is a relative term;  and it does
not  often  happen that  a  practitioner  is  so apt  at
gauging  as  an exciseman,  which he should  be,  in
order to say  whether the os tincai is rather shorter 01 
 J24    THE LONDON PRACTICE OP MIDWIFERY.

 longer (ban it used (o be.  It acquires a  granulated
 feel, resembling the third day of the small-pox ; but
 this does not happen with all women, therefore cannot
 be trusted to.
   A( the end of the third month we may plainly feel
 the  tumour formed by  (he uterus  as large as a full-
 sized orange.   Bui even (hen, unless otiier symploms
 of pregnrncy  are  present, this will  not  enable  U3 to
 say more  than (his, (hat there is a tumour, which may
 be owing  to polypus, hydatids, or any  other  diseased
 enlargement of the womb, as  well as pregnancy. At
 die end of the fourth month the   tumour  fills the
 pelvis, and the os uteri  is (urned  rathar  backward.
 About Ihe beginning or middle of the fifth month, the
 woman becomes sensible of a change; she feels the
 motion of the child; and this is usually called  the time
 of quickening: and  the  only  reason why  it  was not
 felt before is, the uterus having only lately risen  from
 the cavify of  the pelvis.  But  why was it  not felt
 while  remaining  \n the pelvis?  The reason  is  this;
 the uterus in itself has little  sensibility; and tbe vi-
 brations of the child's motions  can be conveyed no
 further than (he uterus, as i( is surrounded by  bone.
 But as soon as the womb rises into the abdomen, it is
 surrounded by soft and sensible  parts; and  then the
 motions of the foetus are  fell.  A( (he (ime (he uterus
 ascends into (he abdomen, if (he woman  be standing,
 i(  is very  probable (hat  she will faint;  but  (his will
 not happen if her  posture  is  reclined.  Fain(ness
 arises from (he pressure of (he uterus being (aken off
 from the inferior parts of the  aorta ; the  blood imme-
 diately rushes down, and a partial deficiency is felt in
 (be sys(em;  and (ha(  is (he  reason (he uterus has
 iwo sets of vessels, (he hypogastric and spermatic:
 when (he   circulation is  interrupted in one  set, the
other carries it on.   When the fainting  comes on, the
 capillary vessels all contract, and  the blood being con 
             EXAMINATION PER VAGINAM.        125

sequenlly driven back into the large vessels, die pa-
tient  is as well as ever in a few  minutes.  At (he
sixth  month the uterus reaches the  navel ; at the
seventh, above  the navel and  below the scrobkulus
cordis ; and at the eighth, reaches the scrobiculus cor-
dis,   beyond  which  it  cannot  extend ; there  it re-
mains till it subsides a week  or a fortnight before
delivery.
  A woman is also examined to know whether she  is
in labour, and  what part presents.  It is right to in-
troduce the  finger while (he pain is on, but not at-
tempt to ascertain by the touch till (he pain  is gone ;
otiierwise (he  membranes, which during the pain are
stretched and tense,  may be burst;  and when once  in
the practice of  examining, the fiuger grows very cor-
rect.   Examination may also be made to discover the
dimensions of the pelvis, and to ascertain any existing
disease in the soft parts.

             Sect. iv.  Natural Labour.

  When labour comes  on after a pregnancy of nine
months, the head presenting, and over in twenty-four
hours, unattended  with  difficulty or danger, it  may
be defined a natural  case : though  an arm may  pre-
sent  with (he  head, (hat will not materially alter tbe
state  of  things.   Natural labour is (ha( which is qui(e
unassisted by art, and uncontrolled  by  the woman ;
every thing takes place  in regular succession, and the
foetus is expelled by  the contraction of the uterus and
abdominal muscles.  It  will be like the ancient statues,
in which all the  perfections were united.   The woman
should not be quite young  ; if quite young,  the pelvis
will not have attained  its full dimensions,  and  the
powers not reached their acme.  If very old, the  parts
will be indurated, and  the  labour cannot be easyv
There must be no distortion  of  parts,  but  the pelvis
                         u 2 
120    THE LONDON PRACTICE OF MIDWIFERT.

must be well formed.   The placenta must come away
naturally.
  There are four stages in natural labour ; at least, in
treating of it, we find if is best to  adop(  these  divi-
sions, though nature knows them not   The firs( stage
is (ha(, when (he bead  of (he child enters the pelvis,
passing down as far as it can move without  changing
its position.  The second includes the  period  of the
child's head passing through (he os uteri in(o the vagina.
The Ihird, (he  change which has  (aken place  in the
vagina and os externum.  The fourth, the delivery of
(he body of the child, and the expulsion  of the pla-
centa.  In one of the two first stages (he  os uteri di-
lates, and in one of the (hree first the membranes are
»upt tired.

           Sect. v.  First Stage of Labour.

  The first stage of labour is formed when the child's
head has passed down into the cavity  of  the pelvis ;
where it lies diagonally, with the occiput (o (he  groin.
and the face (o (he posterior joint.   The cavity of (he
pelvis is covered with the peritoneum,  and,  from its
shape  and  state in  the living subject, warrants the
Greek  appellation  signifying a basin.   It  supports
weigh!, and its position being that which is  most
proper, is illustrated by setting the  pelvis upright on
the sawed  extremities  of  the  thigh-bones,  and  it
stands.  AH (he  deficiencies of  (he  pelvis are for
wise  purposes.  The  anterior superior space in (he
pelvis, above (he pubes, is for (he purpose  of allowing
the conlents of the uterus room for ease.  The great
breadth of the female pelvis is a perfection ;  in men a
deformity.
   The capacity of the pelvis is only (hat space which
is below (he sacrum, being divided  into two portions,
an upper and lower cavily.   The brim of (he pelvit 
NATURAL LABOUR.
127
is marked by a  line,  from which the depth varies in
different parts.   It  is five inches behind down (o the
coccyx ; three  at the side down to the lower edge of
the ischium;  one and a half, or two, deep  at the
symphysis pubis.  Each aperture of the pelvis has two
diameters, a long and  a short  one.  At the upper
aperture the long diameter is from side to  side, and
the short from pubes to sacrum.  The lower aperture
may be  considered as oviform, when the long diameter
will be from sacrum to pubes; the short, from ischium
to ischium.  We see,  (herefore, (hat (he  diame(ers
are reversed so, (hat  the long diameter above is the
short below, and the short above is the long below.
  The  axis of the  pelvis is next  to  be considered.
The pelvis is a cavity  of a  complex shape.  It is'
most essential  in  midwifery  to recollect, that the
axis of  the  upper and that  of the lower cavities of
the pelvis are  not the same.   The axis of  the upper
may be found by a line drawn from  the os coccygis to
the navel.
  Human  parturition from  the  mechanism of parts
concerned, must be  difficult;  and that  of. animals,
from its nature  also, is and must be  easy.   We know-
there is, throughout the whole  of this globe,  a law
of matter,  by which every thing tends to move down
ward, or fall: now this does not act  upon the con-
tents of the pelvis in a quadruped,  because it is not
situated in  the same manner as the human pelvis.
The parietes of the animal abdomen  sustain the weight
of the viscera.   That being the case, (he pelvis is in
them large and easy,  because it would be  no advan-
tage to  the life  of the animal to be  otherwise.  But
in the human species it is different.  It is very plain,
that, were  parturition easy,  it would be the greatest
misfortune (hat  could happen to the  female.  Make
tbe  cavity of the pelvis  large and easy,  and reduce
the two axes to one and the  same, and make the soft 
 128    THE  LONDON PRACTICE OF MIDWIFERY.

 parts more  yielding, and what would  be the effect ?
 Prolapsus and  rupture, which, now, are too frequent,
 would then be universal.  For that reason the pelvis
 is  not in  a line with  the  back-bone; and, in order
 that a body pass, into the cavity of the pelvis, and pass
 through it in  its way out, it is necessary that the di-
 rection  of it  should be changed several  times.  It
 must, while passing through  the  vagina, take a dif-
 ferent direction to  that which brought it into  the ca-
 vity of the pelvis.
   The head of a child is a  body of an oval figure,
 having a long and short diameter ; being longest from
 the fore to the  hind head,  shortest from side to side.
 It is easy to perceive also, that the proportionate  size
 of tbe child's head  is greater  than (hat of any other
 animal; the final cause for which is,  that the  human
 subject has a greater portion of brain than any other
 animal.   But on  this  account  labour is by so much
 more  difficult,  and  delivery  perhaps  would not  take
 place  at all, were the bones  of the head completely
 ossified.  Nature  begins several points of ossification
 in the cranium of the foetus,  that  the process, being
 in  itself slow, may be  as soon finished as possible.
 The sutures are formed by the union of one bone with
 the next to it.   The  principal  sutures of  the head  are,
 the  lambdoidal, surrounding the occipital bone; the
 sagittal, between the two parietal;  the coronal, passing
 from one temporal  bone  across to the  other.   The
 frontal suture  is another, the traces of which are lost
 in a perfect cranium, being a continuation of  the sw-
 gittal, down to  the  nose.   The  anteriorfbnlanelle  is
 the unossified  space between the  coronal, sagittal, and
frontal sutures ; the  posterior€/on&me//e  is  that space
 between  the lambdoidal and sagittal sutures.   The
 anterior  is formed between four angles;  the posterior
 between three.  It is necessary  to attend to all these
 circumstances,  inasmuch as it generally happens  that 
NATURAL LABOUR.
129
 we must operate in (he dark.   The  head of the child
 enters the pelvis with its long diameter to  that of the
pelvis, and  its short  diameter to that of  the  pelvis
also ; in other words, it enters it transversely, though
not  speaking critically, for (he occiput is to the groin,
and  the  head  (o (he pos(erior joint.   The dilatation
of (he os  uteri now and  then happens as the head
enters (he pelvis;  but in many it  dilates while the
head is  making  its  turn, where the pelvis  is large
enough to  admit the  head  clothed with the  cervix
ideri.

          Sect. vi.  Second Stage of Labour.

  The os uleri is  dilated by two  different  powers,
the  contraction  of  the  longitudinal  fibres of  the
uterus,  and the protrusion of  the membranes contain-
ing the wafers.  The  longitudinal  fibres  arise from
one side of  the os uteri, and taking  the sweep of the
uterus,  arrive  at the os uteri again on the opposite
side: as this is the case, when  all  the  longitudinal
fibres contract at once, the os uleri must be  drawn
back.  In this way does the  dilatation begin, as the
effect of the membranes cannot be of any avail till the
os uteri is of sufficient size to  allow  them to pass into
it, forming  a cone, which  cone  increases  in size at
every  pain.   Where  the membranes are broken  too
early, we see that the longitudinal fibres  alone  are
capable of dilating the os lincce completely.  At every
pain, then,  the tumour formed  within the os uteri
by (he membranes increases, till at last the head, by
following these membranes, is received into the cervix
uteri ; and (hen there is no more benefit as to dilata-
tion  derived from the membranes.   The dilatation of
Hie os uleri is not circular;  the child's head is  not
circular; it  is  elliptical, its long diameter  being  ap-
plied to that of the pelvis.   The dilatation is the most 
130    THE LONDON PRACTICE OF MIDWIFERY.

painful and difficult stage of labour.  The reason is,
the resistance is very great compared to the strength
and power of (he contracting fibres.  The os uleri is
drawn forcibly  open; and  (he nature of its  state  is
best conceived  by  supposing  that,  to  the different
parts of the mouth, fish-hooks  and lines were fasten-
ed, by which it could be stretched violenlly  open in
every direction at  once.   As the os uteri becomes di-
lated, (he  presenting part  may  be felt, (he head may
be distinguished wi(h (he an(erior, or posterior fonta-
nelle ; the presenting part must not be examined  while
the pain is on,  for it will then risk the breaking of
the membranes,  and the discharge of  the waters.
The os uteri being dilated, the second stage of labour
in all its parts is over.

          Sect. vii.   Third Stage of Labour.

  The head being  in  the  os  uteri, the membranes
must not be broken, a3 they still  are assisting in the
dilatation of (he vagina and  os  externum;  besides
which (he  waters  being retained,  prevents pressure
on the navel-string or any of the limbs, which would
be to the  prejudice  of the  child's  circulation and
welfare.
  The dilatation of the vagina is entirely accomplished
by force ;  there are no muscular fibres in this  part to
assist its distention ;  therefore it is the effect of  force
alone, the   membranes  passing down preceding the
head  of (he child, (hough  the head alone does this
where the waters are lost.   While all this  is  passing,
the rectum  and  bladder are pressed upon, and their
contents  in general are  evacuated; the  perinoeum.,
which before labour  was  the thickness  of the  handj
now is not so thick as the skin of the finger, and at
the time that tbe  child's head is born is  not half (hat
thickness; it is so thin  that the finger of an  incxpe- 
Natural labour.            l*}i
 ricnced  person  shall not  detect the  line where  it
 bounds the head of the child ;  it is  so  very closely
 braced.   But although this, and  no more, happens  in
 a perfectly natural labour ; very few  of  such labours
 occur.   Women do not bear children (ill  long after
 (he time nature  intended;  the consequence of which
 is, that the parts become rigid,  and  it is not uncom-
 mon  for  the perinceum to  give  way : (his most fre-
 quently occurs in the inner elastic  membrane, and
 rtot in the skin covering i(.   After labour such breach
 of continuity very frequently unites, by  the  contrac-
 tion  of  the parts bringing  the torn edges in(o contact.
 In (his way we may account for a sort of ridge that
 is often found jn the posterior part of the  vagina.

         Sect. vm.  Fourth Stage of Labour.

  To go on with the labour: the successive pains pas3
 Hie head lower and lower in the  vagina,  until it is  at
 last  pushed into the world, or  born.   The  woman
 rests  till  another pain comes on,  during  which Ihe
 shoulders are  expelled.  Succeeding  pains complete
 (he expulsion of (he  child.  A strong pulsation still
 exists (hrough (he  navel-siring ; (he  child breathes,
 cries, and moves ; the pulsation  gradually subsides in
 the cord, ceasing  first  at  the placenta.   In   about a
 quarter  of an hour, or from that to an hour, the pains
 return, though in a lighter degree, by  which  the pla-
 centa  is separated and expelled from the uterus.  It is
 forced down into the vagina, the contracted  state of
 which will sometimes detain it there  for some hours,
 till the discharge behind it from  the uterus increases,
 and by its volume it provokes (he  contraction  of  it
 again, and is expelled itself.  This is  the regular pro-
 cess of labour unassisted by art.   Proceeding (bus, the
 head, by the  contractions  of the uterus, is forced
down  and passed through the os externum. The ute- 
 132    THE LONDON PRACTICE OP MIDWIFERY.

 rus, after an interval of res(, again contacts, by which
 effort  (he  shoulders  are expelled.  The breech and
 lower extremities presently follow.  During the pro-
 gress of expulsion the  uterus contracts around the
 remaining  parts of the child, and  at  the time the
placenta only remains, the uterus  is  only sufficiently
large to contain it.   The next effort  of the  uterus,
therefore, by contracting its internal surface, not only
assists  in pressing  out the placenta, but becomes the
cause  of  the  separation ; while the  same  power,
which  separates the placenta and throws it off, pre-
vents  the  occurrence  of  any  serious  hemorrhage.
This is a most beautiful illustration of the mercy  and
power, as well as wisdom, of the Almighty.

    Sect.  ix.  Symptoms which accompany Labour.

  We  say (he child is  expelled  by a pain ; and  (his
feads us to consider what are the  signs of labour,  and
what are the local changes and violence  done to the
parts themselves.  Before labour is established, (here
is an anxiety, not about the event of the labour, but
an uneasy oppression about the prcecordia, a particular
sensation often  occurring before  pain  becomes pro-
perly established, or even felt.  This is succeeded by
a slight shivering, and some sensation of pain in (he
back and loins ; which going off will relurn in  half or
a quarter of an hour.   From (he  violent distention of
the os  uleri, vomiting  will sometimes  arise, unat-
tended with nausea, as  the sickness depends on  its
.sympathy with the uterus, so  that the woman would
cat with  avidity,  but for  the consciousness that it
would return directly.   In the progress of labour the
pulse generally rises in strength and frequency.
  Another occurrence may prove the presence of la-
bour, which is, the desire to pass the urine and faeces :
this arises from the pressure of the child's head in it? 
          SYMPTOMS ACCOMPANYING LABOUR.      13J

descent into the pelvis.  It is a favourable sign  at  (he
beginning of a labour, as the  bladder  being emptied
is convenient, while the  rectum  being  cleared  also
answers a good end ; it gives the uterus more space (o
act in.
   From the vicinity of the sciatic nerve, cramp  and
paralysis will  happen  occasionally, depending  on  the
pressure of the child.
   Another symptom of labour is, a discharge from
the vagina ; it is mucous, and generally a little tinged
with  blood : this is what  the women call a  show ;
and as this is sometimes, though very  rarely,  consti-
tuted by a considerable discharge of blood, we  should
not be alarmed, if such an occurrence should take
place.
              Sect. x. Labour Pains.

   The symptoms severally described attend labour,
but none  of  them constitute labour till there is pain.
It is not a sensation of pain that delivers the woman,
but it is from the contraction  of the muscular fibres ;
to which contraction there is great  resistance,  which
resistance cau-es pain ; and the quantity  of pain is
always found  to  be in proportion to the resistance
from  the pelvis,  &c.  The  pains  frequently  shoot
forward from  the back to the belly, and  down  the
thighs ; the pain in  the back is most distressing  whilst
(he os uleri h dilating, and often entirely leaves it
when the dilatation is  completed.  The  periodical
return of the pain arises from its dependance on mus-
cular  action, which cannot be permanent,  although
it might be so if it proceeded from nervous irritation ;
between the pains there are the most complete  inter-
missions, during which the patient is perfectly well.
   Labour pains are generally slow  in their  return at
first, but occur more frequently as  the state becomes
established.  Ih every labour there are (according to 
134    THE LONDON PRACTICE OF  MIDWIFERY,

some authors) two sorts of  pains, profitable and un-
profitable pains.   Now, (here is no such thing as un-
profitable pain.   They may properly be distinguished
either as grinding or expulsalory pains  : (he grinding
pains a((end the dilatation of the os uteri, and towards
the latter end gradually  change into  expulsatory ef-
forts ; and though at first these efforts towards expul-
sion will occur at the latter end Of each pain, yet in
lime the pain commences with (he expulsalory  exer-
tion  of the patient.  Those who are accustomed to
lying-in apartments, very easily know the state of the
labour by the complaints and moans of the patients.
While the grinding pain is  on, the patient will cry
out as  loud as she can scream ;  if it is milder and
more gentle, she will complain anil moan only: but
(he pain is intolerable when (he contraction is stronger,
and the os uteri is distended with greater force ; and
if we examine,  she will  think, and  firmly  believe,
that we are cutting  her.  When, on  the contrary,
the os uteri is perfectly dilated, she will at  the  begin-
ning of the-pain take  in a full inspiration, and bear
down with ail her force.  If the patient  cry aloud,
nothing can be done ;  the best way is to tell her, that,
by her crying out, the strength is  exhausted,  and the
progress towards  her delivery made more tedious, by
which she will very likely make less noise, which is a
considerable point gained.
   It now and  then happens, that (he forcing  pains
shall all at once go  back  to grinding  pains  ; thin
only happens from the premature rupturing  of the
membranes ; after which the os uteri has to be dilated
by (he head itself.

              Sect. xi.  False Pains.

   Now, the symptoms above described,  when occur-
ring with pain, constitute  labour, without  any doubt 
FALSE PAINS.
13b
ot their nature; but towards the latter end of preg-
nancy women frequently have pains which they think
the commencement of labour, and  by which them-
selves and the practitioner are often  deceived; these
are the false or spurious pains of labour: they arise
from  various  causes ;  one reason is this,  (he uterus
descending at the  laUer end of pregnancy, the lower
segment  gets  into  the  upper aperture of the pelvis,
presses upon  the  rectum and  bladder, exciting (hat
uneasy sensation of tenesmus which affects all women
in this situation.  The tenesmus begets bearing down.
so that the  patient thinks she is in labour,  and the
practitioner is sent for.   The more common case is a
disordered state of the  intestines  exciting tenesmus ;
sometimes it  will  arise  from irritation on  the  mind,
and then probably  the contractions of the uterus are
concerned.
   One means by which  we may  always arrive at
truth  so  as to ascertain  the false or true nature of the
pain,  is to examine, when the os ideri will be found
quite  unaltered if it is  a false pain,  while  it will  be
enlarged  and elongated if the pain is a real pain of
labour.   The os uteri is always  tense during a labour
pain, if it be ever  so slight; if, however, it  is  unal
lered and unenlarged, it is a false  pain,  in which the
uterus and its contents  are acted upon  by some cause
pressing them down, as being a  part  of the  abdominal
viscera.  All that is now to  be  considered  is, wha( is
(he cause, and how is (hat cause to  be removed.   II
excessive exercise,  too long riding in a coach, or other
such cause,  has occasioned  it, it  is  proper  to direct
rest and a recumbent posture;  but if the patient is a
poor  woman, with  a large family to  take care of, (his
could not  be done; it would  be of no use  to say,
" You must lie down and not stir from  your sofad:
fhe cannot do it; instead of which  she should take a 
 13b'     THE LONDON PRACTICE OF MIDWIFERY.

 mix(ure, containing  thirty drops of laudanum,  every
 nighf.  Where there is fever, this state will admit of
 taking a few ounces of blood.
   The  false  pains  are often very trying  to the tem-
 per :  but, when a  practitioner is  sent for  without  oc-
 casion,  he should particularly  avoid showing  that he
 is  out of humour; it  can do no good,  and it is often
 productive of harm.  A gentleman being  sent for on
 one  of these fruitless  errands,  began  abusing   the
 nurse most unmercifully; the consequence was, that
 the lady sent to another gentleman when really  in la-
 bour.  The great object is to remove the cause ; to do
 which we should  empty the bowels,  and afterwards
 idve an opiate draught.

        Si:ct. xn.   Treatment of natural Labour.

   With regard to the last month of natural labours, it
 has been said that women require no medical  treat-
 ment, nalure  does all (ha( is necessary, and i(  is not
 likely (ha( a woman should not be able to go through
a natural transition,  which  only arises  from her ful-
filling the command  of increase  and multiply; most
medical  men  also, who do  not  practise  midwifery,
 fall into this  opinion.  It is true (hat  women  might
 be equal to whatever is necessary  to be done, if they
were  property educated; but they are  not;. and it  is
impossible to  beat into their heads what is  necessary
to  do, which  is, lo  do very  little :  they  are  ready
enough to do ; the mischief is, they do too much, and
it  cannot be  prevented.  The great art is to keep a
labour a natural labour.  A good practitioner meets
with very few difficulties ; a bad one frequently creates
as  many as he could  wish.   By  far the greater num-
ber of difficulties occurring  in general  practice,  are
manufactured, arising from  officious  interference
thus it is that  we learn, those who are in a state of 
            POSITION OF THE WOMAN, k,C.        137

nature,  and perfectly uninterfered  with  by  art, get
better through labour, than those who are assisted by
people who have only the infancy of science for their
guide ; and we are taught this by the sacred writings,
where, at the time Pharaoh ordered all the male chil-
dren to  he  destroyed, he was told, the  Egyptian chil-
dren could soon be exterminated, because their la
hours were long and tedious,  the  women being the
most important in the nation, having the lords of the
land for their husbands; but the midwives at the same
time represented the difficulty of destroying  the He-
brew offspring, for the women had all easy, safe,  and
short labours, and why ?  only because  they were left
entirely to  nature, and had no assistance; so that from
this we  find, that, in natural  labour, our object should
be to put the woman as nearly as possible into a state
of nature.

       Sect. xiii.  Things to be attended to by the
             Practitioner during Labour.

  There are  many  little things to be  attended to.
which,  though seemingly frivolous, are  yet  of  great
importance, and, in general, are only  acquired  by
practice.   First, then, is  the manner in which the bed
should  be  made: now this belongs to  the nurse, yet
it  is necessary  that every practitioner  should know
how the bed  should  lie, for it sometimes  happens
that a  medical  man is called  to a labour suddenly.
and the child is borne before any nurse can come ; now,
the bed in  such cases would be spoiled if the practi-
tioner himself did not  know how to lay it; besides,i(
conveys a  favourable idea to the patien( if she  does
no( happen (o know him, and it will often occur that
the nurse herself will not know how to make the bed.
It should be made  so, (hat  (he woman  may lie com-
 orlably bo(h in  labour and after labour,  and that she
                      N  2 
133   THE LONDON  PRACTICE OF MIDWIFERY

may lie in (he  best way with regard to  our conve
njence.   If she is used to a mattress, she may lie  on
o ne, it being  the best sort! of bed; but if she is afraid
of dying if laid upon a mattress, she may be allowed
to lie on a' feather-bed,  first making  it as  nearly as
possible a mattres, by beating the feathers all away to
the other side of the  bed : if she gets upon a hill of
feathers,  down she goes  into  the  hole,  where it is
impossible  to get at her: she must lie as close to  the
right hand  of the  bed as possible,  lying  on her left
side, and with her back  towards the accoucheur,  for
unless she is  close to the bed-side, he  cannot support
the perinceum  properly.   Upon the  feather-bed a
blanket should be laid and  a sheet, and upon that
sheet a common  red sheep-skin,  or instead of it a
piece of  oil-skin  or  oil-cloth;  upon  (his a blanket
doubled to four thicknesses ;  and lastly, a sheet  upon
this four times doubled ; this sheet is to be laid cross-
wise, securing it  to  the bedstead by tapes; and  the
side which hangs over the bed on  the side where  the
practitioner remains, forms a very good apron,  which
he has only to lay upon his knees when examining.
  There  is no occasion to  wear an apron, as  some
practitioners  do;  it looks ill to see a man stalking
about dressed as if he  was an executioner; all  show
and parade is very petty, particularly where it can be
avoided.    Such people will  say, they do it to  keep
(heir  linen and clothes free from  meconium, stools,
&.c.; but this is not a sufficient reason, for  there  are
other ways to prevent being soiled besides these.
   Another circumstance,  which is awkwardly  got
over, is,  the first going into the room.   It is very  dif-
ficult  fop  a  man at first  to find his way,  where it
happens he was not  known to the patient before ; for
(he sight of him will at times, indeed generally, cause
a sort of sensation which frightens away  the pain  for
 a length of time.  In the early part of labour  this i« 
         '  DURATION OF NATURAL LABOUR.       139

of great  consequence; a practitioner's  time may be
consumed,  when it may be the woman only fancies
herself in labour ; how then is this to be discovered 1
There is no other mode than by doing away the first
impression, which, as a stranger, he has made.   With
this view it is very easy to remark on her family, that
Richard is the picture of his papa, and that little miss
Sally has the countenance of her  mamma,  observing
that the girls are the handsomest,  and how  natural it
is to expect that they should be so  ; that it rained yes-
terday, but has a fairer prospect to-day; that the wind
was yesterday in the north, but to-day to  the east;
that the weather is very odd for the time of year, but
there is reason to expect it will soon change for (he
better.   In the midst of this she will get a pain, which
will  bring  the conversation very naturally round to
pain; then we may inquire the number of  pains, the
length,  violence, and interval of them,  &c.  till she
gets a second, which it is right always  to insist upon
as being a very bad one, just for the sake of urging
an examination, the necessity for  which should be ex-
plained on  account  of giving her satisfaction, which is
necessary.   She will say, perhaps, " But I have not
had a show yet."—" Have you not, indeed !" may be
the answer : " If that is true,  it is very  necessary I
should examine  if the child lies  right."  If she says
she has had a show, we can still make it an argument
in favour of  examining.   If the waters are broken,
or  not  broken, if she is strong or weak we may
 easily make some  reason  or other in favour of our
 examining, for we  cannot know  with  accuracy how
 a woman is going on, till we have  examined her, after
 which,  we may  make up our mind as to the probable
 duration of the labour ; but in  the early stages  of
 labour we  should never allow that they are in  labour,
 but say, that we think  they are  going ou very  far
 lewards being in labour, and  this  more  especially 
140    THE LONDON PRACTICE OP MIDWIFERY".

where we know it is a first labour.  If we tell them
they are in labour,  the  woman will then go on fati-
guing  herself and get  no repose,  while, by another
mode  of conduct,  we  obtain for her a  good night's
rest.   We should never allow of their  getting us to
form a prognostic as to the duration of the labour ; we
may generally prevent them, by telling them that we
have ascertained the child lies well, and it will be  an
easy labour, or some such thing; adding, that, as to
the time it may last, we are  not able  to say exactly;
or if we do hazard an opinion, it is never till we have
the child's head in  our  hand, and even  then we are
very cautious, having been often deceived ; we  may
then perhaps say, the  child  may be born in  a pain
and a half, or a pain and  three quarters.   When the
os uteri  is so  far dilated, that,^in the event  of  the
membranes breaking, it  would receive the apex of the
head, the patient  should be put to  bed, but not be-
fore : for, with some women who have had children,
it is astonishing how fast the  os uteri will dilate itself;
it sometimes takes  place  with such prodigious rapi-
dity, that there is  only time to get the woman  on the
bed before the child is born.
  The woman  should  be undressed  before  getting
into bed ; her shift had  better be  tucked up round
her ; and, instead of a shift below, a petticoat will do
much better, as it saves the  linen ; or some women
use a half-shift  or jacet.  When placed  on the  bed
she must lie  as near as possible to the edge, and in the
posture before described ; it is  proper  both  in the
easiest and most difficult labours.
  The lying-in room should be as airy as possible ;
upon this principle it is that  the poor people  in the
country  get about sooner after lying-in, than the same
class of inhabitants of  this metropolis:  in the gene-
rality of cottages it is not necessary to be very anxious
about this, there  are few of them  so  air-tight but 
DURATION OF NATURAL LABOUR.
Hi
that they will do without a' ventilator.  If food is pro!
posed during labour, we should generally speak rather
against  than in favour  of it; for if food is taken, it
must  be either digested  or undigested ; in either case
it is productive of mischief; if digested,  it becomes
the fuel of fever; if it  remains undigested, the sto-
mach and bowels are all the worse for it: the proper
refreshment is tea with  dry  toast, as this will do no
harm.   It is often requisite, more particularly in the
lower orders of the community, to  guard against hav-
ing too many  attendants ; it is necessary to keep the
room  cool, which  cannot  be done if  it is full  of
people; besides,  when there are  women,  they  must
talk ;  a  great disturbance to  a woman who wants rest;
and they will  not only  talk, but  talk of all the dan-
gerous and difficult  labours they ever heard any story
about in their  lives; (his (he  patient applies to her-
self, and it alarms and does mischief.  The best way
for a medical  man to serve  them is, to observe  thus .
" Well,  you certainly have  been very  industrious in
collecting all these  wonderful stories that ever  were
heard ;  I  have made it my  business, but never saw
one half of what you relate;" hinting,  that he does
not believe any thing about it.
  Another occasional inconvenience of having a great
number of women in the room is,  that, after eating
and gorging themselves  full, they will force the prac-
titioner  (o call a consultation,  because they  want  to
go away, and  think  they can  go with a  better  grace
then.   This is a very disagreeable situation; they will
tell the practitioner that they think he had better not
keep  her too long under hand (which is  a favourite
expression,) and  what a sad  thing it is her being so
long  ill, and that he is a very young gentleman; so
that at length he is  fairly  driven  to a  consultation,
whether he sees it necessary or not.  Another annoy-
ance is, their talking bawdy, which  they will same* 
142     THE LONDON PRACTICE  OF MIDWIFERY.

times,  and not partially either:  they will be talking
of a man, " Oh,  Mr. So and So, yes, oh, he has a
large family; and I do not wonder at it, he likes  that
business well."  Whether the practitioner attends to
this nonsense or not,  they  will form their opinion of
him from  it, and against him  in both  instances  too.
If he laughs with them, and the labour is a good one,
It is very well, he is a good-natured  man : but if  the
labour proves tedious, they  will  soon lose any confi-
dence they might have in him, and  he who was an
old woman at  the  beginning,  they will expect to be
an old  woman throughout.   On the contrary, if he is
obliged to hear  their  long  conversation, without
laughing or taking any notice, they  will afterwards
say to  each other, " Oh, it was a sad  thing, there
never  was a pleasanter party in the world; but he
was the mo3t  surly morose  man 1 ever saw;  he did
not take  notice  of one of our jokes."  When such
company  is unavoidable,  (he best way  to get rid of
them is, to make a confidant of some one, telling her,
as a  profound secret, that  the lady will  not be deli-
vered  before  to-morrow morning ; this  she will tell
to another as a  great secret, which will in a short
time be known to all the company  as one of the most
inviolable secrets,  and perhaps the patient herself  will
know of it; however, if the women, who in this case
are of no comfort to the  patient, and often a great
interruption to the practitioner, are got rid of, that  is
sufficient.
   It is  of infinite consequence, that the  practitioner
should  always be cheerful and  unembarrassed: the
mere appearance of his  being tired, in a tedious la-
bour, will produce a  bad  effect on  the  woman; he
should appear cheerful, but not gay, the occasion does
not  warrant that: it is astonishing how  great an ad-
vantage it is  to have  a pleasant  smiling countenance :
naturally it is very prizable; but when a man carries. 
MANAGEMENT IN NATURAL LABOUR.      143
the picture of ill luck in his face, certainly he is to be
pitied; it is then politic to make the best of a bad bar-
gain, polish it up by a good humour and habit as well as
he can, as Swift says in his Pastry-cook, that the man

       ......" chiefly show'd his art,
       Of much foul dough to make a savoury tart."

Wrhenever he  perceives his patient looking  at him,
he  should  brush up,  and  appear  as  cheerful  as  he
can.  He  must prevent  the  patient exhausting her
strength  by  bearing  down  when  the pain is not  on
her, and  encourage  her  to exert herself when it  is ;
he  should, through the medium of the nurse, tell her
she must empty her bladder every ten  minutes, and
for that reason  he  should  frequently leave the room,
and tell  the nurse that he is going on that account;
and in this way he may proceed till the child's head
rests  on the perinceum .- this is the time  when support
is wanted.
   The reason why the perinmum needs  this  support,
is simply this;  a woman bears down  with a force
equal to three, one of which is voluntary ; the natural
structure of  the perinantm has enabled it to support,
without  danger, the contraction of the  uterus ; it  has
therefore, of itself, a  power superior to  two, which is
the force of  uterine  contraction ; but, in consequence
of the patient's voluntary efforts being added to  the
involuntary  efforts of  the  uterus,  a force  equal to
three is acting against a power equal  to only two.
 By pressing against this  part, we  d<> not say the head
 shall  not  come out; we  only say it shall not come
 through a hole whi'.'h is' too small to receive it.   In
 supporting the perinceum, it may be done through the
 medium of a  folded cloth, which is  held in the hand
 upon the perinceum,  and  keeps the hand clean from
 occasional discharges of meconium or feces, waters. 
 144    THE LONDON PRACTICE OF MIDWIFERY.

 Sec. and  the perinceum should not  be left  unsup-
 ported, till the shoulders are born ;  indeed laceration
 more  frequently  happens  while the  shoulders  are
 passing, than when the  head is.   The great art is, to
 give support close to  the  edge,  against which  the
 greatest force is acting, for the parts give way first at
 the edge.   The perinceum is to be supported from the
 time that  it is stretched by the pressure of the head
 upon it, and we must take care (hat we apply pressure
 sufficient  to  counterad (he voluntary efforts of the
 woman;  and besides all  this  it  will  be proper at
 times to ask the patient if  she can help assisting ?  She
 may say  she cannot; but that the pain  forces her to
 bear down with all her force.  The  truth is, that she
 sometimes can, and at others  cannot,  help  bearing
 down.   The most successful mode of conduct here is
 to tell  her she must endeavour to speak while the pain
 is on  her; it does not signify what it  is she talks
 about:  she  may be told to count twenty.  If sue is
 able to do that,  she  is perfectly free from the danger
 of breaking her perinmum.
  A midwife attending a  labour thinks  that as soon
 as the head is born her business begins; she catches
 bold of it, and working it about, she  endeavours to
 make the  same pain, which expelled  the head, expel
the body also, which is  very wrong;  the  child should
be left  till  another pain  comes on ; the great  art is, to
 keep a  labour  natural  in its progress which was na-
tural at its commencement.  If a woman is  left to
 herself, in  nineteen cases out of twenty the same pain
 expelling  the  head would not  push  out tbe child.
 Tbe best plan is, as  soon as the head is expelled, to
 say, "  Now,  Ma'am, it i3 all over;" she is satisfied,
 thanks her stars for i(,  and rests  herself; presently
 another pain  comes  on, when she at once  feels the
 child ;  " Oh,  dear  Sir," she will say, " I  thought you
 told me it was all  ever."—" Yes, so I  did with  the 
            CUTTING THE NAVEL-STRING.         14;)

head ; did you not understand me  so  ?"—" No, 1
supposed  the child was born ; I am sure if I had
known that, I could have finished it all with the last
pain."  The body will as well remain in the vagina as
in the air ; and at the same time when the  shoulders
are coming, we must  never deliver the  woman, bul
at most assist her at the time when the pain is on her.
in the most gentle manner.

   Sect. xiv.  On tying and cutting the Navel-string.

   When the child is born,  breathes, kicks,  and cries.
it does not signify how soon  we tie the navel-strint;.
To do this, about ten threads must be joined  in  (ho
ligalure: (he first made  about  two inches from  the
body, and the second,  the same  distance  from that
again or towards the placenta.   The  division is made
between the  two ligatures,  the second being only in-
tended to prevent the blood escaping from the divided
cord, and  soiling the bed.  We must here recollect,
that in no case should the woman ever be exposed,
by raising the bed-clothes quite away; there is every
reason why she should not; therefore the navcl-striug
must be cut  under the clothes, and to do it safely we
should have it in our hand in such a manner as to pre-
vent the risk of any mischief to the child from its di-
vision, for sometimes a finger or thumb is snapped off
in this  way.  Dr. Denman used  to mention in hits
lectures, an instance of a child who was delivered by
an incautious practitioner, who  unfortunately  had in-
cluded the penis of the infant within the blades of the
scissars.
   The  next step  to the separation  of the child is the
placing dry clothes under the woman and to the peri-
niBum.   Midvvives apply them warm ;  this  should
only  be done in winter, for  warmth increases  the
discharge  from the uterus.  The nurses will be hand- 
 J 46    THE LONDON PRACTICE OF MIDWIFERY.

 ing  warm clothes, which  may be laid on the bed;
 they are ready to be used when  wanted, and  are per-
 fectly dry and cool.  The next step is to lay the  hand
 on the abdomen, to ascertain whether there is a second
 child in the uterus ; being  satisfied  that there is not
 another, we  are to  proceed to the extraction of the
placenta.

        Sect. xv.  Extraction of the Placenta.

  The uterus contracts after (he birth of the child,  so
 as to contain only the placenta; and its contractions
 being continued, the surface naturally must first loosen
 and  then separate itself from that of the placenta; and
 the same contraction which detaches this  mass from
 its adhesion to  the uterus, also expels it.   When the
 practitioner occasionally leaves  the bedside of the pa-
 tient before the placenta is thrown  off, he may say,
 " When you feel the waters (which he knows to  be
 blood)  come away,  tell  me; because,  I  know then
 (hat some part of the placenta must be separated; and
if there is pain, I know that the uterus is contracting."
It is  then  generally  necessary  to pass the fingers  up
 upon the cord, which is  held in the other hand, and
 if we are  able  to feel the  root  of the placenta, the
 separation  is complete, and we have only to get it
 gently out from the os uteri.  If the root  of the pla-
 centa cannot be felt, it is dangerous to  pull the cord
 with any degree of force :  it is  still attached  to the
uterus,  and  may  produce inversion of  tbe  womb.
 When, by  gently drawing  the cord, we have got the
placenta and  membranes down  to the os externum, it
is necessary (o have  a basin ready (o slip it under the
 bed-clothes; and in drawing the placenta out, the
 cleanest way to bring the  membranes with it, is to
 turn it round, by which means,  after a few turns,  we
 coax them out  very neatly ; and after having covered 
          EXTRACTION  OF THE PLACENTA.        147

die vagina with dry clothes, there is an  end of the
business.
   It is convenient  not only to lay under  the patient
(he end of the folded sheet which hung over the bed-
side, but also to make some degree of pressure upon
(he abdomen by bandage.  This  is all that is to be
done in natural labour.

  When we look back  at what has been said, we see
that in labour a great deal is to  be done, and still
more is to be left alone: nature is to be  regarded as
the sole guide: and where any person describes num-
berless difficulties  that he has met with  in practice,
we may suppose that he either created the difficulties
himself by mismanagement,  or manufactured  them
while telling the story. 
148
                   CHAP. VII.

              ON  DIFFICULT LABOUR.

         Sect. i.  Species of difficult Labour.

Of difficult labour (here are (hree species or degrees,
and to avoid circumlocution we  may  explain Ihein in
the following manner:
  First,  those  labours  which, though protracted, are
ultimately accomplished by the  powers of nature  un-
assisted by art.
  Secondly, those labours,  which although requiring
the assistance of art, yet are compatible  with  the  life
both of mother and child.
  Thirdly, those labours which, besides being  accom-
plished by  artificial means, require that  either the life
of the mother must yield, or the life of the child ; either
(he child must  give way (o save the parent, or  (ho
parent to preserve the child.

   Sect. ii.  Predisposing Causes of difficult Labour.

  The first source of difficulty is weakness: we know
that  labour requires a  certain  quantity  of force  or
power, therefore labour is  more likely  (o be  difficuK
in weak  (han in strong  women.  Not that  all weak
women  will  have difficult  labour;  we  have many
proofs to the  contrary f but, generally speaking,  it is
so.
  Fatness is another predisposing cause of difficult la-
bour : fatness offers  resistance,  and generally occurs
in women of weak constitutions; so that  here  we have
resistance and want of power.   All asthmatic and pul 
DIFFICULT labour.
149
monary complaints generally  will cause difficult la-
bour.  We know that, to assist the contractions of the
uterus, it is necessary  to take and retain a full inspira-
tion ; and the inflation of the  chest  being necessary,
if  it is not equal to the task  imposed upon it, it might
as well be wanting, as far as regards labour, for which
reason labour will be more probably protracted.
  Deformity  of body,  attended with constitutional
weakness, will generally produce difficulty in labour ;
it  is most likely that  in these cases the pelvis is not
formed as it should be, partaking of the state in which
most of the other bones are.  If a woman be too
young, the pelvis will not be perfectly formed ; and ii
too old, the parts will be rigid: the  best  lime for a
woman (o commence  child-bearing  i3 belween the
ages of eighteen and  twenty-five.  For though a wo-
man may be in perfect health  at thirty-six, yet we
know that the parts were designed to be used at eigh-
teen ; and have been  inactive for the rest of the time,
and cannot then be so fit to act.
   We before described  all difficult labours as depend-
ant  on one or two different  causes ; either diminished
power,  or increased  resistance.   Diminished power
may either depend on the constitution at large, or  on
previous disease, which has  reduced the powers of life
below the  natural standard; and in consequence of
the diminished power,  the  labour will not be over in
so short a  time as it  otherwise  would.  The manner
of living may also  diminish the powers of life.  The
effect is to render the  pains tedious and  ineffectual;
they last only a short time, and have long intervals.
The management of labours  of this kind  shows the
 skill of the attendant more  than  any oilier  situation;
 in which  management none  agree.  A  bad practi
 tioner will say, " Oh, my dear, how short your pain-
 are ! pray bear down, and assist as  much as ever you
can d* instead of bearing down and wearing herself out.
                       o 2 
150    THE  LONDON PRACTICE OF MIDWIFERY.

she should nol do either, but wait till  the parts dilate,
which they will do gradually. Such a woman should
not be  allowed to be in labour if she asks;  we then
may say  (ha( we  (hink she  is very  like (o  fall info
labour in about two or three days, for appearances arc
certainly in  favour of that  belief.   If night comes,
and the occasional pains prevent her from sleeping,
she may take ten drops of laudanum; still  persisting
in our first story,  that  she does not seem likely to be
in labour for some time.  In a short time a  pain may
come on, when we  shall find the  os uleri a little
dilated ; she will  persist in declaring that was a labour
pain.  " Why yes, it  was a good deal like a labour
pain certainly;  but  although very  near,  it  is not
exactly that."  In this way we may go on till (he
os uteri is quite dilated,  and the child's head at the  os
externum; then we  may  give a little  wine,  or nour-
ishing  food; jelly,  broth,  &c.  not  too  stimulating.
Now,  an ignorant midwife would tell this woman.
" My dear, your pains are very slack, and  you  have
been in labour all last night; you mus( help yourself,
my  dear : you had beder get up and walk  about and
take hold of (he  bed-post, and strain as hard as you
can.*'  Now,  where is  the advantage of  all this?  of
wha( use  is endeavouring (o expel  the head  of the
  diild,  while the os uleri  is not larger than  a crown-
 i»iece? and  again, what will become of (his woman
 a( the lader end of labour? She  must be  delivered
  >vith the forceps.
   The midwife  will  be  saying, " Oh, dear, she has
  not had any sleep all night;" for a very good reason.
  because she would not let her sleep ; instead of which.
  when the woman is  faint  from  those exertions she
  should not have made, (hey  give her  brandy,  or
  spiceries,  or  both:  which are  sure to  wear her
  slrength away, if she had  ever so  much originally ;
  and (hen they are wondering at  her not being deli- 
        MANAGEMENT OF DIFFICULT IABODB.    ]£]

vered sooner.  We must endeavour to  preserve her
strength  till  the  head  is against  the  dilated os ex-
ternum, and  then give  a little wine and water, and
encourage  her in every possible  shape.  If the wo-
man in a long and tedious labour  is weak, she  must
be  nourished;  if tired, she  should  go  to  sleep.
Where the  pulmonary organs are diseased, by  which
(he patient  cannot fill  the lungs and keep  them full,
but is obliged to let the  air out again, as  it may be of
the most serious consequence (o (he woman if she is
allowed (o s(rain  herself during her pains, i( is here
necessary to  deliver her with instruments;  for what
advantage is it, if by the woman being  able to deliver
herself she bursts a blood-ves3el in the  lungs and loses
her  life ?   She must be delivered  by art, and that as
soon as possible.
  The next kind  of difficulty in regard (o  labour is
local weakness in  (he uterus, not disposing it to con-
tract : this  may happen in a woman otherwise strong,
as a man may have a weak arm, while  the rest of his
body may be strong.   Such  a  woman may have  no
character of  weakness  about her but (his, so  that we
may not be  able very  readily to  guess  at the cause
when it  exists.   It is  not  proper to  give  stimulants
and opiates here to provoke contraction of the uterus .
when stimuli are given, it is  sometimes not recol-
lected that  they produce fever.  Opiates  arc not quite
so  exceptionable; they save the  time of the practi-
tioner, and the strength  of the woman.
  Another cause  of difficult labour is  (he irregular
con(raction of (he fibres of (he uterus; where (he
Jongiludinal set and the circular set i\o  not contract at
they should do relatively to each other.  This alwayt
arises from irritation of the os uteri, in  needless ex-
aminations.  The patient has strong labour pains with
out  the  delivery  being forwarded.  We may here
give from  twenty to (hirty drops of tinct. opii, in  an 
 !.)2    THE LONDON PRACTICE OF MITlU'IFF.BY,

ounce of mint-water, which generally affords  relief,
and disposes the patient to remain quiet  a few hours;
after which it  is probable, that, upon their action  re-
commencing, it will be in the natural manner.
  Passions of  the mind are  the next set  of causes of
difficult labour; the effect of them is to diminish the
strength and frequency of the pains,  till they  at last
subside altogether;  and this will all  occur in consti-
tutions where (he powers of  action  were originally
very good.  These things show the necessity of keep-
ing up the hopes of the patient  to  the pitch  of secu
rity and confidence; for, from the  moment  that  her
confidence fails her,  from  that moment the pains art
protracted, and that merely  from  the state of doubl
and increasing anxiety.  This points out the necessity
of never forming a prognosis of duration ; we may
form,  and declare  our opinion as  to the event,  but
never the length of  time  which the labour  shall last ;
for  if we were to speak the truth, our prognosis would
tie in general very unsatisfactory; we might say, we
doubt  not the lady will be  brought to  bed within a
week,  but that would give very little satisfaction.   II
we  only  tell a patient  it will be to-morrow before
the child  is born,  it will depress her resolution and
damp her perseverance ; the pains  will  diminish, and
she will be  all the  worse for  what  has been said.
There is a great necessity to gain the confidence of
the patient; therefore  we should  never stay in  (he
room  when we can as wrell  be  oul, nor  even stay
while (he os  uteri is  dilating;  and  (his we should
observe with (hose  pa(ien(s  who, from rank or fee,
think they  should be able (o command our continual
attendance.   We cannot well  leave the house,  but
we  may  propose that,  if convenient,  they make us a
bed in the house ; and this  implies that the labour is
not in  that state (o  render our  presence  necessary.
Some  patients will  wish us to stay ;  but (here is  nt
*\ 
        MANAGEMENT OP DIFFICULT LABOUR.     153

 occasion to stay and see pain which we cannot pre-
 vent  or relieve.   Here  we  may  escape  by a little
 artifice : we may call the nurse aside :  " Now, nurse,
 you know the child presses very imieh just now; you
 understand.*'—" O  yes;" (ask them  if they under-
 stand it, they will be sure to say Yes, for (hey  would
 not  be supposed ignorant of any  thing; and when-
 ever we want them to say Yes,  we have only to say,
 You understand me.)   " Well, nurse, now you see it
 is very necessary  that the water should  be kept clear;
 your mistress should make wa(er every ten  minutes."
  " Yes, certainly," she  says again.  We say to our
 patient, " I  shall  not  come again for some time;
 nurse understands me :" by (his means we may escape
 from  time to  time  till the child's head has pressed
 against the os externum ;  then our presence  is of con-
 sequence.
  Another very bad pain comes,  which draws the
 labour still forwarder; and  when the pains are very
 violent and tiresome,  although  the  labour  may  be
 going on remarkably well, yet it is necessary that  we
 inspire her with  confidence  to  go (hrough with it,
 else (hey will sometimes cease before they should ; for
 no mind is able to bear up under some degree oP pain
 beyond a  short time.   One practitioner  will lose the
 confidence of his patient in eight hours, while another
 shall keep  it  up  for three or four days; so. that  we
 must learn to manage the patient;  this  it is which is
 the most difficult part of practice, and is of more im-
 portance than many are aware  of.  If a practitioner
 comes (o  a bed-side  with  a  dismayed countenance,
 can he suppose it will put (he patient in better spirits,
 or inspire  her with  confidence ?  There is a great
 deal  in those  trifling  things.   If a man walk firmly
into  a room,  the  patient sees at once that she is
better : so does the practitioner, or at least, if he does
 not see it,  he should tell her he does, and she believes 
1.54   THE LONDON PRACTICE OF  MIDWIFERY.

it,  which  is the same tiling.   As a proof of (his posi-
tion, we  may mention (he lale Dr. Warren:  man}
otber practitioners are as gentlemanly men as he was;
many as  good  scholars; but yet  perhaps there  are
none in whom all  these qualifications are  so happily
blended as they were  in  him.   Like  a great naval
commander,  who signifies to his crew,  that where he
is no harm can come ; which intimation has the  best
effects on  all  occasions of real danger; it is generally
to be obtained by making ourselves acquain(ed  with
tbe best  means that can be  adopted to  relieve  (he
patient,  which gives a manly confidence and decision
in our practice.
  These then are the causes which weaken the action
of  the uterus: diminished  energy of  the muscular
fibres in  general;  an  irregular  contraction  of its
fibres; and lastly, passions of  the mind acting by di-
minishing the powers of the uterus.
  The os uteri may become a cause of- difficult labour
by its being rigid.   This state is natural to- some  wo-
men, and especially those who are somewhat advanced
in life when they begin to bear children; also  with
the first child the  parts dilate more slowly than in sub-
sequent labours.  Rigidity may arise  from repeated
and useless examinations; and  where the os uleri  is
rigid, it forms one of  the most painful labours, ac-
companied with excruciating pains in the back.   This
state is attended with inclination to vomit and to sleep,
both which things are in themselves useful:  for sleep
restores the strength of the  body, while the vomiting
strengthens the bearing down.
  It is astonishing how  soon the  woman forgets the
sickness which occurs in this state of os uteri.  As soon
as the pain is over, if we only step aside and return,
she is fast asleep.   The os uteri,  when in  this rigid
state, resembles inflammation,  in befng tender to (he
touch;  its hardness almost  reminds us  of a board, 
RIGIDITY OF THE OS UTERI.
155
which  is bored  through  the  middle with an auger.
This is one of two kinds of rigid os uteri ; the other
description of which gives a very different feel:  it is
more apt to give way under the finger, is of  a pulpy
substance,  and in some measure  resembles the intes-
tine of an animal filled with water and drawn into  a
circle; and though this  is not so rigid to the finger
as the other, yet  it is longer in giving way.  This sort
of swelling or thickening is sometimes occasioned by
oedema, or ecchymosis, as it has been known to  arise
in a quarter  of  an hour; lying between the  os pubis
and the child's head.  It generally happens that  from
the pain there is a degree of  fever present.   But
when once one part of the enlarged circle retires be-
hind the head, the whole of it slips up, and the  child
is sometimes  born in five minutes,  if there is no re-
sistance from (he soft parts.
  We must here be  very cautious  not  to allow the
woman to exhaust  herself  in  fruitless efforts; for
which reason we should explain to her that it will be
of no avail; (dat the mouth of the  womb is not  large
enough to admit  of  the  child's  passing; and that  it
must be a work of time, and will be a work  of  time,
notwithstanding all the endeavours  she  may  make to
shorten it.  In  this way we  should let it go a consi-
derable time, preaching  to her  the doctrine of pa-
tience ; and when we find that  we must do some-
thing more, we may order  a  clyster, which is to be
formed of many articles prepared at the apothecary's,
which we may tell her  will be very powerful in its
effects : the preparing of this  will take up some time ;
and for the same  reason  it  should  again  be  warmed
before  using.   After tbe clyster is given, we may wait
Tor two hours to see its good effects; and just at the
Lime the next should be given, we may find  out that
it is cold,  and must be a little warmed.   In this way
we  shall  get  rid of four  hours;  when we may exa- 
156    THE LONDON PRACTICE OP MIDWIFERY.

mine her, by which examination we  shall find how
very useful the clysters  have been, that  she  is won-
derfully better, which is very  true, for she is four
hours forwarder  in her  labour  than she  was before
they were given.   The  grand object, and the only
object, is to gain time without her being aware of it,
30 (hat her exertions  may  be saved.   It  may occa-
sionally be necessary, for the sake of preventing the
woman  from desponding on account *bf the length of
time requisite for the  dilatation of the parts, (o have
recourse to a little  finesse; therefore,  when about to
give a third injection,  they ask what  it should  be
made of; we may inquire if they have any oatmeal in
the house ; if they have it, we  may say  it must  be
made of the whole grits, and if  they happen  (o have
bo(h, we (hen prefer  pearl-barley ;  and if very hard
driven, we may still have a good resource in a " me-
dicine from which we have seen (he finest effects;"
then we forthwith order an eight-ounce mixture witii
colour and taste, though  otherwise it signifies  not
what i( is made of, provided it be harmless, directing
a table-spoonful every hour.   Where  the os  uleri is
very irritable, and by frequent examination has been
rendered more  so  by being deprived of its  mucus,
twenty  drops  of  laudanum  may  be added to the
mixture.
  In difficult labours if will now  and (hen happen (hat
the vagina is very rigid, making considerable resist-
ance ; this very  generally  depends on irritation, by
the interference of the midwife ; for it often happens
that the midwife docs not even know that there is an
os uteri,  much less that any mischief can arise from
the hand being so frequently introduced  into the va-
gina; and if, besides  this perfed ignorance, she  hap-
pen to have a taste for drinking,  and has had (en chil-
dren, she is then perfectly qualified for  a parish mid-
wife : such a woman will  tell a practitioner,  if sent 
         RESISTANCE OF THE VAGINA, &CC        157

for, « Oh, yes, she is very tight made,  very tight
indeed, the  tightest  woman  I think I ever saw."
Now, if the midwife does not know that the patient
has an os uteri, she knows very well she ha3 an os
externum, and therefore she what she calls screws H
open,  not considering  while screwing against the cs
pubis, that  if she expects  the soft parts to give way,
she yet has no reason to expect the same compliance
on the part of the bones.  The consequence is, that
inflammation of the periosteum  and membranes co
vering the bones very often arises.   In such cases we
see that  patience and horizontal  posture are  both
grand remedies ;  besides  which, why not use fomen-
tations, as in whitlow, or any other case, where relax-
ation  is wanted ?
   The next cause impeding labour, from resistance of
the soft  parts, is a full  bladder and suppression of
urine; this is not a formidable evil.  In early exami-
nation we  shall, instead  of feeling  the mouth of the
uterus, come to the neck  of the distended  bladder;
but in the progress of labour the child's head presses
upon  the neck of the bladder,  while  pressure causes
the suppression.  This will  never happen if the blad-
der is frequently emptied in the  early part of labour,
because from the time of the head being at the upper
aperture of the pelvis to the delivery there is in general
but a modera(e interval, in which no serious accumu-
lation can take place in (he bladder, unless (he labour
be very long.
   When it is necessary to draw  off the urine, the
catheter will  enter  the  meatus urinarius with greater
ease if its curve is a little increased.   With regard to a
woman in  this situation, we should never rest satisfied
that her bladder is  not  dangerously full, because we
see a little water which has passed  without the instru-
ment.  We must never allow  the woman's  delicacy
or dislike to prevent our examining:  wo must repre-
                         p 
158    THE LONDON PRACTICE OF MIDWIFERY.

sen( to her (he importance of it; for, if she dies from
a burs( bladder, i( will be a  very deplorable circum-
stance, as  it is so easily  prevented.   Where we are
satisfied of the necessity for  drawiDg off the water, it
is  advisable not to mention it  first, but (ake the ca-
theter  with our hands under the  clothes, when we
can find the  urethra  with  more convenience, as  (he
patient will not be so much disturbed; and when the
catheter is  in the bladder, we have then only to ask for
a basin and draw  out  the  urine.  The instrument i<
thus  introduced  unobserved  by the  patient, who, it
the practitioner was young, and, as she would imme-
diately conclude, inexperienced,  would  not  often
allow the  passing  of it by any but some one of  esta-
blished reputation.  After we have brought away the
catheter, we may show it to her, and calm her fears.
   Another cause of difficult labour  is stone in the
bladder :   this acts by its mechanical obstruction of
the child's passage  through the pelvis.  One of (hese
(hings  may  be done here; the whole may be left to
nature; the  child's  head may  be opened,  (he ex-
(raction being then made ; or lastly, (he woman may
be cu( for (he s(one.  As  (o (he merKs of each (rea(-
ment; the bladder being left to  itself will slough away
from the  pressure of the stone  in delivery, supposing
(he patient does not die  directiy.  The child's  head
being  opened, cannol be said   (o prevent  pressure,
while it surely is attended with the loss of  one life out
of the two.   If the operation  for the stone is per-
formed on the woman, there is a chance for saving
both lives: (here  are several instances on record  of its
having succeeded.
   Having considered fulness of  the bladder and stone
in the bladder as being causes of difficult labour,'we
shall now  consider tumours of  (he soft part3 as being
also causes of difficult labour, whether they  are form-
ed by  the parts situate  within  the pelvis, or by the 
TUMOURS ON THE  SOFT PARTS.       159
falling down of a diseased ovarium;  or indeed by any
thing which  occupies part of the space, producing
difficulty of the first, second, and third degree, accord-
ing to its dze and situation, or according to the  de-
gree  of encroachment  made  into  the  cavity  of the
pelvis.  In all cases of this kind it is best to treat it as
a deformed pelvis.  The idea  of treating it by punc
luring (he tumour is  very dangerous  and highly im-
proper.*
  Contraction of the  vagina  forms another impedi
inent to labour.  If this is the  consequence of a cica-
trix, it will sometimes be proper to divide by a knife,
in order  to  allow the child's head to pass;  though
when we attempt dividing high  up, we are in a very
delicate situation on account of the bladder and rec-
tum; and if the head has passed so far forward as to
come into view, it will then also be advisable to leave
it to nature.   Excrescences arising  from the os  uteri
or vagina may impede labour, though these causes in
general  have  only produced  difficulty   of  the  first
degree ; the os uteri has been known to be  in such a
state from a tumour on its side, that only  two thirds of
the  circle have dilated for the passage of the child's
head.  In most cases  the tumour is pushed aside, so
that it occupies a protected  situation during  labour,
and the head passes very well.
   As it is proper to know whatever may  happen, it
will be right to mention a case that once  occurred to
a very celebrated practitioner in this town : a gentle-
man called  him in to  a labour, where  every  thing
appeared just as it  should be,  except  that  neither
himself nor  the gentleman whom  he called in  could
feel the os uleri.  Once he thought  he felt the breech,
but he was mistaken:  nothing  could be done, and

  * Consult on this subject, Park's paper  in the Medico-chiruv-
«ical  Transactions, vol. ii.: Merriman's ditto, ibid.  vol. iii. ;
Christian's ditto, Edinburgh Medical Journal, vol. is. 
160     THE LONDON PRACTICE  OF MIDWIFERY.

the woman died.   On  dissection it was found  (hat
theos uteri was projected up over (he symphysis pubis,
by a large tumour in one of its sides, which presented
at the vagina.  The only chance (his woman could
have had would have been a slender one—(he Cesa-
rean section might have been made.
  An unfavourable  state  of the  ovum may protract
labour.   It is stated that the  navel-string may be tied
round the neck of the child in its passage through ; by
which the effect of each  pain is lost : being held on
each side by the string, it is forced a little forward  in
each pain, retiring again as soon as  the pain goes off.
It does  not  appear likely,  however, that this ever
happens, because the effect attributed to the elasticity
of the cord may be seen iu every labour, from  tbe
elasticity of  the  soft  parts,  and more  particularly
where the head is larger than the cavity of  the pelvis.
So that there is no reason to believe this to be a cause
of difficult labour.   Yet we  may now speak of  its
treatinent, when i( does occur.  The cord is frequently
turned round (he neck  of  (he child, when (he circula-
tion is not in the least interrupted ; in this case we
have only to  turn it off the neck, and if (he circula-
tion is felt, leave it.  W7here the loop  round the neck
is so light as (o interrupt  (he  pulse, we  may  loosen
i( by passing (he finger between it and the skin of the
neck, so  as to feel the  pulse again.   It has been said
to be sometimes so tight as not  to admit of its being
slackened  at  all;  (his  is just  possible, and the most
improbable thing in the world.   It  is then to be  di-
vided between two ligatures.
  Rigidity of (he membranes has been stated (o pro-
duce difficult labour.  It has sometimes though rarely
happened, that  labour  has  been quicker when the
membranes were  ruptured  early;  but  though  (he
labour be slower, il is  safer where (he  membranes
remain  entire.  Where (hey are to be opened, there 
           RUPTURE OF THE MEMBRANES.       161

nave  been a great number of pretty-looking instru-
ments invented for doing it—long tubes, at the end of
which blades or points were projected.  But it requires
more skill in telling where they should be let alone,
than where they should be  used.  With the first  child
the membranes  must  never be  broken; (he inferior
parts of the  passage dilate but slowly, and require the
assistance which the membranes are capable of giving ;
and if tiiey are  then broken  without knowing why
they should be  left,  the woman suffers  considerable
inconvenience from the want of them  in dilating the
os externum.  Dut in  subsequent  labours  perhaps  it
may be admissible, where the pelvis ar.d soft parts are
known to be capacious and yielding.  The time when
Ihey should  be broken is when  the head  may be re-
ceived into the os uteri upon their breaking, but never
before this (ime ; if (hey  should be ruptured earlier, it
will delay (he labour considerably ; it has been known
to pro(ract a labour three weeks : it is  a troublesome
occurrence at any time, and always  keeps us in hot
water;  and  though we are not absolutely confined for
ail the time, yet we never know  when  we  may  be
sent for, and when we  are, it is always in haste.  After
the waters are all come away, the  labour  may  go on
very well; since an aggregation of small pains will do
as much good as a few sharp ones.  A  patient in this
situation requires a little  management; it is  not jus:
to stay with her  at the  time; and yet it is neces-
sary,  if we  leave  her, to leave her in confidence ;*
therefore we may  give her the idea of making pro-
vision for whatever may happen in our absence : we
may pass our finger up the vagina, and  make a mode-
rate degree of pressure for a few seconds  on any part

  * The confidence of our patients is always  best obtained by
integrity and truth.  The finesse here recommended would de-
ceive very few women; and the suspicion that an attempt was
ii»ade to dupe her, would probably induce the patient to employ
another practitioner on a subsequent occasion.      Editok. 
 162    THE LONDON PRACTICE OF MIDWIFERY.

of it,  so that she may just feel it, after which we may
say to her,  " There,  Ma'am, I have done something
that will be  of great  use to you in your  labour."
This  she trusts to ;  and if, when she sends for  us,
we get there in (ime, it is  all well; if later (han  we
should be,  we easily satisfy her: " Yes, you  know 1
(old you I  did something which  would be of great
service to you  in labour."  If the placenta is  not yet
come  away : " Ah,  I am quite in  time  for the after-
birth,  and  that you know is  of the greatest  conse-
quence in labour."  And if the whole is come away,
" We  are glad the  after-birth is all come away, in
consequence of what we did  before we last left  the
patient, and the labour terminated just as we intended
it should."
  A frequent cause of the rupture of the membranes
is,  the using  of exercise too  violent for the parts to
bear.   The riding in a coach over (he rough s(ones
will bring it on.   AnolLer cause of (he membranes
giving way, may be the death of  the child, for dead
members vjjjll yield when a  living member will not.
  The next cause  of difficult  labour is (he dispro-
portionate size of the child's head, compared with  the
cavity of (he pelvis.  This is not mollilies ossium ;  but
a disease which, independent of (hat, is capable of pro-
ducing difficulty of  the first and second degree.  The
different size of the head will  regulate the progress of
the labour.   The head may be so large as not to pass,
and this increased size of head may be combined with
a  state of  pelvis which in  shape resembles a man's ;
which pelvis would not admit a head  of an ordinary
size.   Also the head may be  accidentally larger than
it should be, for two heads of the same absolute size
 3hall  in labour prove (o be  of different sizes : that is,
 one shall give way and allow of compression by (he
 soft parts;  while the other, by being  more  perfectly
 ossified, will not allow the bones to slip one over  (he 
               ARREST AND IMPACTION.           163

 other, a3 in the first  instance; for which reason one
 of these two heads will be,  in effect, larger than the
 other.  The volume of the head may also be increased
  by one or both of the  hands coming, down with it.
  Independent  of these  causes, the same head, when
- differently placed, will be of very different sizes with
 regard to the  cavity of the pelvis.  The head lies be-
 fore labour with the face to the sacrum ; and the occi-
 put to the pubes ;  now,  if the occiput is to the sacrum,
  and the face to the pubes, the head will not, because it
  cannot pass.   As to  the presenting  part of the head,
  we know how to discriminate  between the anterior
  and  posterior fontanelle.   Many practitioners have
  supposed that there  were but two remedies for the
  wrong presentation;  time, and instruments.   It might
  however be always altered by those who were masters
  of the subject.  The way to turn the child in  a pro-
  per direction is merely  to pass up one or  two  fingers
  into the  vagina, and using  gentle pressure upon  the
  .»ide of the head, we shalf in general be able to return
  it,  and then the succeeding pain  will place it in its
  right position.*

             Sect. hi.  Arrest and Impaction.

     Reviewing what has been said on difficult  labour,
  we see that almost all die misfortunes are to be attri-
  buted to bad management.  One man will keep up a
  continuai fever by stimulants, while another will stu-
  pify  the  patient  by opiates.  One breaks the mem-
  branes,  leaving a useless and tedious draining  of  the
  waters; another  allows them to remain whole.  One

     *  See " Observations on the Management of Cases in which-
  i'ue Face of the Child presents towards the Os Pubis, by John
   Clarke, M. D." in the Transactions of a Society for the Improve-
   ment of medical and chirurgical Knowledge; vol. il 
 164    THE LONDON PRACTICE OP MIDWIFERY.

 will wait in the room till  the  bladder is burst,  while
 another will go frequently  out of the room, that the
 patient may empty her  bladder.  If we now take a
 view of the effect  of these things,  we  shall see that,
 from these various evils, a woman is liable to have her
 powers so exhausted by irregularities, or passions, or
 increased resistance, that one of two things will be the
 consequence—either arrest, or impaction.   Arrest is
 when the head has got down into  the pelvis,  and re-
 mains unmoved, not because there is too much resist-
 ance,  but bemuse  the  woman is too weak for any
 further exertion.  The state of things in  arrest is very
 different  from that which happens in impaction:  in ai
 rest we find the  head not compressed,  nor the  scalp
 drawn into folds or swelled;  the stools cine  away
 naturally, and  the woman  makes water easily  ; and
 with regard to the constitution, it is languid and weak ;
 in short,  she is a very debilitated woman.  What then
 will be the consequence, from this view  of the  case ?
 I3 the woman  likely to overcome  the difficulties now
 (he powers are worse 1 No.  Is there any danger with
 regard to the  constitution 1  No.   While there are a
 number of  little pains which last four or  fjve clays, is
 it right io leave a  woman?  No.   Then  why not de-
 liver her with  forceps, in which there is  no  danger .'
 it is only bringing along  the child,  while the  mother
 has not  power sufficient to do it  herself.  In a case
of impaction, the powers of a woman may be as good
as those of any woman in tbe highest  health.   But
there is a resistance which cannot be overcome, so that
 things are very differently situated to what occurs in
arrest only.  The bones of the head are wrapped over
each other, the scalp  is swelled and wrinkled, and is
so altered, that  upon  any person feeling it  who had
never been at  a labour,  he would guess it to be any
part but what  it is.  If it '13  a genuine case of im-
paction,  the head  will be  locked in the surrounding 
ARREST AND IMPACTION.
165
 parts, producing a stoppage of the evacuations of stool
 and  urine; so that  on this account it  would be clear
 that the head filled the aperture of the pelvis.
   In the next place  we must attend to the constitutional
 changes:  for the first twenty-four hours after being
 taken in labour,  the woman  works away very vigor-
 ously ; while during the  last  twelve hours, (he labour
 will  hardly make any progress, and  she is  sweating
 abundantly.   Tbi3  state  will at  last change ; it will
 gradually sink down to a mumbling half delirious state,
 wandering and low.   No woman should be allowed to
 go into this state ; and if she  is in such a situation, she
 should not be allowed to remain in it.  For if the
 pressure of the vessels upon the brain is allowed to con-
 tinue, she will become apoplectic.   Besides, there will
 be harm done to the abdominal muscles.  What good
 can arise by allowing the  woman to deliver herself, if
 the vagina and bladder slough with the parts around,
 which is another thing that may happen ?  In  a  con-
 sultation that was held on a case of this kind,  it was
 agreed that nature certainly should be  able to deliver
 (he  woman ; she therefore was not interfered with :
 she did deliver herself, but  lost  her life  for it; she
 died,  and  that at a  time  when  an .ear was to be felt.
 This  was certainly a case that required the use of the
forceps, which would have delivered her with safety.
   It is safe to assert, that if, after we are able to feel
 the ear distinctly,* the woman is not delivered in six
 hours, we ought  always to deliver  with instruments.
 We know that in strangulated liernia  nature has,  in
 one case out of fifty thousand, made an artificial anus
 through the  side  after  the   parts  themselves  had
 sloughed off.  But  are we for that reason to avoid

  * We say distinctly, because young practitioners, more especi-
 ally, are very apt to mistake a small segment of the undilated oe
 uteri, or a fold of the scalp, for the  ear. 
166     THE LONDON PRACTICE OF MIDWIFERY.

operating for (he strangulated hernia ? are we to leave
the patient to the powers of nature ? There is not any
difference between pushing a man into the water, and
not helping him  out of  if,  if we  see him drowning;
neither in the same way is there any difference between
destroying a woman purposely, and (he neglecting (o
employ (hose means,  which, when  she  is in danger,
will certainly save her  life.  There are many other
cases in which the forceps may with propriety be used :
hmnoptoe, syncope, flooding, presentation of the navel-
string, rupture  of the uterus.  All  these occurrences
justify their application, provided the case is within the
power of management by these means,  either forming
impaction, or arrest. 
ORIGIN OF INSTRUMENTS.          167
                   CHAP. VIII.

                 ON INSTRUMENTS.

           Sect. i.   Origin of Instruments.

 1 owards the latter end of the century before last,,
two instruments were  invented;  the vectis, and the
forceps.  There has been much dispute as to the  origin
of the two instruments; whether the inventor of one
did not borrow his idea from  the instrument made by
the other ; whether the vectis is not the  single  blade
of a pair of forceps, or the  forceps a double  vectis.
Now,  there happen to be no written documents to
prove  that either side  of the question is riger, and it
is not of the least consequence, because  whichever in-
strument  is found most useful in practice will be pre-
ferred, without even asking the name of  the inventor,
or from whose model it was formed.

               Sect. ii.  The Vectis.

  The vectis is what the name implies, a lever  which
is intended to assist the delivery of the child's head.
  Now,  there are three points to consider in  every
lever : first, the point of action;  next, the moving
power ; and lastly,  an  intermediate place to be  found
between the moving power and point of action,  called
a fulcrum.
   We will now see how far  (he  lever is applicable to
labour.   It is almost needless (o remark, (bat this is the
most powerful assistance we can obtain in labour; be-
cause  (he na(ure of (he lever,  as relates  (o mechanical
character, is very well  known.  It has been truly said,
Hive me a lever and a fulcrum to work it on, and I will 
 168    THE LONDON PRACTICE OP MIDWIFERY.

 move (he universe wi(h a feather, for i( may be balan-
 ced by a breath of air; so (ha(, as an ins(rumen( applied
 to dead matter, no power can be equal to it in force.
 But le( us consider that the parts to  which it is applied
 in labour are not inanimate, nor are  the parts around it
 so either; every part is animated, and liable to be  in-
jured by pressure.  The vagina, for example, is sur-
 rounded by soft parts, all of which are important, many
 of them essential to life.

      Sect. hi.  On the Application of the Vectis.

   We will now consider what circumstances will arise
 from  tbe use of  (he instrument; and first the point of
 action, which is (he head of (he child.   I( is (oo obvious
 to need mentioning, that the force applied by (he instru-
 ment must be equal to the resistance, if not superior to
 it; and then the mischief may arise to the parts of (he
 child's head  so  acted upon,  producing much  injury:
the ear may be injured ; (he lower jaw or  zygomatic
process of the  temporal bone may be broken ;  or any
part of the surface from the pressure  may slough oft":
these  evils are by no means imaginary ; there are va-
rious  instances recorded of each of them, and that
under the hands  of (he  most careful  and  dexterous
men.   When an instrument of this  sort is  used, it is
proper to make the hand the fulcrum on which it acts:
now,  if  the force required is hut small, this may cer-
tainly do well  enough ; but where great force is  re-
quired, this is a very bad support ; besides, the bony
parts of the pelvis  lie so convenient, (hat we may rest
our instrument on almost any part of it, yet  we should
recoiled, that  whatever part we convert into a ful-
crum, we  injure more or less,  according to  circum-
stances : if we apply it over the symphysis  pubis, we
press upon the urethra; or if in other  situation?, we
shall injure the clitoris,  or vagina. 
            APPLICATION OF THE VECTIS.         169

   Wherever we find the ear, over that part is the ap-
 plication of the instrument to be made.   The injury
 done to the soft parts will be greater in  proportion as
 we attend less to their safety, than that of the perinee-
 um.  The integuments suffer again, if we attend to the
fulcrum, by which we get a lacerated perinceum.   So
 (hat we eitiier cannot use much force with the vectis, or.
 if we do, it will be at the  certainty of doing much mis-
 chief.  All these circumstances will depend, however,
 on the smallness of the difficulty to be overcome ; and
 if there is no great danger, there will not be much diffi-
 culty or pressure.

                Sect. iv.   The Forceps.

   This instrument need not be particularly described,
 bu( i( has many advantages, which are of some conse-
 quence (o mention.  The forceps has thinner  blades
 than the vectis, and one objection agains( (he use of
 the last instrument is, its being so very liable to  do
 harm at its point  by pressure; another objection  is,
 that the  force  is applied  higher  up, so that it makc,-
 (he head flafter  in proportion, and  increases i(s volume
 in (he direction in which  i( should be lessened.  This
 i3 familiarly explained by squeezing a pound of butler
 be(ween  two plates;  would it not  increase the circum
 ference of  the cake ?  While (he vectis labours under
4his inconvenience, (he forc.ps is free from it:  by  the
 forceps the  pressure is diffused over a large surface; it
holds more steadily,  and  does not press  partially.   In
the next place,  if we consider the vectis, we find that
 while its pressure is  applied to the upper part of the
pelvis, it increases (he volume of Ihe head  applied  to
the lower part of the pelvis; while we know that the
forceps, so far from increasing the  size of the head  it.
 self, is  capable of compressing the head in such a man-
 ner as  to bring  it into a less compass (ban  before;  so 
 170    THE LONDON PRACTICE OF MIDWIFERY.

 much so, that  the  head included in the blades of the
forceps shall altogether occupy less space  than was
 before occupied by (be  head alone.  It may here be
 objected, that  the head is compressed by this means.
 But granting that it is, we know (hat at the same time
 the child is able to bear (hat compression without (he
 least  injury.  Besides, the practice  is justifiable upon
 other grounds than (hat of the pressure not hurting the
 child: for supposing that it did hurt the brain, no more
 force is used than what is necessary to bring the head
 along the cavity.  It is only compressed to the size of
 (he pelvis,  and  at any rate it must come through (hat
 cavily, therefore it must inevitably suffer that compres-
 sion,  whether conducted through by instruments, or
 forced  through by the labour-pains of  the  woman
 herself.
   There are cases where the head  being actually loo
 large for (he cavity  of (he pelvis, would never gel
 through by the  exertions of  the woman alone.  What
 is to be done ? If no other resource is at hand, we must
 open  the head: bu( here the forceps are to be consi-
 dered, (o save (he child's life by  (he compression (hey
 are able (o  make.  The Irutii is, (hat the brain of an
 infant  will  bear pressure very  well; so (ha(, in (his
 resped, the forceps may always be very safely applied.
 We see (hat they do not act by any partial pressure, and
 that (he action  is diffused.
   Another objection  to the use of the vectis is, that
 It requires one of the  hands  to be employed  as a ful-
 crum, in order to prevent injuring the soft parts against
 which it would otherwise rest:  (he while the hand is
 so employed, the perinosum is negleded, (o  the ha-
 zard of its being lacerated;  and  if we chose rather (o
 take  care of the  perinceum, the soft parts are vio-
 lently pressed against the bone, by which (hey suffer
 great pain and  injury.   If any doubt this, (hey  have
 only (o walk into the first smith's shop (hey mec( with, 
UTILITY OF THE FORCEPS.          171
and request him to do them the favour to screw  theii
finger up in his vice; and if, upon trial, they should
not find the sensation  quite 90  agreeable  as  tickling,
they will then easily suppose how nearly the woman's
feelings resemble their own.
   The forceps are two levers, joined to each  other iu
such a way that the  fulcrum of each blade is found in
the opposite half of the instrument; and now having
two levers united by a joint, we  need not look to the
pelvis to furnish the fulcrum, neither need we neglect
the perinceum.  There is still a query,  that if the for*
ceps are so much  better than the vectis, how is it (ha(
the vectis is still in use by some?  For no other reason
but because it is easier to use ; for one instrument re
quires  less  skill than two, and for that  reason it is
preferred by those  who have not more skill than they
know  what to do  with. They say  they think  it is
best, and with them so it is.  The  man is simple,
the  instrument should  therefore  be simple.   The
complex instruments are safer in the  hands  of those
only who have learned  all  the uses of them, as well
as the modes of managing them.  Though  as  to in-
struments,  the knowledge of  them and (he way to
use  (hem  dexterously can  never be taught;  they
must be used, before  the management of them  is ac-
quired.   It is  said the  vectis is better, as it can be
applied with secrecy ;  but why  should we  be  advo-
cates for any  operation being  done  secretly, when
the woman surely  has a title  not only to know, but
 to be  consulted upon her  choice?  It is certainly a
 convenience to those practitioners who have occasion
 (o make  haste, to  have  this  instrument  in their
 pocket, which is ready at hand, and  may be popped
 up in a moment, to hasten (he progress of the  child's
 head.  There are olher  reasons why it is very im-
 proper : how is a man  ever to increase  his credit, if
 every thing that can add to it  be done secretly ?  It is 
172    THE  LONDON PRACTICE OF MI9IVI1ERY.

a natural conclusion in every person's mind, that where
an operation  is done secretly it is done unnecessarily,
which is a very  strong objection to keeping (he woman
in ignorance of what we are doing.  Some practition-
ers never go without a vectis in their pockets; but those
who adopt this  ins(rumen( should be particularly cau-
tious never (o use a jointed one, which may double up
or unscrew for conveniency of carriage.  In a case
where  one of  these was  used, it gave way, and the
blade would  not coirie away, nor could it  be brought
away;  the gentleman  who  was attending  was in the
utmost alarm, expecting that every pain would force it
through the substance of the uterus.   Fortunately the
instrument came  away  at  (he  time  tbe head came
through (he pelvis.
  As to the history of the forceps, it was invented by
Chamberlen, who with his sons engrossed the whole
practice of London ; for every one soon knew (ha( ho
was r.blc to deliver a woman  safely, while none else
could, and save the child's life besides.  He (ook his
invention over to Paris, offering if (o Louis XIV. who
proposed giving him (wo thousand pounds for i(, if it
succeeded ; he accordingly  applied (hem in  (he first
case of difficulty which occurred in Paris.   It happened
to be a patient of Mauriceau.   The  pelvis was de-
formed ; yet he persisted in applying  his instrument,
with great difficulty and no effect.  The woman  died;
and the body  being opened, it was found that in forcing
(he  blades Up he had forced them through the  sides of
tbe uterus.  The moment he found that this was knows,
he took to his heels without waiting for  a messenger,
for at that time  there were what they called lettres de
racJiet.

     Sect. v.  On the Application of the Forceps.

  In all cases we must first learn the state  of the pel-
cis ;  if  that is narrow or  deformed, we then calculate 
APPLICATION OF THE FORCEPS.        173
whether the head can pass; if it is too small, the for-
ceps are useless.   It is best never to apply them, but
when we are able to include  the whole in the grasp;
to ascertain which we should examine and feel the ear;
when we can feel an ear, the head is within the cavity
of the pelvis.  The reason why we know the forceps
may then be applied is this, we know the instrument
to be so much longer than the finger, that if  from the
05 externum the latter is  able to reach the ear, the for-
mer will effectually encompass the  head. The  next
thing after feeling the ear, is the ascertaining  the exact
position of the head, which being done by examination
of the sutures and fontanelles,  we judge whether a
change of position in that head might not enable the
woman to expel the child by  her power3 alone;  and
if we find we are unable to turn the head round, we
may then apply the instruments to it as it lies; first feel-
ing for the occipital bone and fontanelle : and if in ex-
amination we are able to feel  (he posterior fontanelle,
we know (hat  the occiput must be somewhere in the
range of the pubes, which will be more precisely de-
termined by (he direction of the sagittal suture.
   Supposing this known, the instruments are to be
applied, the convex sides of the blades to the cavity of
the sacrum, so as to accord with the direction of the axis
of the pelvis.  Before the introduction of the forceps,
it will be necessary to dilate the part3 gently, especially
if it be the first child.  The blades of the forceps  must
be creased before  being  passed, to ensure  an easier
passage, and then one blade  first is passed gently  up
between the finger and head of the child ; because by
this means we are certaiu no soft parts can be injured
or pinched by it:  further than the  finger will reach
we must depend on the proper direction  of the instru-
ment, which should at its points be pressed towards the
centre of the heatl, and passed forward with a gentle
wriggling motion, which serves to form itself a space
                        Q 2 
 (7-J    THE LONDON PRACTICE OF  MIDWIFERY.

 between the uterus and head, taking care also to keep
 the handle  of the forceps outward, so that we may
assist our intention of keeping the point of tbe blade
close to  the  head.  In carrying the instrument  up,
we should always put the woman  upon her guard to
warn us if we give her much pain, because, if we do.
we know that we have pinched the uterus, and should
withdraw the blade a little way,  and then return it till
we get as far  as necessary without much pain; which
being done, the other blade is to be introduced in the
same manner;  and as it was found, at the time when
nailing the criminal's ears to the pillory was in fashion,.
(hat  after one ear was  nailed it was easy  enough to
nail the other; so here  it is easy  enough to apply the
opposite blade of the forceps, not  forgetting the little
motion which must  be made on  its own axis.  Both
blades  being  introduced, the instrument is  to be lock
ed ; and it is convenient to pass the finger several times
round the lock, to see that no hair or skin is included,
which might give some uneasiness to the patient at the
time  of using (he instrument:  and before beginning to
operate it will be as well to take the forceps and give
(hem a sort of vibration or shake,  that we may feel
that we have the child firmly by them. Then we should
explain to the patient that every thing relative to  the
application  of the  instrument is done;  and that  she-
must not expect  our assistance will give her no pain.
for it must give  pain, though less than she would feel
in her attempts towards expulsion while unassisted.  It
is not possible to bring  the child into the world without
pain.
  Now we must remember  that labour pains  are  not
continual; therefore  we must not use the forceps as
if they were.  The head will not  bear constant pres*
sure, therefore we must desist every now  and then,
beginning with the least possible force, which can bt
easily  and  gradually increased  as may be necessary 
            APPLICATION OF THE FORCEPS.        17£

We should rest frequently, and from time to time go
round the head with our finger to see how the business
comes forward; always satisfying  ourself that the in-
strument  still encompasses  the whole  of the  head.
The motion we  make with the forceps mu9t be slow
and gradual, inclining them very gently side to side, or
from blade  to blade; always  acting in a line with  the
axis of the pelvis, till we can feel the occiput, when
wc move with regard to the axis of the vagina; using
in the latter part of the operation very little force, foi
the head requires very little force to bring it through the
mgina*

   * Id "  Denman's  Aphorisms" very excellent rules far  tlTc
 application of the forceps are clearly and concisely laid down
 Osborne's  Essays are likewise well deserving to be censultec' 
176
                    CHAP.  IX.


                DEFORMED PELVIS.

Sect. i.  Difficult Labour, occasioned by the Pelvis being
      deformed from Rickets and Mollihes Ossium.

The  last  degree of difficulty which may arise  in
labour will depend on disproportion between (he size
of (he child's head and (he cavify of the pelvis ; not
that slight degree  of  difficulty before mentioned, but
a deformity of pelvis, rendered so by one or two dis-
eases, either rickets or mollities ossium.
  The mollities ossium is  a  disease arising from the
earthy part of the  system  being gone by absorption
while  the  animal  matter only remains, leaving the
bones  soft enough  to be pierced by  a pin,  in  conse-
quence of which  the bones of the  pelvis  give way
to any impression, and  in proportion  to the weight
applied, and the  continuance of such  application:
(hat part yields first that  has  pressure most  generally
upon  it.  All  the  weight  of the body rests on the
lower lumbar vertebrae ; therefore we  find the sacrum,
as being the key-stone of the  arch of the pelvis, gra-
dually sink  inward.   The consequence  is, that the
child's head is absolutely incapable of passing into (he
pelvis.   Patien(s who are  suffering from mollilies os-
sium find (hemselves almost  unable  to  stand, (here
fore they sit more  than others, and the pressure of the
body produces  other deformities of shape.  The lower
part of (he sacrum gives way and is thrown forward.
If the deformity goes on,  the thigh-bones  gradually
approach nearer to the centre of gravity.   The changes:
in every deformed pelvis are alike, and  the causes of de-
formity being pressure, (hey are perfectly mechanical 
CESAREAN OPERATION.
17*
           Sect. ii.  Cesarean  Operation.

  When a pelvis is deformed, (he question is, whether
there be space enough  (o allow  (he  child's head
to pass, and if the  space is above (hree inches, (hat
is sufficient  and the head  may  pass.   Where  it is
less  than three inches  it is not  sufficient, and the
head cannot  pass;  the question is  then  changed,
what method  have we then (o bring (he child out ot
the body, if it cannot pass through the pelvis ?  It has
been proposed to cut it out from the  body,  by the
Ccesarean operation.   This has  been  performed  in
two ways,  by  an incision  obliquely carried through
the  side; or  through  the  tinea alba directly  down.
The object  proposed in this operation  >s the  saving
the life both of (he mother and child.   It is of great
antiquity.   It  has been said that Julius Caesar  was
taken (his way out of the body  of bis  mother; but
there  is no just ground for believing such a report:
many historians  held  him as so  remarkable  a man,
that they were determined he should not come into
the world like any other person.   If it  had  been so,
is it not strange that Pliny,  who wrote  so soon after-.
wards,  devoted a chapter entirely to the history  of a
living child  being cut out of the  body  of the  parent
who was dead;  in  which  he  mentions nothing of
Julius Caesar   having come the same  road?  Scipio
Africanus was said to be introduced by  the Cesarean
section, but there  is no reason  to  believe it.   It was
never known  otherwise than as an operation  recom-
mended till the sixteenth century in Paris.   It was
once performed in Holland by  a sow-gelder upon his
wife.  It is remarkable  that the same  woman was
afterwards pregnant; but when her husband  proposed
the operation again,  she  declined  submitting  to 1^
and was delivered without. 
178    THE LONDON PRACTICE  OP MIDWIFERY.

  The surgeon  who  strongly  recommended  it in
Paris, was Rousset, who never  lived to see it per-
formed, on account of the  opposition he met with in
opinion from  Ambrose Pare and other eminent sur-
geons.
  The manner of performing this operation has been
much disputed; the lateral  incision appears to be (he
bes(:  because we divide one muscle and it retracts,
we  divide the  muscle  under  it and it retracts also;
but the whole of the incision will not be a direct line
through,  so (ha( we stand a better  chance of saving
our patient, as far as exclusion of the air may have a
good effect, when the parts come afterwards to unite.
  In performing this operation there are those things
to be attended to : that the woman  may die under
the operation itself; or  shortly after, from  the loss of
blood : from  exposure of the cavity of  the  abdomen
causing extensive peritoneal  inflammation ; from the
parts suppurating instead of uniting by the first inten-
tion; or  from  inflammation, being so violent as to
prevent  the  formation  of  matter, producing mortifi-
cation.   From these causes a  woman may die.   Yet
if we look at the cases of this kind that <ire recorded,
we shall  see  the fairest  accounts that could be writ-
ten, the  death of the  patient never attributed  to the
operation, but some trifling cause, perhaps relating to
diet ;  such as a small glass of wine, or a few grapes,
producing inflammation of the peritoneum,  or diar-
rhoea : this is decided  upon without considering the
probability  that the diarrhoza or peritoneal  inflam-
mation  may have been  produced by the operation
alone.   These  things should be considered fairly, and
not viewed  with the  partial eye of him  who  has per-
 formed  the  operation.   We see that on  the Conti-
 nent (his operation has been very rarely  successful;
 and  when we inquire  how often  it succeeds in our
 own country, as more nearly  concerning us,  we find 
CESAREAN OPERATION.
179
that it  has  uniformly been  fatal,  that  is, all  the
patients have  died  from it; there  is not a  single in-
stance  of  recovery.  It has  been  performed  in
London, Leicester,  Edinburgh, and Manchester, by
the best surgeons of these places, and there are  none
better in the world ; but all the patients  have died.
Yet we always find  some trival reasons assigned by
the operator for (heir having died;  while those who
are unconcerned observers have attributed (heir death
(o  (he  operation; for certainly there is more danger
in a large  hole cut  through  the belly, than in eating
a  grape or drinking a glass of wine: and when the
patient  has escaped from the operation with life, it is
one of those  hair-breadth escapes  upon which (here
can be no reasoning.  A  man may spring off the top of
a  house, and it i3 possible he may be saved;  he may
fall upon a  feather bed, (hat is possible;  but would
any man on that account say stairs were not wanted?
A  woman in Roderdam, while big with  child, was
met by an ox;  she could  not escape, and the ox
hutted  her  up  against  the wall,  and  gored her  so
dreadfully that it let (he child  out. It has been said
that the woman has sometimes died from being  under
(he hands of a bad  operator ; but, in this instance, we
should  not expect  (he  operator to have  been very
dexterous, and ye(  the patient recovered.   The same
thing happened at the Cordova, in  Spain.
   The  operation should be performed with the  inten-
tion of saving both lives, because it is a safer way of
 delivery to open the head of the child.  In  mollilies
ossium the disease is continually going on;  no case
 recovers ;  it always destroys the woman.  Here it is
 certainly advisable to  perform (he Caesarean opera-
 tion, though not with  (he certain hope of preserving
 both lives; but  the woman is  hardly  more sure of
 dying  after  (he operation has been performed, (ban
 she was before. 
 180    THE LONDON PRACTICE OF MIDWIFERY.

   In (he Manchester cases different opinions were
 given as to (he propriety of operating: these opinions
 were made  public, which, in thing3 of this  nature,
 never should  be done; and a great deal  too much
 warmth  was felt on both side's of (he question.  One
 party said the child's head should have been  opened
 to save  the woman'3  life, while the  other had it that
 the operation was  not calculated  to  save  both lives.
 It is said, that this woman died because she  was re-
 moved in a cart before tbe operation was performed ;
 bu( it is pretty evident that her death was (he  conse-
 quence  of (he operation, and (hat alone.   The only
 way of  taking this  is  to suppose her  death  the conse-
 quence  of the  operation,  because  there  never  has
 been an instance  of  the patient's recovering, and  it
 never should be performed but where the woman  has
 some mortal  complain( upon her, as pulmonary con-
 sumption, mollities ossium, &c. and in all cases where
 the woman dies in or before labour; for many children
 have been taken ou( of the uterus alive from  a dead
 woman.

 Sect. hi. On opening the  Child's  Head, and the Means
        of ascertaining whether it is alive or dead.

  We shall  now consider  the operation of opening
 the head of the child; which is so terrible  an  opera-
 tion (0 (hink  of performing  upon a  living child, that
 the (bought is  truly shocking,  though, when engaged
professionally, we must declare it  is  our opinion that
it  should be done, and must act according to that
opinion,  let it  be ever so  repugnant  to our c-  t feel-
ings, without the opinion being influenced bj '.I: state
of the child any way whatever.
  It will still be  a satisfaction (o U3 to knov whether
it is alive or dead ;  the marks therefore are these : in
the first place, supposing the child is alive, the preg 
DEATH OF THE FCETUS IN  UTERO.        181
nancy of that woman will continue  increasing to the
end  of  her  time; and in labour the presenting parts
will  have a firm elastic feel; the  cuticle  and hair
will  not  come away on  (he  finger; besides which,
there will generally  be a pulsation  at the fontanelle.
But (he  navel-string being pressed, may cause death ;
it may  arise, and  does  often  arise,  without any
cause that  we are able to trace.   We  know that a
child may die in utero from affections of the mind in
the woman.   The death of the child may be known
by shivering fits, preceded by a sense of coldness in
the abdomen.  Whilst the child is alive, it  assists in
supporting its own heat; but when dead, it necessa-
rily  must obtain a degree of heat  from  the parts
around,  which  explains the sense  of coldness felt.
The breasts,  while the child is alive, increase and
continue  firm and  well  supported; but when  the
child dies,   they immediately  become flaccid and
empty.   So that a woman frequently used to  miscar
riage, will foretel  its approach by this alone.   While
the child is  alive, it gives  the sensation of a living
weight, a weight which is capable  of adapting itself
to the different positions of the  mother; but when
death deprives it of  this power, the  woman feels it
flap  from side to side, according to  the way  in which
she  moves    She becomes sensible of weight to a
much greater degree than she did before.  Besides all
which,  there  will be  the cessation of motion in the
foetus, which had been  perceived by the mother for
some time previous to delivery.   These are  so many
signs of the child's death, which may  be observed,
before labour comes on.
   There are  others which  accompany  labour: first,
as the child is dead,  the membranes will be dead also;
and for that reason will break earlier than they other-
wise would.  It has been said, that the  liquor amnii
being turbid, points out the  child  being dead; but 
182     THE LONDON PRACTICE OP MIDWIFERY.

this circumstance sometimes arises while the child is
alive and well.  The strongest sign, is one by which
we may tell it before even we see the  woman; it is
by the waters being corrupted.   The smell of putre-
faction will sometimes  decide the opinion of an ex-
perienced practitioner the instant he enters the door;
also in an  examination, from the meconium coming
away on  the hand, depending on  the sphincter muscle
becoming  putrid  and relaxed.   The sutures of the
head  vacillate like  bones in a bag.  When  we ex-
amine, the hair and cuticle will come away  upon our
finger.  So that if the woman has suffered  from  late
uneasiness, or injury  of body or mind, her breasts
becomiug flaccid,  with a sense of cold and  weight in
the abdomen, with loss of motion, &c. there is reason
to judge the child is dead.   But  when  in labour the
liquor amnii comes away by the loss of  tone and firm-
ness  in  the  membranes; when  the hair  and  scalp
come away on  the  finger, and especially where we
perceive  a putrid smell in  the waters, there  can no
longer be  any  doubt in our mind  that  the child is
dead.

Sect. iv.  In what Cases the  Life of the Mother or of the
               Child must be sacrificed.

   As the  Csesarean  operation does not save both
lives,  the next  important  consideration  becomes,
what means  are most successful, in difficult  labours,
to  save  the lives of mother and child.   These points
we  consider abstractedly, because  in  this  country
there are no religious injunctions, by  which we are
compelled to save the life of the child, though it be
done by sacrificing the mother; although in  other
countries  such  ordinances  do  exist.   Where  the
woman  has  good  general  health,  but  her  pelvis
happens  to  have been deformed  by rickets at a 
         REASONS POR OPENING THE HEAD.       183

former  period of life, if one  of  the two lives must
be given up to the other, there can be no scruple as to
which it shall be : the child has no connexions upon
earth,  no friends to  whom it will  be a loss, or whom
it will regret parting from ; it  has no  regard to occa-
sion a wish even to  remain in  this world    While, on
the contrary, the woman is  an  useful  member of
society ; and setting aside all important considerations,
she  is on  this account alone  of  too much import to
have her life taken away  because she is unable to bear
children.  The  life  of the child surely should be the
sacrifice in this instance.
   It is widely different in the existing state of molli-
ties  ossium; a disease  not   recoverable, a  disease
which always increases,  and  at  last  proves  fatal.
Here we should recommend  the Caesarean  section;
by performing  which we ensure the  saving  of one
life, while, by not  doing it,  both lives  are certainly
lost.

 Sf.ct. v.  In what  Cases the  Child's  Head should be
                       opened.

   The  cases in  which  the  child's head should be
 opened  to expedite delivery  are  these ; syncope, con-
 vulsions, haemorrhage.   In hydrocephalus  extemus it
 is  also  right to open the head,  which  will  not pass
 without its bulk being first reduced : the  disease may
 be ascertained by examination, the  sutures and fonta-
 mlles being at  a greater distance, and the whole  cra-
 nium very  imperfectly ossified :  but the most unequi-
 vocal evidence  is the head's not entering the pelvis ;
 by which  we know that  the head is too big for the well-
 formed pelvis, or that the pelvis is not large enough to
 receive the head into it, which is  the same thing in
 effect*
    When  all the stages  of labour  are gone through, 
 I 84     THE LONDON PRACTICE OF MIDWIFERY.

 and (he head is no( advanced, we  are led lo examine
 what state the child is in :  wheu we  have ascertained
 the existence of a deformity of pelvis, we  may gene-
 rally (ell (he  space left  for (he child's passage,  by
 passing (he finger  from  before backward;  that  is,
 from the vagina, the  space under  the  arch  of the
 pubes, backwards and  rather  upwards, toward the
 projecting front of the sacrum, where the first lumbar
 vertebra  rests  on it.  Now, in a  well-formed pelvis,
 this  cannot  be done; it is  not  possible to reach the
 sacrum in this way ;  but in deformed pelvis we  may
 ascertain  the  space pretty accurately :  when the dis-
 tance  between the projecting part of the sacrum and
 the  symphysis pubis is  rather more than two  inches,
 the delivery i? v«ry simple ;  it would be well if it was
 less so, as then it would not be so  frequently adopted
 as at present.   Many a practitioner  has sacrificed a
 child's life at the shrine of his own ignorance.  It is
 much easier to apply the perforator and open the head
 of the child, than it is to apply the forceps: in the latter
 some  considerable skill is  required, in  the  former
 none.

       Sect.  vi.  Hoiv the Head is to be opened.

   Supposing,  however,  that the head is too large (o
pass through (he pelvis, it becomes necessary to  open
it; and the manner  of proceeding  is  this; first  to
 empty the bladder,  then  to throw  up  an injection,
(hat  the  rectum  may be also cleared; next, to intro-
duce the  hand into the vagina to the os uteri,  upon
which we are to pass up the perforator,  guarding (he
point with (he utmost  care, while passing it up,  by
 means of tbe other hand purposely introduced before
the  instrument.   The  points of this instrument are
 guarded by what are called the stops, by whieh stops,
 when we push the points through the  child's head, 
ON OPENING THE HEAD.
185
vre avoid (he danger of their passing too far, and, by
coming (hrough  the  opposite  side  of  (he  head,
wounding the uterus.  The way they are used is this :
we bring (he points upon a  su(ure or fontanelle, re-
collecting that, when they are introduced, the handles
are brought close  together, and consequently both the
points form one perforator ; now, wheu, by the hand
in the vagina, we have  laid the points opposite the
part of the head we  intend opening, we press the in-
strument down with force  sufficient  to  make it pass
through the integuments: that  being done, and the
perforator pushed in up to the stops, we are next to
lay our hands between  the  handles, and  push it up
between them to  the joint.  The effect  of this will
be, by its  acting as a  wedge to force asunder the
points, dilating and  tearing  open the sides of the
wound before made; we  next close  the  sides of it
and change its position, so that the handles will have
their rings in  a horizontal position ; we open the in-
strument again as before, which gives us a  cruciform
opening.   This being done, the perforator is next to
be pushed  into the  head, and screwed  round  back-
ward and forward, so as to entirely  break down (he
consistence and connexion of every thing within the
skull;  this will generally be sufficient—the pains will
quickly press out the  cerebrum, which  may be re-
moved from time to time; or we may  scoop  it out
with a table-spoon.
  If the pelvis  is not greatly  deformed, the delivery
may now soon be effected ; if it  is not, we proceed to
remove the bones separately taking care to guard each
piece through  the  vagina,  by  laying the scabrous
edges of it against the  hand, which  during the whole
operation should  be in the vagina.  Tbe sides of the
two points of the perforator which come against each
Other,  when  the instrument  is shut,  are  made rough,
so that, as with a pair of pliers,  we may take hold of 
186      THE L0KD0N PRACTICE OF  MIDWIFERY.

a bone which, whole,  is too large to pass, and break
it  in  two.   In this way we must  bring  away the
frontal  bone,  and occipital  bone:  the  temporal
bones, and the parietals; after which,  in  order to
have a firm hold, we should lay the scalp as far over
the parts within as we can, making a sort of flap to
lay hold of.   It is best to put on a glove  well greased
in order to catch hold  with.  It will sometimes
answer very well to carry  up the blunt honk, with
which  we  shall sometimes be  able to catch hold
somewhere, so as to aave a good purchase ; but it is
very apt to slip, as it has  no point.  If  it does slip,
we can  then only pass the crotchet; in the construc-
tion of which we should observe, that the fiat  point,
at its  sharp extremity, looks inward; so that, if laid
to a  surface parallel to it in direction, it will not be
able to peck into it, or wound  it.  It is now and then
badly made, and that without  the workman  being to
blame;  who most likely has not the least idea of the
manner in which it  is used, and consequently cannot
reason on the propriety of its form.
   When employing the crotchet, we  should  begin
with using as little force  as will  be attended with
good  effect; as,  if not sufficient  to  bring down the
head, it may be easily  increased, recollecting that
whenever this instrument is using, we  must always
keep  that hand which is  within  the uterus directly
opposite to the beak of the  instrument, so that  in
(he event of the  parts of the child  giving way  to ac-
cident may happen to the uterus ; there will only be
the risk of tearing off perhaps two or three fingers
from our hand; or letting loose those tendons  which
 move the joints.  Now, although these little acci-
 dents are all that could happen  with regard to our-
 selves, we must always  have our senses  about us,
 with  regard to the crotchet, which is necessary, fo*
 U we either use one of an improper form, or  use  it 
ON OPBNING THE HEAD.
187
carelessly, and it happens to come into contact with
out hand, it will peck a hole in it  as sure as fate: so
that it  is very necessary to  take care that it does not
slip.  We should use a force that we can command;
and, if the pelvis  be of sufficient dimensions, bring
the body down without  removing  any  more : when
once the head is delivered, the body will soon follow,
as it is easily compressed.   But in great  deformity,
we will suppose  that from the pubes to the  sacrum
is only one inch and a half, the  difficulty with which
the body  will pass here must be very great indeed:
and this renders it  proper to explain a great improve-
ment, a  practice invented by Dr.  Osborne : in such
cases of extreme  difficulty he opeus the  head very
early.

       Sect. vii.   On opening the Head very early.

   Sometimes we may know before the labour begins
 that the woman has a deformed pelvis.   If  we meet a
 woman walking in the street, who is not above thirty-
 three  or  thirty-four inches high, we must certainly
judge  that  woman's skeleton is  deformed,  but  the
 deformity  is not  in  proportion  to the  height:* in
 applying the perforator in such cases, we must not
 lose time:  as we cannot  choose whether we  will
 puncture a suture  or fontanelle, we must take  any
 part which presents.  We  must drill a hole in up to
 the stops,  and then open the perforator as far as we
 can; .then  we  may  withdraw  the instrument,  and
 omit doing any thing more for as long as the labour
 will permit: the effect of this will be,  the child being

   * It would be wrong to judge a pelvis deformed, merely from
 tbe external shape or size of the woman.  A few years ago, in the
 poor-house of Burton upon Trent,  a  dwarf, less than thirty
 inches high, was delivered without assistance of a  child twenty
 one inches long. 
 188     THB LONDON PRACTICE OF MIDWIFERT.

 dead, putrefaction will be going on  all the time ob-
 tained by delay ;  for  the  situation possessing the two
 great requisites for that state, warmth and moisture,
 it will proceed very rapidly, and the bones, and indeed
 the  whole body, will come away  more easily, sepa-
 rating from  each other with infinitely  less force  than
 before  they could have  done.   V\ hen  (he patient
 cannot  be  left  longer with  propriety, after about
 thirty-six hours,  we may  go on to the bringing away
 piecemeal,  the  various  bones of the  cranium; the
 temporal, frontal,  occipital, and parietal bones; after
 which  the remaining part  of the head will only be the
 basis of the skull, which  admits of being placed  in a
 more favourable  position for passing through the pel-
 vis : for the parietes being carefully laid over the bones
 whenever (hey may be felt exposed, it will protect the
 iderus from injury, and then if the remains of the head
 be brought forward, and doubled  down with the chin
 to the  breast, it  will,  in  this state, be  frequently ca-
 pable of being delivered.
   This sort of labour is  very tedious; but  requires
 no  skill.  We must  be  aware, that when we  have
 brought the head  along, we must not  always expect
 the  body to follow  as in other  cases, but we  shall
 sometimes be obliged to  bring away the whole child
 by pieces.   It may be necessary, in order that the body
 may pass, to take out the heart and lungs, and every
 other part,  one after  the other.  All the caution that
 need be given, is to take care not to injure the woman,
 iu doing what we are about, either in separating the
parts, or bringing them away.

    Sect. viii.  On facilitating Labour by Turning.

  Breaking down  the  structure of  a foetus in utero is,
 certainly, a very  shocking and frightful  operation;
 and the destroying one life, in order to save another 
        FACILITATING LABOUR BY TURNING.       189

a almost too terrible to think of: let us inquire then,
whether there is no other way of delivery besides this,
in such cases of deformity 1   There are two modes of
relieving the patient;  but  they apply  only  to  the
slighter cases.
  Of the two modes by which  the woman may be
delivered, without the  absolute killing of the child,
the  first is turning: this is not the best of the two re-
sources;  but many women will submit  to this, who
will not. submit to the proposal of bringing on prema-
ture labour.
  Suppose we know, previous to  labour, that a pelvis
is deformed; that it is not three inches, but it is all
but  three.   We propose to  bring on  premature la-
bour : we do not do this without first giving the wo-
man an explanation, in which we must signify to her,
that the child does not lie exactly right.   It will some-
times, though  very seldom, happen,  that  we meet
with a woman,  who would not run any risk of her
life  for all the  children  that ever  were born; here
we  must act accordingly, and propose doing what we
do,  not on account of the child's welfare, but explain
it as being entirely concerning her own safety.
  After turning a child, we  may pull it through by
the  feet, when  we never should  have been  able to
have delivered it  without, for  the  uterus would not
have been able to push it through, in (he common way
of presenting with the  head to the os uteri ; and if
we  are able to save the child's life, it is a grand point.

       Sect. ix.  Reasons for premature Labour.

  The operation that is certainly the besl method of
managing delivery in deformities which admit of it, is
premature labour, which is founded upon these posi-
tions ; that  during pregnancy, the head of the child
is increasing in size, to  the time of delivery;  so that 
190    THE LONDON PRACTICE OF  MIDWIFERY.

if we take them in their gradual increase of size, it is
pretty plain,  tha( one  in the  early  month  of preg-
nancy would pass  with  ease through a pelvis that
would not receive it at a later  period ;  and in this
way,  by  considering the case in all its  parts,  com-
paring the diameter of the pelvis with the size of the
head al different  periods of the pregnancy, we shall
be able to calculate the time when we may bring on
premature labour, fixing  either the  seventh  month,
seventh and half, or  eighth  month,  but not  after;
for if  we do, the head is too much ossified to submit
to the pressure it must sustain,  with that ease which is
necessary to the delivery being perfectly safe.

  Sect. x.  Distinction between  a Pelvis deformed from
  Rickets, and a Pelvis deformed from Mollities Ossium.

  A deformed pelvis dependant on  rickets  is  to  be
Considered in this poin(of view, that when the woman
has recovered from her last lying-in, she is in  perfectly
good  health ; and where the last,  lying-in left  her, the
next finds her.   But though  this he the case in rickets,
it is widely different in mollities ossium, where the wo-
man labours under a continual disease, an increasing
disease, a disease which must terminate in her destruc-
tion.   The pelvis will b<> continually diminished in its
cavify ; anil in a labour about to commence, it may
not he half  the size  it  was on the last time of her be-
ing delivered.

       Sect. xi.  How to obtain premature Labour.

  With  regard  to a woman who  has a ricketty de-
formed pelvis, we are  placed in a new situation with
a view  to  her lying in : we  must  represent to her,
that,  from the peculiar form  of (he  pelvis,  it is not
possible that she should ever have a child born alive, 
PREMATURE LABOUR.
191
at the full time ; but that we propose bringing on la-
bour at an earlier period than the  nine months  com-
plete, in order that the labour may be safe with regard
to herself, and as nearly as possible to ensure the life
of the child.
  Supposing it is agreed to,  what are the steps to be
taken in  producing it, and what time is most proper
for it ?  The time may be bounded on one  side by
seven months, and on  (he otiier  by eighf and half.
It may occasionally be brought on as much earlier as
is necessary, but the child then cannot be expected to
live;  and if it is produced  later  than eigh(  months
and half, (he labour will be as difficult as that at nine
months.
  The first step towards bringing on  premature labour
is, the carrying  up  a catheter through  the vagina to
(he os uteri, and  in(roducing i( witii care, in such a
manner (ha( (he poin( of (he catheter shall be in con-
tact  with the sides of the uterus, using a gentle  pres-
sure only.   When  the  extremity  of (he catheter is
against the membranes, but clear of  the child, the in-
strument is  to be thrust forward,  so a3 to break the
membranes ; and in this the catheter is  preferable to a
rod of silver, that as soon as the catheter enters, we
know the object for  which we introduce it is gained ;
for while the instrument is still  in our  hand, we shall
feel the waters passing off more or less ; if a solid rod
is employed, it  may be necessary  to  introduce it a
second time ; and in puncturing or breaking the mem-
branes, it is preferable to get the instrument some way
up  the side of the uterus, to breaking them immedi-
ately upon  the os uteri, because in the latter  way the
child is  most frequently born  dead; which  depends
on the  different  effect with regard  to  the flowing off
of the waters, which is produced by the mode of punc-
turing or breaking the membranes.
   The breaking  the membranes at the 3ide, only, al- 
 192    THE LONDON PRACTICE OF MIDWIFERY.

 lows a partial escape of the waters, quite sufficient to
 produce the disposition to contract in (he uterus, with-
 out permitting any injurious effect to arise from pres-
 sure ; while on the other hand, when they are broken
 in the front, the whole of the waters flow away, the
 iderus contracts very strongly round the child, and the
 circulation generally suffers, and is either partially or
 completely interrupted.   The delivery, by bringing on
 the action of the uterus prematurely, is for many rea-
 sons very estimable : a month or two before  delivery
 naturally produced, the head is not only smaller, but
 more compressible ; there is a less proportion of bone ;
 so that if we take two heads of the same absolute size,
 one being of eight  months formation, and the other
 seven, still that at seven would have the advantage in
 passing through a narrow pelvis.  It is difficult for any
 one to determine the time which should apply to dif-
 ferent pelves,  as being the proper time for delivery ;
 but where  the distance between pubes and sacrum is
 under tbree,  yet  all but three inches, eight months.
 may be allowed ;  where the distance is two and three
 quarters, seven months; and so on.*  But when a child
 is born at seven months, it will rarely suck ; it should
 then,  if possible, be fed  wi(h  human  milk, sucked
 through the medium  of a contrivance  which  will  be
 explained in a future section.   By  these means, (hen,
 we may be able to save both lives;  by the  Cesarean
 section, or opening the head,  we certainly lose one
 life; and by doing nothing, we lose both.

  * Papers on this Important subject have been published by the
late Mr. John Barlow in the Medical Facts and  Observations; by
 Mr. James Barlow in the Medical and Physical Journal; by Dr.
Merriman in  the Medico-chirurgical Transactions; besides a
chapter by Dr. Denman in his very valuable Introduction to the
Practice of Midwifery. 
193
CHAP. X.
             PRETERNATURAL LABOUR.

 Sect. i.  Division, and Cause, of praeternatural Labour


We  now proceed to the consideration  of prseterna-
tural  labour, or cross births, as (hey have sometimes
been called.  This division includes all presentations,
except that of the head ; and i3 again divided into pre
mentations of  the upper and  lower  extremities: all
other divisions arc useless.
  We know little of the cause of praeternatural labour;
perhaps it depends on a peculiarity of form, either in
the uterus or pelvis.   It is said to arise from accidents;
but preternatural  births  are most likely the effects of
peculiarity of shape in the parts.

    Sect.  ii.  First Division of prceternaieral Labour.

  The first kind of praeternatural  birth  occurs if the
lower extremities present.   Now,  this division of la-
bours is  capable of  being finished by the powers of
nature alone,  and  the  only consequence  would be
upon  the child,  to whom such delivery is not always
safe ;  for, when  the feet  present, and the child is gra-
dually expelled, tbe child in figure forms a cone, which
all along increases  to the  shoulders,  and  the  head is
born  last of all; the navel-string would be born long
before the shoulders were disengaged,  the  effect of
which would be, that the circulation would have been
interrupted in the  cord, and perhaps suspended; for
pressing the navel string before birth, is  the  same  a?
pressing the throat after it; each produces  death.
                        s 
194     THE LONDON PRACTICE OF MIDWIFERY.

  After this observation, we have only to remark, that
when the cord cornea down after the navel has descen-
ded below the  os uteri, a portion of the cord should be
drawn slack after it, that it may not be  stretched by the
child when passing under the pubes.
  When the  feet or breach have presented, there is
plenty of time to  turn the  occiput  to the pubes long
before the head is down.   Whether one foot presents,
or breech, it is better to let it come so, than  to go up,
and  bring  down  either one or both feet; because in
breech presentations the parts are gradually  and  well
dilated  before tbe  cord  is likely to  be compressed,
therefore it is safer; besides, the inferior extremities
in breech cases lie upon the sides of the abdomen,  by
which they protect the navel-string lying between the
two from any  pressure whatever.   So that we see all
breech  cases should be  left unturned;  and  wc  may
know the breech from the head, by the former having
the parts of generation, and various depressions, with-
out  that uniform defined feel  which is given by the
head.   When  the  breech presents, the meconium will
generally come away by  the pressure  squeezing it out
of the abdomen.  Suppose that in a breech presentation
any  accident  happen to the woman, needing imme-
diate delivery, it has been said that the forceps may be
applied  ; but from frequent trials we can say that they
are  of  no  use;  they are not calculated to hold such
parts, and  they always  do slip off, and always will.
Another plan recommended, is to get a handkerchief
between tbe thighs and the body : this is an exceed-
ingly good purchase, but in the living subject we can
scarcely do it; we  cannot get it between the legs and
the body.   If neither of these plans succeed, there is
only one remaining ; this  is the carrying up (he blunf
hook, and so placing il over (he thighs; (his certainly
commands the delivery,  and where  a  small equally
applied force is sufficient, it will be both successful 
     FIRST DIVISION OF PRETERNATURAL LABOUR.  195

aud safe;  but as it  is self-evident that iron must be
always stronger than bone, there  will be a great risk
of breaking the thighbones by this instrument.  But
the woman is not to die to  save the child's thigh-bone
from (he risk of  being broken:  and  it is certainly
better to have to treat  a  child with its thigh broke,
than one whose brains have been all scooped out.  We
should however be  careful never to employ the least
unnecessary force.
  The feet being born and  the breech passed, the part
which next comes is tbe umbilicus ; and as the body
afterwards passes further down, the cord will be both
pressed and dragged; and if a cylindrical yielding
cavity be dragged, the  cavity of that cylinder is dimi-
nished in  its calibre, and tbe tube will  ultimately be
obliterated ; so that  the best practice will be, as soon as
a part of the umbilicus can  be felt, to pass up the finger
and bring down sufficient to prevent stretching in the
progress of the expulsion ;  and as soon as  the head  is
in the pelvis, to bend  the face down,  bringing it  for-
ward upon the breast of the infant, and opposite the
os externum,  by which means  tbe  child will com-
mence breathing;  and if the navel string only  pul-
sates up to that time when breathing commences, the
child is safe in all that regards respiration; and as  to
the head remaining  within  (he os  externum,  it is of no
consequence whatever.
  If the child's head  cannot be brought through,  wre
may pull, drawing it with caution. Some practitioners
will pull  the child very hard, which is quite improper;
not that it is any  material  object  to the woman, the
force being applied with the hopes of the child's be-
ing boru  alive; but is it very  likely that  its life will
be saved  after a leg or an arm is pulled off, or after
the body is pulled so hard as to be separated from the
head ?
  Where the  case is, that  the arms are lying on the 
]96    THE LONDON PRACTICE  OP MIDWIFERY.

rides of (he chesl, it has been said to be the best prac-
tice to bring them forward; for that if (he arms arc
returned to come with  the  head, the uterus will clip
hold of them, and perhaps break them : the mistake
is this, that where mischief arises to the limbs,  it is
not from the uterus  but the-pelvis ; and as to the  head
being kept up  from the action  of  the  uterus, that is
just as unrounded a  notion as the other; for we should
much sooner pull out the uterus fhan the uterus would
pull off (he head.

  SrcT. m.  Second Division of praeternatural Labour.

  The other division of this class of labours, i3 (hat in
which the upper extremities present.  This is now and
then an original presentation ; but sometimes it is arti-
ficial.  It may be  called original,  if felt before the
membranes are broken; when an arm  or shoulder is
felt in the absence  of a pain.   It may  be called arti-
ficial when the hand being felt by the practitioner pre-
senting, perhaps  with some other part,  is drawn down
through the os uteri, and  the position of the present-
ation  varied ;  though  it originally  was  a  head pre-
sentation, it may  be made a shoulder presentation.
When the hands are at  the os uteri, (hey are easily
distinguished from the  feet, by the thumb not being
in  the ssme  line with the fingers:  while in the  foot
we distinguish the toes and heel.  The shoulder has
been mistaken for the back, and it is a mistake easily
made in  practice.   In  distinguishing,  we  should re-
collect the superior  extremities have the scapulae be-
hind them,  which  are not often  felt  at the  breech,
while at the breech we feel the organs of generation,
which are hardly ever found between the scapulce, or
in  the axilla.   We may here lay down a rule, which
is of the greatest consequence, and applies (o all kinds
of practice in midwifery; (hat is, that the shoulders and 
          REASONS  FOR TURNING THE FCETUS.      197

 arm will never pass together :  the labour may continue,
 but if that presentation  is not  altered, the ivoman will
 be worn out and die.  We must return an upper extre-
mity ; and never regard it as a matter of choice, but
 as a rule of practice which must always be adopted.
 We  must turn, because it is a presentation that cannot
 be delivered.   This altering the position of the  child
 in utero, is called the art of turning, which art, in mo-
 dern science,  is attributed to Ambrose  Pare;  though
 it is  mentioned as far back as the time of Celsus, who
 says, it is sometimes necessary : he does  not say whe-
 ther it  was   ever   done on  a living child :—Sed in
pedes quoque  conversus infans non difficulter exlrahi-
 tur,  quibus apprefiensis per ipsas manus commode  edit-
 citurd'   Cels. lib. vii. cap  29.—But Hippocrates  well
 knew the difficulties that  occur in labours  by other
 parts of the foetus  presenting, and recommends re-
 turning them,  whether alive or dead:  this, he says, is
 (o be done  by altering the position of the woman,
 taking the pillow from the head, putting  it under the
hips, and raising  the feet of the bed, thus affording a
 chance  for  the next pain to bring down the head  :
'* Orx ee oi7r]v%et Trlvc-cnTui k«<  ryxtflai cv ru fe^str/ rm
 vriptiv, tccvtcc S~e sjv re cfaovTec. sjv Te tthiuru. $ 7rpoaTavrx
 cmtra iraXiv rpspuv er.a$ yutrct. <pvri<t tv\  nri x.t<PccM»d' c*C.
 If the part presenting could not be returned,  he re-
commends  putting the woman into a warm bath until
a favourable change  take place : if the child should be
dead and cannot  be delivered,  he advises a cautious
reduction of it by the  knife, with an  instrument to
break down the bones of the cranium and a removal
of the parts by the forceps and hook.   Amongst other
means used in his day? to dislodge the toetus, we  find
 taking a woman by the shoulders and giving her a good
 shaking:  " Tsra r«?  /it,x;-;£#A#s  Xot£av ereietv  ivyjopusc''
 It is  almost unnecessary to observe, (hat the experience
 and  improvements of later times have put us into pos-
                         s2 
19S    THE LONDON PRACTICE OF MIDWIFERY.

session of a more safe and certain practice.—Ambrose
Pare's words are, " that in all cases where the upper
extremities present, you  must turn and bring down
the feet; and that if the midwife cannot do it herself,
she must send for a surgeon who can."
  The nature of these presentations may vary so much,
that  it  may be necessary (o mention some  circum
stances. Suppose (hen we are called to a labour, where
(he waters are no(  yet discharged, and the labour go-
ing on very naturally, but  by examination through the
membranes between the  pains, we find (hat an arm
or shoulder presenls, ye( we may, perhaps,  not know
exacdy (he parts;  in (hat case we should not  be ab-
sent from the woman upon  :;ny account, at the  time
of the membranes  breaking, for it will  make  all the
difference in the world, relative to the labour.   We
must ascertain the  exact position of the  child, and we
must then proceed to turning.   The question now is,
what time in the progress  of tiie labour is most proper
for this  operation ?   Baudelocque says,  when the
membranes are broken, and the os uteri dilated.   Dr.
Hunter is of the same opinion.  Dr. Clarke differs from
(hem both.  Dr. Hunter's opinion  wilh  regard to (hi?
matter  is partly explained  from  his disposition and
mind;  he was uncommonly clever; a  man of  great
powers of mind; a  most correct anatomist;  of a  most
clear judgment in every thing; but  with all this, he
was  a  very timid man,  who placed  implicit confi-
dence in the powers of nature ; and these things might
have influenced him in  bis opinions  with regard to
leaving the operation to the last moment.
   Dr. Clarke differed  from him, because  he found
from experience,  that if we delay turning  till the
waters  have come away, and the os uleri is quite di-
lated, we allow it  to remain (o die increasing the dif-
ficulty  of the operation.  If we take it when the os
ideri will admit  the finger and knuckles, it is tbe belter 
DELIVERY BY  TURNING.           J 99
time, because we then turn the child as if in a bucket
of water;  and this gives us so clear an advantage, that
it needs no explanation.
  When the os uteri is dilated to  such a degree as  to
admit the  hand up to the knuckles, is the most proper
time, and we begin  by dilating the os externum, pre-
viously intimating our  design to the woman, caution-
ing her not  to be in the least frightened at what we
are going to say; we may then inform her, " that the
child does not lie quite right, but it  may be soon set
right," and  we  may explain it to her thus;  " The
child lies  in your womb, just as an olive does in the
neck of a flask  when it will not come out; it lies ra-
ther crosswise, and the intention of the operation is to
alter the position of tbe child to  that which it should
be."  It being then agreed upon, the woman  is to be
laid close to the edge of the bed; and we roll up the
sleeve of our shirt,  and pin  it, anoint the hand and
fore-arm, and dilate by forming our  hand into a cone,
first, going gradually through (he  os  externum, taking
our time, and  being very gentle; but we should not
go  on to dilate beyond  the  vagina, until our  hand
passes easily through ;  if  we  do, we  feel the inconve-
nience  of it afterward, by the contraction of those
parts on the muscles of the fore-arm.  Having got our
hand through  the  vagina, we may let  it remain a
while, and should a pain come on, it may waste itself
on  our  band.   We should then gently begin  again to
dilate ;  till we get our  hand into the  uterus ; when we
turn the child gradually round,  bringing the head to its
proper  situation.
   There  is  no difficulty if we once  get our hand  up
through the os uleri, that being dilated sufficiently,
without the  membranes  beiug broken.  But  we will
suppose we are called  to another labour, where the
membranes are broken before the os uleri is  dilated.
We have much more to do, and less chance for doing 
 200    TnE LONDON PRACTICE OF MIDWIFERY,

 it well, than we had in (he  other examples;  we must
 go on, and have to turn  the child  too, under the in-
 creased difficulty  of the contraction  of  the uterus,
 which will not be violent, but quite enough to  render
 tbe turning difficult.  But if we are able to manage the
 most  easy case, and  the most difficult, we shall be
 equal to all the subordinate or intermediate degrees of
 difficulty that may be met with in turning.
  To give an example of the greatest degree of diffi-
 culty, we will suppose we are called to a case, where
 the waters  have  been lost  twenty-four hours, two
 days, or even three.  This will be a case of exlreme
 difficulty.   What we have to do  in overcoming the
 contraction of the uterus, is not altogether a matter of
 difficulty, as to skill, so much as to time and manage-
 ment.
  The last circumstance necessary to notice with re-
 gard to prseternatural labour is, that all  the other parts
 being  brought  down to the os externum, the head
 sometimes cannot  be delivered easily.  We may here
 use a moderate  force, by pulling with the body, re-
membering  that our object iu  not using too much
 force  is the saving  (he life of the child.  Besides, why
should we use a force too great, when we may always
deliver  with the forceps ?  though, where violence ii
unavoidable, it  is  best to open  the head; but if we
deliver by making  a hole in the head, and letting the
brain3 out, we may easily demonstrate that such a child
will not commonly recover.
  To employ that  force which, without violence, may
assist  in bringing away the head,  a sort of loop may
 be made,  by carrying a  handkerchief  loosely round
the neck, and bringing (he ends down upon the breast,
tying  (hem ratiier low on (he breas(, 60 that there may
be plenty of room to place  our hand  within it to pull
by; and if we  succeed, we must mind that, in bring-
ing down the head, we depress the sides of the  head, 
DELIVERY BY TURNING.
201
so as to bring i( into the hollow of the sacrum.   If it
will not come by any means, we must then open it;
when we have extracted (he  brain, we should  inlro-
duce the blunt hook, and it  is used  with the most
effect when seconded by the pulling of (he body.
  In some instances  it  happens that the head is
entirely separated from the  body,  when  various
means have been recommended for bringing it away ;
one way is a purse,  one extremity of which,  spread
out on the hand, is so carried  up into the vagina,  and
laid round the head,  that it shall include  the whole;
by which means it is to  be brought out: another is
by the assistance of instruments, various  descriptions
of which  have been  recommended;  these  instru-
ments  "may be considered as just  so many  contri-
vances to catch the head, as we catch a bird by putting
salt upon its  tail.   If we get the instrument on, we
may catch the head; and if  we get  the  salt  on the
bird's tail, we may catch him too.   The way to ex-
tract the head is  (o open i(, and when we have dila-
ted  by (he  perforator, we  should  in(roduce  (he
crotchet, before we wilhdraw  (he perforator, in order
(o have (he head  always secure from slipping, as it
otherwise would do.  The difficulty is, that whenever
we touch it we have a smooth slippery surface,  which
we cannot keep-,  unless we  always have an instru-
ment within that  hole which  we have made : it will
roll over the upper aperture of the pelvis. We must
recollect always  to  keep  one hand  in  the vagina,
while any operation is  going  on, for the extraction of
any body which may be within the uterus, in order to
guard the instruments,  &c. 
202
                   CHAP. XI.

                 COMPLEX LABOUR.

Complex labours form the next and third division.
There is no  natural connexion between the different
species of this  class.   In  natural easy labours, there
are certain circumstances common to all cases; (he
same in difficult labours.   But complex labour has
nothing in common with other labours.  There are a
number of species collected together, merely with a
view of bringing to a focal  point  all  the  varieties
which are not included in the other classes of labour :
therefore  it  signifies little where we begin. '  They
are  divided  info five  orders.   The first which  we
shall notice, is  the  presentation  of the  umbilical
funis.

          Sect. r.  Presentation of the Funis.

   We have  already explained that  the foetal life is
that of a  fish ; that  it is  furnished with  an  apparatus
resembling gills;  that the funis is analogous  to  the
pulmonary artery and vein; and that the  circulation
through it, if stopped, produces death upon the same
principle  that  suffocation does  lo an animal which
breathes.   Hence the importance  of the funis pre-
senting.   Whatever part may  present, arms,  legs,
shoulders, or breech, it is of  consequence from  this
circumstance chiefly.  It is of no import with regard
to the woman's safety, and does  not  add to the diffi-
culty of  (he labour.   We  may lay it  down  as a
general rule, that all treatment  is applicable  merely
upon  the simple'ground of  preserving. the  child's
life  while labour goes forward; and  that, if the child
is alive, we should take care to keep  it so; and if the 
COMPLEX LABOUR.              203
woman  is not in danger at the beginning, our utmost
attention  ought  to be directed to avoid her being
brought into it by any mode of treatinent which  we
may adopt.
  There are two sorts of funis  presentations; origi-
nal  and  accidental:—original  presentations,  when,
in consequence of the membranes being ruptured, a
sort  of  eddy  is produced by the evacuation  of  the
waters,  which brings down the cord with it.   Which
way soever  it may have been produced, the effect is
the same, and the treatment must be adapted (o  (he
circumstances of (he case:  which  (reafment   has
been laid  down in a very summary way,  " that when
the funis  is down it must be put up, kept up, and
preserved from pressure ;" and  " if it  is difficult to
get it back,  turn and bring down the feet."  Nothing
is easier than to give  these  summary directions, and
nothing more difficult than  to carry them into prac-
tice.  Suppose, for example, we meet with a  case of
(his kind in  a woman  who is  in  labour with her first
child, and the os uteri  not dilated beyond the  size of
a shilling, how  shall  we get  up our hand, and first
(urn, and  (hen save (he life  of (he child ? In (he first
labour (be os uteri i3 always  rigid; and why  (hen give
the woman  such  a quantity  of pain,  in going through
all  these  processes and  manoeuvres, while there is
no chance  of gaining our object, that of saving the
child ?
   Let us suppose (he membranes lately broken,  and
the  os  uteri pretty fully dilated, the funis being down.
The  practice here, will  be  to  turn (he child,  and
bringdown  thefeei; (his affords (he best chance for
saving  the  child's life.  Suppose (he head is in (he
pelvis, and  the navel  string is  pulsating in the  vagina,
the  best  way is to return it,  and follow it up with a
long strip of cloth,  or handkerchief, artfully  pushed
up,  so  as  effectually  to prevent i(s  coming down 
204   THE LONDON PRACTICE OF MIDWIFERY.

again: as this is the only chance that  we have of
keeping it above  the pelvis, it should never  be left
undone;  and at  last the head  will get so far  down,
that it can be delivered  by the forceps immediately.
So  that  in all cases we should recollect that the
woman's safety never must be hazarded wrhile we are
doing that which  will afford but a precarious chance of
saving the life of the child.

  Sect. ii. Cases where there are more than one Child.

  The next  description  of complex  labour  includes
those cases where there  are more than one child.
  The disposition to multiply" is general  throughout
the whole creation;  even in vegetables  it is  not un-
usual to  see two kernels in one  nut; and  (he  sheep,
instead of one Iamb, will sometimes  bring two.  All
uniparous animals may have two young ones,  though
in some species  it is more frequent than in others; it
is not so common for a mare to have  two foals, as for
the ewe  to have two lambs.
  In the human   subject,  twins occur once in about
eighty-eight labours: this  calculation was taken from
the  lying-in  hospitals of London,  Edinburgh,  and
Dublin.   There  are sometimes more than two;  as
three,  four,   and  five;  but such instances  are ex-
tremely  rare. Dr. Osborn mentions  a case where, iu
an  early miscarriage,  he saw six distinct ot;a, each
complete ; and there is  a monument in Holland to  a
woman,   who, the  inscription  declared, had  36fi
children.  But it signifies not,  whether there is one
or  365 in  the uterus,  for each has still  its distinct
ovum, each  its  own placenta: though sometimes the
placenta? are joined so closely, (hat they would almost
seem one mass.
  There  is  no mark by which we can  distinguish
(wins till after the  birth of one child.  It has been 
TWINS, OR MORE CHILDREN.         205
said that labour is then more slow  than at  other
times ;  but this  would imply that single labours were
never slow, which happens to be very far from true.
Another opinion is, that the woman is bigger than in
other labours, and  this would seem to  be very  na-
tural ;  but it certainly  is not very true; and many
practitioners have declared that they have never once
been  right in their opinion upon  this.   So that  the
labour being complex at  first, will depend  on itself
without any reference  to  the child;  but after one
child is  born, we  can easily  lay our hand upon  the
abdomen, and determine the  point; not forgetting
that where there is more than one child, the placenta
must  never be brought down  till the last child is de-
livered ; for if we use any force so as to detach a part
of the placenta from  the uterus, we produce a flood-
ing, so  that if possible we should find  out  the feel
which  a child  in the uterus  conveys; to do this  we
should feel the abdomen, examine  it carefully before
and after  birth;  before birth .we  shall feel  the
tumour  reaching high up to  the  scrobiculus cordis;
and after we shall perceive a rounded tumour lying on
one side above the pelvis like  a football.  If we  ex-
amine the abdomen in a  twin  case, after one  child is
delivered we shall not be able to say,  from  the  di-
minished size of the tumour, that one child has come
away.
  As soon as we ascertain that there are two children,
we  should let some one know it immediately : if  the
nurse is in the room,  we may at  once give  her  the
hint, by holding up two fingers; but we should never
say a word to the patient herself about  the matter;
and if by her own efforts she thinks she feels another
child, we  must not let her into the secret, we may
»ay it is the after birth.          ,.,.,.  ^ ,-    A-
  Now, with regard  to the second  ""child: deliver di-
rectly, says one; leave it to nature, says another j do 
206    THE LONBON PRACTICE OF  MIDWIFERY.

nothiug at all, a  third.   We generally  find truth in
the medium, rarely in eitiier of the  extremes.   If we
deliver directiy, we shall  nol be  acting  righ(;  and if
(he woman  is  allowed (o remain, that is, if she is
left to nature for two or three  days, it is not  right
either.   We must no( leave her  till she is delivered;
if we do, we do  it to her hazard.   It is proper,  (hen,
to wai( a moderate time, and by the recurrence of the
pains we shall find the part  that presents ; an arm or
shoulder.  Immediately  when we know that  (o  be
the case,  we should  tuck up the sleeve of our  shirt,
 and pass up our  hand, smeared  with fresh lard, into
 (he uterus, without any preparation on the part of the
 woman;  it is here better avoided, and the  child may
 be turned at once.   The one child has already  passed,
 therefore the contractions  of the uterus and  vagina
 will be a smaller impediment here, than in any  other
 case.
   It is much better to permit  the woman to recruit
 herself awhile, before her  labour pains are excited,
 to expel the second.  If (he practitioner is a young
 man, it is best  to wait about four hours, before be
 does any thing  towards  the  delivering  the  second
 child;  an experienced  person  probably  need not
 wait so long.  If we wait  lour  hours, no harm can
 happen from hastening the  delivery ; we have waited
 so long as  to justify ourself  in the eyes of  all  the
 world ;   but,  in  general,  the   contractions  of the
 uterus will  return before this time,  and force  down
 theftetus, when it will be necessary  to pass the hand
 into the uterus  and  bring down  the feet.  The re-
 maining part of  the labour is conducted as in cases of
 a single</ce/t«.
   As it is necessary to wait before delivery the second
 time, we mus(  be  prepared  for it, and  amuse  the
 patient with conversation : she  may inquire, " Dear
 me, Sir, why does   the  afterbirth stay so long  this 
MANAGEMENT IN TWIN-CASES.         207
time ?"—" Oh, they will sometimes be very tedious."
She will  say,  " But the  last  time I  lay-in,  it came
away  in ten minutes."—" Did it,  Ma'am? ay, 1 have
attended  so  many  since I attended you  last, that I
don't  recoil, rf  exactly  tbe  time it took  in coming,
though  I  recollect all  the   material circumstances
clearly "  We  should,  therefore, let  her  have  an
hour to cool and to nourish ;  and if, when she begins
to feel  herself strong, she should  be again uneasy
about  the af;er birth,  we may alarm  her a little,  so
that, after playing this piece  of artifice,  she will  be
quiet enough    Thus we may begin  by explaining  to
her that the after-birth is like a sort of sponge, which
ought  to  contract, and  will  not, in some cases,  till
after a  considerable time ; when it  does so, it will
get free; but, if she is very anxious, that we will  get
every thing ready to go up and perform the operation
of separating this spongy mass,  that we will  not give
her any more  pain than we  c«n help,  though  it is a
very painful operation without a doubt.  Before  we
have  said so mue.h. a& this, she  will feel  herself less
inclined t > it than  she was, and  tell us  that she  feels
herself  ea-ier, and,  if we please,  she   will  wait a
 little.    We may then urge it, for  we may be sure  she
 will be  against  it    The time, however, comes when
 we  really  see it necessary to turn and deliver, or at
 least  to deliver.  We  have now to  undo  what  we
 have  been doing   This we do  by  representing that
 the sponge  is separated and  is  kept by the uterus,
 which it  is  easy to  set  right  without  much  pain
 Thus we must  amuse  the  patient  by  talking of  the
 after-birth till the  second child  is delivered.   When
 the last child  is delivered, we may pull gently at  the
 cords of all the after-births at once, iu  order to pre-
 vent  a  partial separation,  which  might  bring  on
 flooding: pulling at one cord separates one placenta;
 this   brings  on  bleeding, and  the  woman  may die $ 
 -08    THE LONDON PRACTICE OF MIDWIFERY.

 therefore they must all be considered as one, and treat-
 ed, in giving assistance, as a single placenta.
   It is necessary for a young man to be prepared for
 a question (hat may be asked :  one of (he women may
 perhaps say, " Pray, Sir,  did you ever see a case of
 twins ?'"  If he  was off his guard, he would be apt to
 speak the truth, and say, no, he never did; now if he
 says No, he does an injury to the woman and himself
 too.   She will reason thus: "Oh dear  me, I hope I
 have not got twins, for he won't be able  do deliver
 me,  as  he  owns he never saw a case in his life."
 Her pains will gradually go off from the alarm.  The
 way is to give an equivocal answer, as, " It would be
 very odd if I had not seen a case of twins in so large
 a  town  as  London, in  the midst of which there are
 so many advantages, such a number of large hospi-
 tals, that I declare a person  has an opportunity of
 seeing much more in London than he would have any-
 where else."                    'V> ;
   A twin case  is not quite so safe as  a single brth :
 the woman will sometimes die without our being able.
to give  uie feasT reason for ft.   As there  have been
some  fatal  instances, we should be upon our guard
not to say there  is no danger in such a case; we may
say (hey are commonly  not cases of danger, but
 should not, when asked, say that it is perfectly safe.

     Sect. hi.  Labour attended with Convulsion.

   The next case of complex  labour, is that in which
 [he labour is attended with convulsion,  commonly
 called convulsion cases.  Cases of puerperal convul-
 sion bear a strong analogy to epileptic  fits:  so much
 do they resemble  each other, that it is nearly impos-
 sible to distinguish  them at first  sight; the only way
 is to be aware of (he differenf degree of violence al-
 iending each.  The  fit  of  puerperal  convulsion is 
       LABOUR ATTENDED WITH CONVULSION.     209

much more  severe  than  any fit of epilepsy.   The
paroxysm is so violent, that a  woman, who  when in
health was by no means strong, has been so convulsed
that the whole room was shaken.
  Puerperal convulsion may occasionally arise at any
time between the sixth month  and the completion of
labour; it seldom or  never happens  before the sixth
month.   It may arise as the first  symptom of labour,
or in the  course  of  labour, or after the labour  is in
other respects finished.   This convulsion we know
depends on the state  of the uterus ;  and that, at  any
rate, the period of pregnancy predisposes to it.
  Puerperal convulsions have these characters belong-
ing to  them:  they always occur in paroxysms, and
those paroxysms occur periodically like labour pains;
so that there is a considerable space between, perhaps
two  hours,  before the two first  attacks, as  there is
between  the  first and second  labour pain : after  this,
they become more frequent.  They not  only occur
with the labour pains, but in the intervals between;
and whether there have been labour  pains or not, be-
fore they come on we shall always find the os uteri di-
lated, and it is sure to become dilated from the  con-
tinuance of these convulsions;  and, at  length, if the
woman  is not relieved, and the convulsions continue
without killing  her, the  child is actually  expelled
without any  labour  pain  at all.   On opening such
cases after death, where the convulsions have been
violent, the child  has been found  partly expelled by
the contraction of the uterus.- which power is ca-
pable of  expelling it even after death.  In one  case
in which  it happened, the whole child was expelled
except the  head: the mother was  a ^ioor woman,
and  was  laid in a  shell  directly as she  expired, to
prevent  dirtying  the bed  from the discharges,  &c.
The gentleman who  attended  her the following  day
obtained leave to open the body, and, upon removing
                       T  2 
210    THE LONDON PRACTICE OF MIDWIFERY.

the lid of the shell, actually found the  child as above
mentioned,  no  part of which was protruded at the
time she died.
  It is a disease depending on the uterus, and brought
on by the labour pains; or if arising before them, is
of itself capable of expelling (he child, if the woman
survives long enough : it occurs in all  presemations.
It has been  said that it always arises in a first labour,
and that its cause  was the  first child; that however
we have no reason to believe, though  there is a  cir-
cumstance  that frequently assists in producing  con-
vulsion, and that  is,  the  first child being  born,  and
the mother an unmarried  woman  at the time.  The
nature of it partakes of hysteria ; but  it differs  from
hysteria so far as to be always distinguished by its ex-
treme violence; for a patient in puerperal convulsions
will shake the room  by the alternate contractions and
relaxations of the  muscular fibres. No force can re-
strain  a woman  when  in these  convulsions.   The
distortion of the countenance, again,  is beyond  any
tiling that can be conceived : in regard  to  deformity.,
nothing bears any resemblance to  the progress of this
disease ; the rapidity with which the eyes open and
shut, the sudden twirlings  of the mouth, are altogether
frightful and inconceivable.
  These convulsions are  by no means external  only.
Respiration is  first effected with a hissing and  catch-
ing.  The patient stretches  herself out, and imme
diately the convulsion  begins.   The  next symptom
which arises comes on after the convulsive motions
have continued in their  utmost violence for a time;
die  woman foams at the  mouth, and snores like an
apoplectic patient, indicating great fulness about the
brain.  These symptoms are succeeded by a comatose
sleep, out of which the patient awakes astonished, on
 being  told  what has  happened, not in the least
 ware that  she has been  in a fit; and  then she will 
PUERPERAL CONVULSION.
211
fall into another fit, out of which she will again re-
cover as  before.  It rarely happens that the under-
standing is taken away in this disease until it has been
repeated several times.   In the fit the skin becomes
dark and  purple, proving that the circulation through
the lungs is not free, which  purple colour leaves the
woman  gradually  after the  fit is gone;  and it is not
only the  external parts of the muscles of respiration
that are affected here, but the uterus also.   This was
known by introducing the hand when the convulsions
came on,  and the uterhs contracted,  but with a tre-
mulous  undetermined sort of force, perfectly different
from what it does at any other time.
   There are two cases of puerperal convulsions, which
are very distinct:  one  is a convulsion dependant  on
some organic  affection  of the brain; the  other,  an
irritable state of the nervous system. By organic affec-
tion of the brain is meant those cases  where there is
fulness  in  the  vessels  of the brain,  which  may  be
merely  the pressure  of blood in vessels, quite  inde-
pendent of- extravasation.  Another case may be, ex-
travasation of blood from vessels in the  head; which
may be greater or less, as it'may have been obviated
in its early stage by the preventing more blood being
effused.   A lady living in  the country  applied to a
gentleman who attended the family, and had unfor-
tunately come  to a determination that all ladies  must
be nervous women: she had  evident symptoms  of
fulness  about the head, was treated  improperly, and
came up to London.  This lady's  appearance was
such, that, had  she  been a washerwoman, we might
have said she had been accustomed to eat and drink
too much.  From  the jolting  of the coach, she had
symptoms of approaching miscarriage.   She was ad-
vised immediately to lose sixteen ounces of blood,
which she did:  and for all that, in the middle of the
night,  her  nose burst forth bleeding profusely,  by 
212    THE LONDON PRACTICE OF MIDWIFERY.1

which,  in a  short  time, she lost a pint and a half
more ;  it stopped,  and before the night was  over,
burst out the second  time.  This was the  first  time
in her life that  she  had bleeding from the nose at all
That lady, some weeks after, was  delivered prema-
turely, and for some time after the labour had lost the
sight of her left eye,  which was restored by degrees.
There is little doubt, in this case, but  that there was
an extravasation either about the optic nerve, or tha-
lamus, which was gradually absorbed.
  Another case of puerperal  convulsions  was from
inflammation of the  brain.  This  patient had  met
with much distress in her family, having  lost her hus-
band and a child.  From the attendant symptoms, the
physician thought she would have  convulsions from
the irritation, and so  it  was; one night he perceived
them coming on, by  the woman telling him that she
had got a new motion with her arms;  he supposed it
depended upon  the uterus: upon  examination  he
found the os uteri considerably dilated.   While he and
another practitioner were talking in  another  room,
they were called in : she;  was in a puerperal convul-
sion; the disease increased till she died.  On examina-
tion, a firm  layer or coat of coagulable lymph was
found between the dura and pia mater.
  The last state of diseased  brain we shall mention as
producing the puerperal  convulsion,  is  suppuration.
In one case the woman died of the puerperal convul-
sions, and the brain above was of a perfectly  sound
appearance;  below, in the choroid plexus, it was in a
state of suppuration.   Now,  during the time this must
have been forming, she had no symptoms which just-
tified the supposition of so much mischief below, till
the convulsions came on.
  Where puerperal  convulsion arises from an organic
affection of the brain, but  more  especially where it
arises from fulness of vessels or extravasation, it is al- 
CAUSES OF PUERPERAL CdNVULSTON.     213
ways preceded by some symptoms, which, if watched,
will enable us to relieve, if the patient  sends in time,
which is  rarely done;   and if these symptoms  are
neglected, on some unlucky hour the patient falls into
convulsions.   The  lady, whose  case was mentioned
before, who for a time lost her  eyesight, most likely
might  have been   prevented from that  accident by
proper treatment,   that  is,  by  taking eight  or  ten
ounces of blood from the arm, and repeating the ope-
ration in a day or two; keeping the bowels  in  a  re-
laxed state  by 5ss. vet 3yj. magnesia? sulphat. or an
appropriate opening draught every second or third day.
until the plethora was diminished. There area number
of cases  in which the disease may certainly be pre-
vented from reaching any formidable height, by adopt-
ing a proper treatment.
  In  patients  strongly  disposed  to this complaint,
there will be a sense of  great fulness in the  region of
the brain, which amounts even to  pressure,  giddiness
in the latter periods of pregnancy,  dizziness in  the
head- an4 ^ *ea*ation. of weight when the head stoops
forward, which gives her the idea that she shall  not
be able to raise  it  again; imperfect vision; bodies
dancing before the eyes, sometimes dark, at others
luminous.  This state of eyes denotes  fulness of  the
vessels  of  the head more  surely  than any  other
symptom, and, if allowed  to  continue,  wid lead to
extravasation  and  puerperal convulsion.  The  dis-
turbed vision  is a  very  strong  symptom, and must
never be passed over.  If attended  to early, even  if
symptoms  of  the complaint are present,  still  it may,
by timely assiduity on our part, be  prevented, from
ending in  premature labour.  In one  case, where  a
iady had four puerperal  convulsions,  sixteen ounces of
blood were taken from her, she was  well purged,  arid
she not only  lived, but  fell into labour four weeks
afterwards,  and went through without any symptom 
214    THK LONDON PRACTICE OF MIDWIFERY.

of convulsions occurring.  In another case, the woman
had felt her<elf indisposed a  long time, but would
not send  for any  body.  She  was so ill when the
doctor saw her, that  he sent for another, being aware
that it was a bad case; they both agreed on the pro-
priety  of  bleeding her to tbe great*-*! extent, and she
recovered, and was in five weeks after delivered with-
out a convulsion.
   The practice is all contained in this;  when there is
too great fulness, to bleed, and bleed, and bleed again;
take off all stimuli, and  purge  and bleed.   The first
thing to be done after bleeding, or before a pume can
operate, is to give a solution  of  soft soap, in  warm
water, one ounce of soap to a pint of water,  as an in-
jection; it is the quickest as well  as the surest: then
a  purgative  mixture,  with manna and  Epsom  salts.
By these  means, that is, by  bleeding, purging,  and
abstinence from solid  food and wine, no more blood
is made, what she  had  is diminished,  and  she gets
gradually  better.
   Another cuise was that of a lady  of some conse-
quence in the fashionable circles:  she  was under  the
necessity  of being confined to  her lodging, with only
a servant  maid.   When near her time, she was seized
with a violent pain  in the head, which  was in degree
dreadful beyond what she could express. It resembled
a pointed dart, shooting across between tbe  temples.
She felt it so violently  affect  her eyes, that it took
away the sight altogether; she could not see the prac-
titioner who  attended;  she knew that he  was near
her, because she beard him,  but she  could not  see
him; he held the caudle  to her eye ; she was conscious
it was close to her, because she felt it hot,  but did not
perceive the least degree of light.  Sixteen ounces of
blood were  taken  away directly; the soap  solution
injection  administered,  and  the laxative  medicine
 taken soon after; the head was shaved and  blistered: 
CAUSES OF  PUERPERAL CONVULSION.     215
she  got  better, and at a proper time fell into labour
without experiencing the slightest return  of the convul-
sions.
  Cases of puerperal convulsions, depending on pres-
sure of the brain, may be in most instances  detected
while the disease is forming, and before the convul-
sions arise;  and if the woman applies  to  us in time,
we  may check  the  disposition to  it; where there is
fulness of the head and face, when  she complains of
frequent pain in the head; where the pulse is full and
laborious, not beating above 50 or 55, while  in health
it is rarely  below  75.  The plan  then is to  bleed,
purge, blister, and lower the circulation  by abstinence
and diluting  liquids: and  in bleeding we  must, as
often as  possible, take it from the neighbourhood of
the oppressed part; from the temporal artery  or ju-
gular vein.  The  latter is   preferable;  it  is  more
easily got at, and we  are not so likely to be frustrated
in getting away as  much as we  want.  This is  the
treatment which is to be adopted previous to deli-
very.—We now proceed to the description of (he next
case, which depends on an  irritable  state of  the brain
and nerves.
  The other way in which this complaint arises, when
it is not  dependant on plethora, is a general irritable
state of  nerves: when this is the case, it is difficult
to distinguish the disease before it becomes established.
It is most frequent in large  towns,  and in those  wo-
men who lead the  most indolent life;  therefore it is
found in the first circles of fashion, in  preference to
the others;  and  there is  one  grand  circumstance
which has great influence in its production, that is, a
woman's  being with child when she should not be so.
She is obliged to live in a state of seclusion from society
for some months perhaps, when she reflects and broods
over every thing  which relates to her situation, and
which gives her pain.   She recollects she is not to  ei- 
 216   THE LONDON PRACTICE OP MIDWIFERY.

 joy the society of the babe she has borne,  but on the
 contrary, will be obliged perhaps  to  part with it for
 ever.  She is afraid of her situation being known, and
 that she shall be considered an outcast in society.  In
 this way she will repine in solitude, till  at last the mere
 irritation of labour shall be sufficient to excite puerpe-
 ral convulsions.
   Affections of the  mind are  capable of producing
 organic mischief in the brain.   We see  other things act
 upon it which are equally immaterial,  such as fright,
 the effects of which are inconceivably violent in some
 irritable habits.  Two ladies of consequence were go-
 ing  down the ride at Ranelagh, when by some acci-
 dent the pole of the carriage behind their  own came
 through (he back pannel of (he chariot, by which (hey
 were both very much frightened; one of them was in
 the  last  month  of her  pregnancy.  She did  not fall
 into labour  till a fortnight after the accident,  but du-
 ring that time she was not free from the most terrible
 state of irritation,  which continued up  to the time of
 labour, and threw her into paerperal convulsions, of
 which she  died.  Another  peeress was walking in
 her garden,  when a robber sprung  from a hedge, and
 presented a pistol demanding her money, which she
 delivered: the man went away again, and was seen
no more ; there was an end of it.   She walked back
 into the house, but was, nevertheless, throwu into the
 most violent state of irritation and pain, which was
 insupportable at her stomach: the pain was dreadful,
 and  in the latter part of the time  she also fell into
 puerperal  convulsions, but she recovered.
  The difference between this kind of  puerperal con-
vulsions and the other does not probably exist in any
thing visible: it is  not possible to tell tbe difference
exactly;  but just as it is coming on, the woman will
Complain suddenly of a violent pain in the head, or the
stomach, which is expressed  in the same way by all 
      TREATMENT OF PUERPERAL CONVULSION.   217

women;  they all say they cannot survive the pain if
it returns once or twice.
  The wife  of a merchant in  the city was sitting in
the counting house with her husband;  he was at his
books : all at once she cried out she was seized with
the most violent pain in her  stomach that ever was
felt.  " Perhaps," says he,  " you have taken some-
thing that has disagreed with you."  No,  she  had not
eaten any thing many hours.  " Well," says he again,
" I hope it will  be better in a little time."  So  she
was: it went off almost as suddenly as  it came on.
" Well," says she, " it is almost impossible to conceive
so dreadful a pain as I felt, and  I'm sure if it  was to
come  back  I   should die immediately: I'm  sure I
could not live through it."   He treated it lightly ;  but
she did not:  the impression remained clear enough in
her mind : after a while the pain did return,  and the
manner in which she  expressed its violence alarmed
her husband; he sent for a medical man, and soon
after he arrived, she expired.

     Sect. iv.   Treatment of puerperal Convulsions.

   These, (hen, are (he ways in which  puerperal con-
vulsions come on wilh irritation,  when  labour, or  any
other  cause, excites  them.   We  now come to  the
treatment.   It has happened, that the woman has died
of the first convulsion ; but it  happens  much more
frequently  that  a  number come  on  in  succession,
arising either before  or after  delivery.  The  patient
very rarely  dies  in the fit,  though  she dies from the
convulsion ; she dies in the comatose state which suc-
ceeds to the fit; and if we are suddenly called  to a
patient in (his state, where we are unable to learn  the
circumstances of the  case, and we evidently see there
is a great fulness  about  the head,  we should imme-
diately open a  vein, and  draw blood largely, being
regulated by (he appearance of the body and what  we
                         u 
218   THE LONDON PRACTICE OF MIDWIFERY.

are able to learn from those around.  From twelve to
twenty ounces may be the extent of the first bleeding;
if the disease goes on, and the os uteri does not admit
of delivery from its not being in the least dilated, the
convulsions not gone off, and the pulse in such a state
as admits of it,  we  should bleed  again,  and  again.
Some practitioners have, with the greatest  advantage,
taken sixty ounces of blood in a day.  A woman in
this state will admit of divided bleedings very largely.
This takes off the pressure from the  brain, made by
the blood while  in its vessels ; and  lessens  the chance
of its being extravasated out of its vessels.   This must
be done immediately : then the head must be shaved,
and a large blister applied over the  whole.* The next
means of relieving is getting the bowels into action as
quickly as possible: first, tbe throwing up the soft
soap solution in the form of injection, and then giving
a concentrated solution of some neutral salt as potass.
tart, magnesice  sulphat. or soda tarlarizat. with infu-
sion of senna.
   If it is a case of convulsions depending on irritation,
we may  certainly do something more  by  the  use of
opiates; but  here  we must be limited in (he quantity
of blood  which may be taken away.   The proportion
must be  small, compared wilh that proper in plethora.
Eight or  ten ounces will be a full bleeding; and if it
is necessary to take more, we may apply leeches to the
temples, never neglecting the  bowels, which must be
kept very open.   It has been directed that the patient
be pu( into a warm bath; but experience  contradicts
its use: the fits have been found to be more violent
in it, and the patient is  liable to bruise herself in it,
and be otherwise much injured.

  * The application of a cold wash to the shaven head seems a
better method of giving relief, than a blister.  I he patient on her
return to recollection generally expresses her feelings of comfort
from the cold ablution. 
TREATMENT OF PUERPERAL CONVULSION.   219
  Puerperal convulsion is an extremely dangerous
disease ; it is impossible  for the brain to bear violent
pressure long : opium, in cases of irritation, is proper,
and should be given to the greatest possible extent.
  A German  doctor used to affirm he had found a
specific for puerperal convulsions, and  what was it?
why, a grain of ipecacuanha; but then, to be  sure, he
had  sometimes  little auxiliaries, such as stimulating
clysters, or the taking away forty ounces of blood ; not
that these could have  any effect  in  themselves,  but
they gently enabled the grain of ipecacuanha to display
its powers! !
  An old remedy, and one that certainly has a chance
of being useful, is  the application of hot bricks to the
feet, &c.   Another remedy is the use of cold water:
Dr.  Denman, whose work,  " An Introduction to tbe
Practice of Midwifery,"  should be in the  hands and
memory of  every  practitioner,  has seen the patient
relieved from that state of irritation immediately  pre-
ceding the convulsion, which, he says, was  done by
having a basin of water in one hand, and a bunch  of
feathers in the other, dipping  the feathers into the
cold water, and dashing it over the face: the  effect
was, to rouse the  woman, and interrupt  the  progress
of the fit.   If a further application of cold water is
necessary, we  must have a full pail and an empty
pail, the patient's head being brought over the side  of
the bed; and before the fit has come on, we may,  as
 iu other convulsions, detect its approach, by attending
to the intercostal muscles, the vibrations of which will
 warn us that no time is to be lost; and if after this the
fit.is put off, the water having  been  poured over the
 head, it is surely a ju3t inference  that it was the effec
 tual remedy.                              .      .
   Having now stated ail those  means, which  being
 applied to the cause of puerperal convulsion will  lessen
 the operation of that cause, we  shall point  out that 
220   THE LONDON PRACTICE OF MIDWIIERi.

plan which should be pursued when this complaint 01
curs at or near (he time of labour, when it is uniformly
right to deliver: to  dilate the os uteri, and deliver im-
mediately.  We should deliver in all cases where it is
practicable;  for in  such a  state of things this is  (he
only cure for puerperal convulsions.

     Sect.  v.  Of Convulsions that may remain after
                      Delivery.

  After labour, (he  uterus is  emptied of its contents ;
all that can be done, therefore, is to  keep the brain
unloaded, and if we have any faith  in a particular an
tispasmodic, we may use it here; but if the disorder
should remain for a few  hours, apply a  large  blister
over the head, and  the next day, if considerable  be
nefit is not obtained, put a blister on  each  leg:  these
act as  counter-stimuli; that  is,  by exciting an irrita-
tion upon a part distant from the seat  of disease,  they
have a strong tendency  to diminish the diseased ac
tion, and thus afford relief.
  One of the causes of puerperal convulsions is  indi-
gestible food, as oysters.   A  lady had gone through  a
labour remarkably  well, and  at the end of a  fortnight
asked  if she might not come down into her  drawing-
room.   She one night ate some scolloped oysters : she
was attacked with the most terrible head-ach, in such
a manner, that she  sent for her physician, who  bled,
purged, and blistered her. She lived to the Friday fol-
lowing, and then expired.  Another lady, who had in
the same manner eaten  stewed oysters, was attacked
by  inflammation of the  brain, and puerperal convul-
sions, after almost  entirely  recovering from  labour.*
When the  cause can be traced to improper food,  a

  * A posthumous paper of Dr. Clarke on this subject, contain
fng many cases, has been lately published in the 6th vol. of thf
Transactions of the Royal College  of Physicians, 
RUPTURE OF THE UTERUS.
221
dose of castor  oil,  or of some quickly-operating ca-
thartic, should be administered as speedily as possible.

          Sect. vi.  Rupture of the Uterus.

  Rupture of the uterus was formerly considered as a
very rare occurrence, though it probably happened
oftener than  practitioners were aware of.  We have
many  descriptions  of sudden  deaths in  labour, the
symptoms of which  exactly  correspond with  those
known to attend this complaint.  It  may be divided
into two kinds, spontaneous and accidental:  the first
happening most commonly in the cervix uteri, and the
last at any part of  the uterus.
   Spontaneous  rupture  happens suddenly and unex-
pectedly, and  always without any warning ; and for
this reason, that it depends  on the  irregular action of
the muscular  fibres, and all  muscular contraction is
immediate.  When the tendo Achillis is ruptured, it
is  from the violence  of muscular contraction; when
the patella is broken, it is not because its situation as
a bone  exposes it  to more danger of being fractured
by an external force ; but it is capable of being placed
in  such a situation  by the actiou of the flexors and ex-
tensors of the leg, that the force of muscular contrac-
 tion in this instance always effects the division—it is
 torn asunder.  The rupture of the uterus  is conducted
 upon the same principle.  It most commonly happens,
 that when the head of the child is in the cervix uteri,
 the lower segment of the uterus is received into the
 upper aperture of  the pelvis ; and the aperture  of the
 pelvis without the uterus being opposite  to the bones
 of the  head  within  the uterus, the consequence  is,
 that  the uterus is pressed firmly  between  the two
 forces: from the pressure being applied in this situa
 tion the longitudinal firbres can only contract from the
 nressed circle towards the fundus; and upon this pwi-
  1                       u 2 
2,22   THE LONDON PRACTICE OF MIDWIFERY.

ciple it will not be lacerated  at the  extremity, but
from the part so pressed upon :  the  laceration once
made, may run in any direction.
  The accidental rupture occurs from tbe action of the
uterus being violent while the hand of the practitioner
is  within,  for  the  purpose of turning; or the  same
thing may happen from  the limb or  the knee  of the
child ;  which last is frequently the cause.
  The manner in which the  uterus gives way  in this
instance, is exactly as a fibre contracting over a pulley,
which being a disadvantageous position is liable to be
ruptured if the contraction is  strong.   Certain  symp-
toms take place, which are   evidences of its having
happened; one is a sensation of a sudden and most
excruciating pain which  always comes on at the mo-
ment of the rupture.  A lady, when in  labour, was
attended by a most respectable practitioner, and a man
in years:  this  case is an example  of the manner  in
which it may come on.  The labour went on perfectly
well, and  it being late at night,  he proposed that the
husband  should go to bed, as his wife would be deli-
vered in three  or four hours  more.  The gentleman
then sat  down by the bedside of his patient, and  in
about three quarters of  an hour  she  began to scream
suddenly ;  he supposed the head was in the vagina, as-
the labour had gone  on so well;  when, to  his asto-
nishment he found the head was not  to be  felt, it
bad entirely receded.   She would get up, and he  in
vain prayed and begged her  to lie still.   It is  almost
unnecessary to say that the  case terminated  fatally.
This state of pain and restlessness was succeeded by
faintness,  from two  causes,  hemorrhage and pain.
These are attended with another, which is the sudden
loss of labour pains.   There is a faint inclination in
die uterus  to keep them up, but  they are sure to sink.
The organ is destroyed, and its functions must neces-
sarily  cease.   The fainting, which depends on loss of 
            RUPTURE OF THE  UTERUS.          223

blood, shall appear without  any external discharge ;
for it may flow, and  often does,  into  the  abdomen.
Vomiting attends this misfortune, and this  does not
cast off the contents of the stomach only, but a tena-
cious chocolate-coloured fluid, different in its appear-
ance from any thing else.   All these symptoms com-
bined, become  a proof of the woman having a rup-
tured uterus ;  but any  one of  the symptoms may
occur;  she may  be in violent  pain  without  rup-
turing the uterus;  she may  faint,  but it does not
follow that her  uterus is torn :  but all  these things  in
common ; excruciating pain, a fainting, sickness, and
vomiting of that singular kind, and the retiring of the
presenting part; these in  the aggregate  wi|l  deter-
mine our opinion.  If in a  case of this kind we find
the  head  has only entered the upper aperture of (he
pelvis, we canno( get the forceps applied : here it has
been said we  might  turn  and bring down the feet;
but this should never be attempted, it  only occasions
more mischief; the only chance i3  to  open the head
of  the child.   If, however,  from  the head being high
up,  and loose,  we think that we can embrace  it with
the  forceps, we may try, for we  by  that means give
another chance for the delivery of a living child, which
is a great object at all times.
   Suppose we were called  to a case where the child
 had actually retired from the cavity of the uterus into
 the cavity of the abdomen, what is to be done ?  There
 have been different  opinions: some say it is best to
 bring the child back, while others leave it to  nature.
 It should always  be returned and delivered  by  the
 feet; but with regard to the  leaving it to nature, it
 has  been urged that  the bones of a  child's skeleton
 were voided by an abscess in the side; and it has been
 supposed that the uterus must have been ruptured, and
 the child pushed into the  abdomen;  that  the uterus
 healed, and the surrounded  parts formed a  cyst to 
"224    THE LONDON PRACTICE  OF MIDWIFERY.

enclose it, by a little  adhesive inflammation, which
afterwards was resolved into an abscess, in order that
the bones,  &c. might be  thrown  out;  and all  this
without the patient's feeling any symptom  relative to
(he accident!!  As to the bones being so discharged,
there' is no doubt, because they  were seen; but the
ease was plainly that of an extra-uterine conception.
The idea of believing such a wild sort of conjucture
argues insanily, for it is as perfectly  unreasonable as
the belief of a  madman.  The foetus in  this case was
either contained or nourished in one of the Fallopian
tubes, or perhaps in a dilated ovarium.   That the child
should  tear its way through the side of the uterus,
scramble  among  the intestines,  kick and maul the
liver, and knock about the spleen, and all this with-
out exciting any but the  mildest  inflammation, is one
of those wild opinions, of which  there are vast num-
bers in physic; which were they  stated with the same
freedom in  regard to the ordinary affairs of life, the
Chancellor would  do well to grant a statute of lunacy,
for the taking care of such valuable members of so-
ciety.   In a professional point of view these are called
ingenious men.

           Sect.  vii.  Uterine Hemorrhage.

   Flooding cases will be next noticed ;  and are natu
rally introduced here, hemorrhage being  one of the
constant attendants on  the last-mentioned accideut.
We have already  considered the  history  and  manage-
ment  of trifling floodings occurring in  the six  first
months of pregnancy, when speaking of the manage-
ment of abortion: what we are now going to treat of,
relates to the three last months, and is of the greatest
importance, and  is most common at this period.  It
 does not refer  to the treatment of the practitioner, in
 the same  way as convulsions; it happens  with the 
         CAUSES OF  UTERINE HEMORRHAGE.     22J

best as well as  the youngest practitioners, which is
not the case with convulsions.   If a patient is  giddy
and heavy, and the practitioner bleeds and purges,
the approaching convulsion may be prevented :  this is
not the case  with flooding.   When convulsions have
once come on, they sometimes continue in spite of the
most  skilful  management;  but with regard to flood-
ing, if the woman does not die of the first flow of
blood, she ought not to  die  of  the disease  at all.
Uterine hemorrhage may occur at any time during the
last three  months; at the  commencement of the  la
bour ; during the progress of labour, or after the dc
livery of the child, and before that of the placenta;
and each  of these divisions, as regards time, will run
into the rest.
   The proximate cause of puerperal floodings is in all
cases the  same thing, consisting of a partial  separa-
tion of the surface of the placenta from that  of the
uterus.  The difference existing in structure, between
the human placenta and that of brutes, accounts  for
its happening less frequently in them than in us.  In
quadrupeds, the foetal part separates  from the ma-
ternal portion, as was before explained; while in (he
human subject the  whole placenta comes away  entire,
leaviug vessels with open  mouths; so that  when any
portion of it is separated   by any mischance, a con-
sequent hemorrhage  attends,  which is proportioned
in violence and  duration   to the extent of the part so
exposed.  The vessels are largest towards the middle
of the placenta: and some of them are very large on
the inner surface of the uterus.
   The occasional causes of uterine hemorrhage may
be any of the circumstances capable of separating  a
portion of the placenta from  the inside of the uterus.
These were enumerated when speaking of abortion :
all acute diseases ; passions of the  mind, as rage, &c.;
strong liquors  in large quantities;  and besides these 
226    THE LONDON PRACTICE OF  MIDWIFERY.

if the placenta is attached close to, or over the os uteri,
it will be very likely to  produce hemorrhage, either
before or in labour.   When it is attached on the cervix
uteri, it must in the course of the labour be separated
by the dilatation of the  uterus at its neck; this is so
plain, that it cannot require illustration: it  will almost
ensure uterine hemorrhage in the last months of preg-
nancy, which may be more or less in quantity.
  If it is very slight, the necessary means to restrain
it need be nothing more than what are used in slight
hemorrhage from any  other part;  but when violent,
and  the  patient either  gets one gush of blood, or it
comes in quantity till  she  faints, and then it is re-
strained, and  she  gradually  recovers; and it recurs
from her taking some stimulus into her system, either
food or drink;  she  has  no sooner  recovered  a little
strength, than another  bleeding  comes on, and  she
will  faint and recover,  and the flooding again recur,
and  so on; the  faintness causing the restriction of
the vessels ; the restriction of the vessels allowing the
circulation time to restore its  own equilibrium;  and
when once  that has  arisen, the force of  (he circula-
ting blood again overcomes  the slight resistance
formed by the contraction of the vessels, and the coa-
gulum.
  When once a  woman has  bad an uterine hemor-
rhage, from  whatever  it has proceeded, that woman
is never safe:  she  must remain  in  jeopardy every
hour, until she is delivered, for the slightest circum-
stance may reproduce i(.   The danger in this state is
not from tbe quantity of blood that is lost, so much as
the manner in which it  is lost.  A bleeding has come
on at the third month, which was exceedingly large in
quantity, but, in consequence  of its  not flowing very
quick, the woman  survived.   Miscarriages occur,  in
which a> large quantity of blood is frequently  lost,
 without the  woman dying:   insomuch  that where 
         CAUSES  OF  UTERINE HEMORRHAGE.     227

abortion  has occurred in the tenth  week, she very
rarely dies from loss  of blood, though sometimes it is
excessive.   What then does this depend upon ?  The
time in which it is lost, and the way in which it comes
on ; for although  lost from  the constitution, it is from
small vessels, and not so dangerous ; but when there
is a sudden gush of blood from large  vessels, the case
is quite different:  by experience  we know that large
vessels do not contract so soon as small ones, there is
not time for faintness to come on,  and the patient,
consequently, dies immediately.
  There is  another  danger, the more formidable  be-
cause it creeps  over the practitioner so insidiously that
it is not even observed, much less  regarded : suppose
a man to be resolved to pay the utmost attention to
his patient, yet  he is  beguiled from hour to hour, from
day to day,  by the supposition she can still be deli-
vered safely if left a little longer.   This has happened
to the most expert, experienced men, who have been
thus led away, (ill (he woman  was almost dead, and
(oo far gone ever to recover : such people may not die
directly: they may die a twelvemonth afterward,  but
their death arises  from the loss  of blood during their
flooding.
   One symptom  of the greatest danger in a flooding
case, is  a want of labour pains, when it occurs in la-
bour; and that is the reason that the midwife hardly
ever sends for us  till  it is too late : she thinks nothing
can be necessary to be done till the pains go on as they
should do, while  in fact  their subsiding is one of  the
worst symptoms : they wait till they see their mistress
near expiring,  and  then send for us to  clear them-
selves.  This symptom shows that the uterus has not
energy enough  left to expel  the child; so that we al-
ways judge uterine hemorrhage to be worse when not
attended with pain than when i( is.
   Anotiier  bad symptom  is, when the os uteri feels 
228    TH)E  LONDON PRACTICE OF  MIDWIFERY.

relaxed and flabby, like  a piece of meat with a hole
through (he middle  of it, resembling an inanimate
hole; we may wilhout resistance move i(3 lips in any
direction.   When the hemorrhage continues long, the
face loses its colour, the mouth and lips become quite
pale, and the little projection at (he inner canthus of
the eye is a very significant part with an attentive ob-
server,  although not usually attended to; if sunk, it
is a symptom of decided danger.   These appearances
are followed by  want of rest; the  patient will be
moving about in bed, notwithstanding all that can be
objected to it:  if we even represent the risk of her
producing her own death by it, still she will be throw-
ing her arms this way and that way, and rolling back-
wards and forwards.  In this manner then will she go
on, one fainting  fit succeeding another, at  last so
rapidly, that it  can scarcely be conceived until seen:
fits of vomiting  towards the end will occur, and a sort
of convulsive rising and lowering of the pomum Ada-
mi, and life will at last leave her suddenly; perhaps
after she has been speaking she will lay her head down
and die.
  The next danger is, that she may drain to death, by
a slow progressive state  of the complaint.  To-day
she shall lose a pint of blood, to-morrow half a pint,
next day none, the day after that  again a quart, and
so on,  till the powers of life are exhausted.  Thus is
she drained to  death; for the stomach is not capable
of supplying  nourishment quick enough to counteract
so rapid an exhaustion.
  There are  still  other dangers  arising from uterine
hemorrhage, the consequence of which there is great
reason to fear.  Suppose a woman in labour loses two
quarts  of blood by the vessels of the uterus, that wo-
man will, about the fourth day, have a  perfect fever
in all its characters, somewhat  resembling the milk
fever, (he pulse 120, (he countenance flushed, (he skin 
UTERINE HEMORRHAGE.
229
hot and  parched, though we should naturally enough
expect that, instead of producing fever, the loss of two
quarts of blood might more readily be expected (o take
fever off where  it  existed  before.   Supposing  even
(hat the patient gets quite clear from any return of the
hemorrhage, the fear that remains is, whether she has
not already (oo much for (he cons(i(ution [to repair ;
and we must again wait in expectation  of (he fever:
if (hat does no( come on, so much the better ; (bat is
another danger go( over.   But she may die many
months afterwards, from the debilitating effects of the
complaint.   This will in most instances happen in those
women who are of a flabby loose texture, and have a
heavy fat body.  Hydrotiiorax, or ascites, will in  (hese
persons come on at a greater distance of time, entirely
from the debilitating effects the loss of so large a quan-
tity of blood has induced.
  With regard (o (he powers by which hemorrhage is
restrained in different parts  of the body, we  may say
that they are two fold ; one of which i3 the contrac-
tion of the blood-vessels themselves, the other is the
coagulation of the blood in the mouths of the vessels
which are ruptured.  With regard to tbe contraction
of blood vessels, it is well known  that an hemorrhage
is  frequently stopped by that power alone.  If we
prick our finger, or shave a bit off, it would long con-
tinue to bleed, were it not for  (he contraction of the
divided  branches,  which stops  it, and that  so effec-
tually, that if from time to time  we even wipe  away
the blood with a sponge to  prevent any assistance
which might arise from the formation of eoagulum,
yet the bleeding will stop.   But as  the ves&els con-
tract gradually and slowly, the blood which forms on
the surface,  being exposed  to the  air, coagulates, and
becomes the second cause of the blood ceasing to flow
from the divided vessels.   So that hemorrhage, con-
sidered in general, may be said to be restrained partly
                        w 
230     THE LONDON PRACTICE OP MIDWIFERY.

by the contraction of vessels, and partly by the coagu-
lation of blood in the vessels.  The power of contrac-
tion is greatest in small vessels; which is a wise pro-
vision of the Author of Nature, as the larger vessels
are constantly replenished  by the immediate impulse
of the heart's contraction ;  while the smaller branches
are at a much  greater distance,  but  are  yet able to
press on the blood through them by  their contractile
power.   The consequence is,  that the quantity lost
from small vessels will be less felt by  the constitution,
than  the same  quantity that  is more suddenly  lost
from a  large vessel.  A person shall  bear an hemor-
rhage from small vessels, that will be  five times as
much in quantity as (hat which,  flowing from a large
vessel,  will certainly destroy  life.  The power of con-
traction is various in different animals :  a sheep shall
outlive the division of  the femoral artery,  which is
more than we can venture  to assert with regard  to our
own  species.  So it happens that the  blood-vessels
from which  the hemorrhage is effused in the separa-
tion  of the  placenta will  sometimes occasion very
sudden death.
   The other power by which hemorrhage is restrained
is the coagulation of the blood ;  in order to which it
 is necessary to  stop the stream before the blood can
jelly: hence the smallest vessels  are the most quickly
restrained.   Iu  large vessels there is so  great a quan-
 tity driven through them,  that the flow of blood pro-
duces death before coagulation can take place.  We
see thai neither of (hese powers is sufficient singly  to
stop  hemorrhage, therefore  to the tendency  in  the
blood to coagulate is added the power of contraction in
 the  vessels.
   There is a part of the body in which both these
powers are insufficient  for the checking of a flow of
 blood,  and that is  the  uterus ; here provident  Nature
 has  supplied a  third power,  which  compensates for 
       TREATMENT OF UTERINE HEMORRHAGE.    231

the large size  of the  bleeding vessels; this power is
contraction, by which the organ is capable of lessen-
ing itself to any degree necessary, compressing those
vessels which, after traversing its substance,  open on
its  surface.  Therefore  (he  power which is  of the
greatest consequence  in uterine hemorrhage  is the
contraction of the uterine fibres, and this binds all the
bleeding vessels as effectually as if we were to send up
the Spiritus  Archatus of Stahl,  with a  lidle pair of
scissars and a tape (o tie up all the orifices: we clearly
perceive  (he  view of Na(ure in (his mader, seeing
that, in the uterus, the  powers of contraction of ves-
sels, and coagulation, are  both  unequal to the check-
ing the stream of blood  flowing  into the cavity of the
uterus ; the  third is  provided, the power of  contrac
tion in (he fibres of  the uterus; (his is not only one
of (he  three, but it  is the most important,  as being
the most effectual of them  all, iu  stopping the he-
morrhages which flow from the  internal surface of this
cavity.  It should appear from  the experiment of
Hewson, in his book on the blood, (see  Experiment
xxi.), that the coagulation of the blood is more rapid
in animals when dying, than  at any other period;
hence he argues that coagulation is  always in propor-
 tion to necessity.

       Sect. vii.  Treatment of uterine Hemorrhage.

    With regard to the treatment that is necessary, we
 may observe that in slight cases, where (he quantity of
 blood lost is  very trifling, it will not be necessary to
 regard the existing state of pregnancy, bu( make use
 of die common remedies usually employed to restrain
 slight hemorrhage from any internal part; as infusum
 rosea cum tine, opii,  or conserva rosx, cum guitis ali-
 quot acidi vitriolici diluli, and the horizontal posture.
 A woman, for example, shall, from strong exercise. 
232    THE LONDON PRACTICE  OF MIDWIFERY.

rolling in carriages, falling down,  or  from mental
agitation, separate a small part of the placenta, and
have a small loss of blood ; here it is not necessary to
make use of any of the means which will be  men-
tioned as applying to more serious cases; where per-
haps only an ounce of blood is lost, and then  it is at
an end, and  nothing short of the application  of the
same cause would  reproduce the hemorrhage.   This
will not be liable to bad consequences, and should
never excite (he least alarm : there is  nothing of any
import in an hemorrhage  proceeding  from known
causes.   But if there is increased action of the  heart
and arteries, and we know that the  constitution will
bear it, we may take away ten ounces of blood, and
desire the patient to abstain from animal food;  mode-
rating the sanguiferous action,  so that there  shall be
no risk of displacing the  newly-formed coagulum, iu
its recent state, a  tender jelly.   It  these things are
attended  to, the blood  will perfectly cork up the
bleeding orifices of the ruptured vessels.   Let us here
imagine  an  amputation  of the leg  above the knee.
The tourniquet is applied  to  that  part of the limb
which places tbe pad over the  artery, where it pene-
trates (he tendon of (he triceps magnus.  The quan-
tity of blood lost in the operation will  be only that
which was contained in the arteries of the limb to be
removed; certainly there will  be some more lost, all
that which filled (he femoral artery between  (he edge
divided and (he point pressed  (ogetiier by (he tourni-
que(;  but (hat is, comparatively speaking,  nothing;
yet that  is all, if the  various  branches  are  properly
secured by ligature.   Suppose then the'ligatures come
off  in six days time; if the artery  should then be in
the same state as it was  when  (hat ligature  was put
on, the patient must die  in a few seconds, from the
spout Of blood: but provident Nature  has  not  neg-
lected securing it in the most perfect  manner; the 
       TREATMENT OF UTERINE HEMORRHAGE.    233

blood which lies between  the  tied end of the vessel
and  the  branch next above it, is out of the circula-
tion, it  coagulates as it is at  rest;  and the provision
extends further;  for  as  the pressure  made by  the
blood against the sides of the  vessel is now less than
when in the course of circulation, so the vessel is
enabled to contract itself with  more freedom, forming
a sort of cone with the  apex towards the ligature;
the vessel in this instance becomes conical, which is
not the case in any part of the body while they are in
their  primitive  state.   From  observation  we know
that a basin of blood being set aside,  does not all co-
agulate ;  the  coagulum forms a cake which floats in
the middle.   So it  is  with   the  coagulum  in  the
vessel;  which,  as it  gradually contracts, is pressed
on towards the end of the vessel by the continual im-
pulse of the heart:  wc  see  therefore, that it is as
effectually driven into the vessel as a cork can be into
a bottle.
  In uterine hemorrhage, it is necessary to diminish
the action of the  heart  and  arteries, even  if it has
stopped, to allow time for the coagulum to fill up the
space: we see the  necessity of avoiding every thing
which shall increase the momentum of the circulation;
for any exercise may reproduce it.  We must take
blood from the arm, and procure stools;  setting aside
the use  of animal food and stimulating fluids, wine
and spirits.  We must adopt these  means, independ-
ent of the  emptying  of the  uterus;  they will often
remove an  hemorrhage completely, and the woman,
afterward, goes  through  her labour without the least
immoderate loss of blood.  These means will be fur-
ther assisted by the  patient  being confined to  an
horizontal pos(ure for some days; (he  weight  of  the
column of blood will be thus  taken  off,  in part at
least.  This last circumstance  is to  be regarded ;  for
often, while the  patient keeps a reclined posture, she
                      w  2 
234    THE LONDON PRACTICE OF MIDWIFERY.

is quite free from any return of bleeding, and as soou
as she gets up the coagulum is immediately displaced,
and the bleeding returns.  We should therefore order
her to remain absolutely in (he horizontal poslure, and
(hat will often put a stop to the hemorrhage,  provided
it comes from  any  other part besides the  placenta.
But  we  must   remember  that the  treatment just
recommended  will  only succeed  in  slight cases,
where we are sure  the constitution cannot be affected
by the  quantify lost.  We must be upon our guard
not to  allow ourselves  to be deceived  and  beguiled
into  security; we  are not to think that, because  the
hemorrhage stops repeatedly,  the patient  will  not
die: this, (hough a  slow, is a  sure danger;  and  on
accounl of (he insidious  manner  in which  it creeps
over (he constitution, is the most  to be feared of any
other  danger,   and  is  more  likely to destroy  her
during the pregnancy.
   All that we  have  said leads to this conclusion, that
we must never let  a woman lose  such  a quantity of
blood as may  endanger the constitution without deli-
very.   A French  author, Puzos,  goes short of this;
he directs that  the  membranes be ruptured, and  the
 waters,  iu running off, will  produce  the  uterine
 action : this may happen; but because it may happen
 we  should  not trust to it.  Delivering at once never
 does any harm: allowing the  waters to escape may
 produce the death of  the child by the pressure of the
 contracting iderus; because it may  happen  that  the
 child shall be delivered in this way, it does  not follow
 (hat we are to trust in this possibility ; if it does not
 happen, we are worse off than before, and have either
  lo turn the child in  a contracted uterus, or to open the
  head.
    The wife of a respectable tradesman was one night
  sitting with her  family, when a  friend came in who
  asked her how she did, and addressing himself (o the 
       TREATMENT OF UTERINE HEMORRHAGE.   235

husband, " Ay," says he, " your wife  looks  very
well indeed:   I  remember very well  my poor wife
was  going  on just  as  she may do,  when she, one
time, was taken with something, I believe they call
it flooding;  however, the  doctor  delivered her too
soon, and the poor  thing died."   This was pleasant
information to a pregnant  woman certainly, and she
did not forget it.   She (hough(, al any rate, (hat she
would take care the doctor should not deliver her too
soon,  if ever she had a  flooding.  One morning she
said (o her husband,  "  I feel (he waters are coming
away, I wish you would  gel me a clolh to  lay  under
me :" he  did so;  presently  she  asked for another,
and had it; a third,  it was given her.   After this, she
said, " They are still coining, I wish you  would get
me  a dirty sheet to lay under me."   All  this time
she was  flooding,  and  knew it,  but would not  tell
him  of it for  fear of the doctor.  He thought  he
perceived  something strange  in her voice : he asked
her if she was ill:  she answered,  no ;  but he was not
 contented with this, for she  answered  as  if dying;
 and  then  he  discovered this flooding.   She then told
 hirn the reason  why she  had  concealed  it.   He sent
 for an eminent  practitioner, who had  reason  to con-
 clude, from seeing her situation, that it was too  late
 to save her  life.  He delivered  her,  and  she lived.
 But it was upwards of twelve mouths before she re-
 covered   her  strength  from the immense  loss  of
 blood.
   Another state of the case is, where the quantity  of
 blood lost is very small,  but is  frequently recurring.
 In  this way  it will weaken the constitution  to  the
 greatest possible degree,  and that without  our being
 led  to suspect it.  But no  patient ought to die of
 uterine hemorrhage who is  not in danger when  we
 first see her.   It so happens,  that many women have
 a great idea  of the impropriety of  delivering till  the 
236   THE LONDON PRACTICE OP HIDWIFERf.

labour pains come on;  here they require  manage-
ment.  We may, " Bless me, Ma'am, your situation
is really a very curious one: have you felt no pain V3
—"No,  Sir," she will say,  "not any."—" Not any
pain at all V1—" No."—" What, are you perfectly cer-
tain you  have not felt any thing like a labour pain V*
—" No,"  she says again.   " Well then, I must  ex-
plain this matter to you; for it is very curious, that
although  you are in labour,  it is a rare instance of
its  coming  on without pain; and when it does hap-
pen so, instead  of the pains  there generally comes
on  a flooding.   So that  you see, if  you have  no
pains, I must give yon some."   There is much less
danger where there is pain;  and she knowing that
(he labour is in general  adended with a pretty good
share of  pain, will more  readily believe  us  when
we  tell  her that where  it occurs without pain it is
very dangerous.
  Where the os uteri very easily gives way,  it is  the
very essence of danger,  proving a want of contrac-
tion in the part, so that after getting the feet  down
we  must  not deliver  the  child  immediately.   We
must wait for the contraction of the uterus, and then
may gently assist;  we  do not want to empty the ute-
rus so much as we wish for  its contraction ;  for if we
get away its contents at a time when it cannot or will
not contract, we do no good.
  Suppose the placenta  seals  up  the os uteri;  we
must go directly up: we may screw our hand through
it with great facility, for it is  a loose pulpy mass  easily
torn.  We should  not wait long, nor be afraid, and,
if the labour is recent, we  may turn  the head and
bring down the  feet;  if the  head is  low enough to
apply the forceps, we may deliver so.  The  whole of
this practice lies in  a very  small compass;  to deter-
mine to deliver early, is to determine that our patient
shall not die. 
      TREATMENT OF  UTERINE HEMORRHAGE.     237

  We have now shown the necessity that there  is to
deliver as soon as possible in floodings, and explained
it on this principle,  that hemorrhage from the uterus
cannot be  restrained  by the two powers which are
sufficient for stopping a flow of  blood  in most other
parts of (he body;  by (he contraction of the vessels,
and the coagulation of the  blood in them :  therefore
lias Nature appointed a third power, by  the presence
of which,  the human uterus differs from that of all
other animals:  it is furnished with a great number of
very powerful fibres, and out of that  arises this ad-
vantage,  that it is  able to  restrain its  own hemor-
rhage by  the contraction of its muscular  structure.
When the  maternal  and the  foetal portions of the
placenta are separated,  at  the  time it  comes away,
there  are  many large  vessels exposed; this  only
happens  in the human placenta,  for  in brutes the
maternal pari is not separated,  but left  entire at the
time the after-birth  separates.
  In the contraction of fibres in the transverse direc-
tion to any cavity situated between them, it is  plain
the cavity  must either be  partially closed,  or  quite
obliterated; and though we  impress the necessity of
delivering from hemorrhage in (his part, yet it is nol
because the emptying the uterus will necessarily  stop
the flooding, but iu  hopes  that  it will be enabled to
contract;  and that  our interfering will have  the  good
effect of exciting its action.   For  which reason it is
right,  after  turning, and bringing  down the feet, to
allow the  child to remain  undelivered for a  short
time,  attending (o  (he  leasl pain (hat  may  be felt,
and gentiy assisting  in forwarding the expulsion;
and when  the child is born, wait the action of the
iderus again for the expulsion of (he placenta : for we
must still recollect  the grand object is con(rac(ion of
the uterus, without which, its, being emptied would
produce very lidle  good j it then will happen that the 
238    THE LONDON PRACTICE OF MIDWIFERY.

same  contraction which  expels  the placenta, di-
minishes the area of the vessels, and the dauger from
flooding ceases.
  But suppose the uterine hemorrhage to arise before
the delivery of the child, and continue after (he de-
livery is over, depending on partial separation of the
placenta, still the same object must be kept in  view.
The contraction  which thrust  forward the  child is
not sufficient to expel  the placenta, until,  by waiting,
we allow the uterus time to recover its force ; and if
tbe blood still continues to flow after  (he delivery of
(he child, we must'consider whether the streng(h will
nol be lost, and the safety of our patient endangered :
if so, the placenta without delay mu3t be separated by
introducing our hand.

Sect.  ix.   Hemorrhage  continuing after the Placenta is
                     extracted.

  The next view of uterine hemorrhage is that where
it does not stop on (he  extraction of (he placenta.
Such cases as (hese are very  rare ; (here  may be,
and often is, a sudden  gush of blood following the
placenta ; the reason of which is,  that the uterus, at
the time it expels that substance,  forces down every
particle of blood  with  it; and in this way a pound or
a pound and a half may escape, but that need not be
regarded in the least;  it does  not affect  the consti-
tution, because  it was  not evacuated  immediately
from vessels ; it was lying in the uterus.   So  when
we amputate a limb, there is no loss  of blood  to the
constitution, because the  whole of the blood which is
taken away is necessary to the limb,  and no  longer
necessary  than while  the limb  was to  be  supplied.
But supposing that, from  (he  vessels not  being pro-
perly secured in  the operation, there is a bleeding af-
terwards from the stump;  then it is  that  the  consti- 
HEMORRHAGE FOLLOWING THE PLACENTA.
fution  suffers: there is  a demand made upon the
mas3 of  circulating fluids, which must be  replaced
before the heart can recover its proper balance in the
system.  Apply this  to  the  uterus,  and  we  shall
consider the blood as  belonging (o the  gravid uterus,
and not to the circulating system.  This is  what,  in
the practice of physic, is called an immoderate dis-
charge of the lochia.  Such hemorrhages frequently
arise from the cord being pulled  with too  great vio-
lence,  by which  the  placenta comes  to be injured;
and this happening when  the uterus is not disposed  to
contract, the vessels will, for a time, remain exposed
and  bleed.  This is  the  reason  why  it happens  so
frequently  in the hands of  bad  practitioners  and
midwives; and that it is  so rare when  no improper
treatment is adopted in regard to the placenta.
   Now,   supposing  (he   hemorrhage  yet  remains,
after the uterus is emptied, the child being born,  and
the placenta come away ;  what are the means next  to
be employed to restrain it?  The application of cold,
and  the  abstraction of heat in  every  possible way.
We should take the clothes from  the bed, leave no-
thing but a sheet  to cover, and that from motives  of
decency alone.  If there  is a fire in the room, it must
be put  out;  the  windows kept open, to preserve  a
cool and fresh air; and   if the  patient is faint,  she
may have a cup of cold water.   In all this treatment
we differ from what  women would advise.  If they
see the  patient faint, every midwife  knows that her
skin  feels  cold:   well,  what  is  the  means of re-
medying cold ?  Why,  giving  her  a  little warmth ;
so they give her  a little  nice  warm brandy, and put
her on  some warm things, and so make  her comfort-
able.  The midwife's plan does recover her certainly,
and the effects  of all  that has  been done in making
her warm,  and giving stimuli, increase the action  of
the heart and bloodvessels;  the consequence  is, 
^
 240   THE  LONDON PRACTICE OF  MIDWIFERY.

 that the flooding returns, till fainting relieves  that;
 then the midwife  relieves  the fainting,  and  back
 again goes the woman into another flood, if she can;
 that is, the fainting and flooding succeed each other
 ad mortem.
   Cold water and ice are the proper applications both
 to  the  parts  (hemselves and (be body  round (hem.
 The coldest  water  made  colder by  throwing  two
 handfuls of salt into a couple of quarts of it, may be
 used by cloths many times double dipped in this,  and
 laid over the back and abdomen; besides which, we
 may with (he greatest advantage expose the  body (o
 an increased degree of cold if it  can be done.
   This treatment in hemorrhage from any other part
 would do mischief.   If we were to put a patient who
 spit blood into an ice house, we should certainly  kill
 him : the principle upon which it is proper is this,
 that cold applied to the skin produces contraction of
 the  uterus, as being  an  internal  muscular cavily.
 This if does produce, not to  the uterus alone ; all the
 internal cavities  are  affected in (be same  manner
 exactiy,  by cold  so applied.  It is well known, that
 many people  have  a skin  of so irritable a  texture,
 that if  exposed to cold  it will bring  on  purging.   In
 all constitu'ions cold increases the peristaltic motion
 of the intestines;  and again,  if cold is applied to the
 external surface of the body,  even though the blad-
 der is not full, there will be a  strong inclination to
 empty  it.
  If these means do not answer, we must introduce
 ice into tbe vagina,  or even uterus; this  will often
 succeed ;  if this is  ineffectual, we must, as  (he  last
 resource,  plug up  (he  vagina with lint or  tow,  or
 something  capable  of entangling  (he  blood;  for
 while (here  is  a  clear channel  (here  will  be  no
coagulum formed.   If (he flooding continues still,  the
best plan is that of carrying  something permanently 
      HEMORRHAGE FOLLOWING THE PLACENTA.   24 i

cold into the uterus itself; a large dossil of lint dipped
in the cold solution will  carry up  a  great  degree  of
cold ; but the best thing is to cany up a piece of ice,
and allow it to thaw  in  the  uterus.   Dr. Baillie,  of
New-York, was  the  first who  introduced  the  use
of cold applications here ;  he was in the habit of using
a bail of snow for this purpose, which often stopped it
directly, when nothing else would.  Ice being intro-
duced into the vagina, will often  prevent abortion;
(his (hen is the best and last remedy in flooding; if
none of these  things will stop it, there  is nothing else
that will.
   After (he hemorrhage ha3 ceased,  (be  patient wi!l
be so reduced, so exhausted,  (he action of the heart
30 weak, and  the quantity of blood circulating so de-
ficient, that our first care  must be to supply tbe waste.
and remove  the  greatest danger,  which is  that  of
the  patient's  having  been  exhausted  beyond (he
point at which the constitution  is  able to rally, and
recover itself.  These cases must  be supported and
stimulated; boiled milk with  grated crumb  of bread
in it, must be quickly cooled by spreading it on a flat
dish, and when cool may  be giveu as one of the most
nutritious  things that can be  had ; or  good broth  in
which grated  bread is mixed: and if these  remedies
do not  stimulate  the  heart and arteries, the  proba-
bility is, that  the patient will die.   In many of these
cases the  best stimulant  is the volatile alkali,  next to
which brandy and  water; the ammonia is preferable,
because, although the  first effect of the spirits is good,
it produces too  much heat in the system at large;
while that effect never arises from the other remedy.
Therefore we may  state to  (he  nurse  beforehand,
tha( she had  better get a lidle hartshorn, to be ready
in the room,  as perhaps the child may want to be set
to rights  when  it is born,  and  for  that purposc
nothing is  better  than a little hartshorn ; it  is not
                          x 
 42     THE LONDON PRACTICE OF MIDWIFERY.

necessary we should tell the nurse (he probability that
it  may be useful to the woman.  It is inconceivable
the quantity of vol. alk. a woman in this situation will
bear.  It may  be given as strong  as it can be taken;
and if it makes her sick, as soon as the sickness has
gone off, we may give  more directly.   It is sometimes
two or even three hours before we  can leave such a
patient in the certainty of her living.
  After the flooding has stopped, we are not to con-
sider the patient as safe.  The fever coming on about
(he third day, may be  troublesome;   nothing is so
efficacious  for it as the saline  draughts, with lauda-
num  to  tbe  amount of a  grain  of opium in the
twenty-four hours.  It  was  an  observation  which'
originated  with Dr.   G.  Fordyce,  whose  work  on
fevers is the best  book  of the kind  that  ever was
written, that in all that irritability  called hectic fever,
we do not  do  good  by giving  large doses of opium,
but small ones are always useful: by  such means we
take off tbe irritability that supervenes to the flood-
ing,  and which  resembles fever.    Immersing the
hands and feet in warm water about eighty degrees, is
useful;  it brings down the  pulse, and does a  great deal
of good.
   After  flooding, another circumstance requires at-
tending to, a throbbing  of (he  head and  loss of me-
mory, which  will  remain for  weeks:  in such  cases
(here is  nothing so good as  purging, although (he
cause of (he complaint is hemorrhage.  The best way
is to give infusion of senna wifh (he Epsom  sails, after
which a draught of tbe decoction of bark, two or three
times a day.

Skct. x.   Consequences of the Placenta remaining, and
                   its Treatment.

   The general treatment of the placenta has been a!*
 ready explained, where nothing  more than ordinary 
      HEMORRHAGE FOLLOWING THE PLACENTA.  243

attends it, togetiier with the proper time which it may
be allowed to remain.  We will  now consider the
consequence of it3  remaining, and treatment when it
is not expelled.
  It was said before,  when it remained  too long, it
was  necessary to pass  up the hand and bring it away
by separating it from the uterus.  Some say, that im-
mediately after the child is born  we should go up and
bring it  away, if the  same pain which expelled  the
child does not separate and bring down the placenta.
Thi3 is said to save another unnecessary pain.  It is
said the  uterus will afterwards  contract,  and all will
be well.   The truth is, the uterus is designed to expel
the placenta as well as the child:  if it had been in-
dispensably necessary to have extracted that substance
directly when the child was born, Nature  would have
made some further provision, as her works are perfect
in all their parts.   There is a case in Haller where it
was  left  to  nature, and  remained, it is  said, thirty
days.  We should never think of leaving our patient
while the  placenta remains behind.  When  a woman
is properly managed, it will rarely be necessary even
to separate with  the   band.  In  this Dr.  Hunter's
practice  was exceptionable; he was in the habit  of
leaving this (o nature ; he  used  to leave the woman
upon the child's  being born, desiring (he nurse to pop
the  placenta  into (he  basin, when it did come away ;
that  was  enough for him.  He  one day met with a
lady, who had been used to having her attendant with
her till every thing relating to the labour was over.
As  soon  as the  child   was born he took his leave;
the  nurse  directly  said to  her  mistress,  " Why,
Madam,  the  Doctor has gone  before the after-birth
has come away :  I had better desire master to  beg of
him  to stop."  Away  ran  (he nurse down anotiier
staircase, and  was in  the  study  before  the Doctor
was  half  way down stairs.  Having told  the gentle-1 
 2 14    THE LONDON PRACTICE 01  MIDWIFERY.

 man why she came, Dr. Hunter came in, and told him
 his wife was delivered.  « She is ?"—" Yes."—" She
 is completely delivered?"—"Yes."—"Because (he
 nurse  was saying  something  or otiier  was  not yet
 done."-—" Oh !"  says the Doctor,  " that does not re-
 quire my  attendance, I have directed the nurse how (o
 dispose of (hat."—"Well,  Sir," says the husband.
 " there can be no doubt of your opinion being perfectly
 correct,  therefore I shall  not make myself uneasy ;
 you would not have left my wife unless she was per-
 fectly safe, I am convinced."  Dr. Hunter went away;
 after which the patient was seized with a flooding, and
 before the Doctor could be  found, she died. Although
 a man's  reputation may be very high,  such  an un-
 lucky accident as this would shake it; and Dr. Hunt-
 er  had the mortification to see, after  this,  a man,
 although much inferior in abilities, interfere very much
 with his  practice.   A drawing-room  will in one night
 injure a man's credit more than a year's diligent prac
 tice will increase it.
   We  should never leave the placenta in (he  uterus ;
 and if we have left  it two hours, we  should never
 leave it beyond that  time.   It  is  always  right  to
 bring it away.   If it adheres, we  may introduce out
 hand as   in turning, guiding the hand by the cord;
 we should  then   separate  the  edges, peeling it
 gradually  and carefully off, recollecting  not to  have
 our nails  so long as to scratch the uterus.  After (he
 whole is separated, we may make a feint to withdraw
 our band, to observe whether  the  uterus will  con-
 tract ; if  it does not, we should use a degree of pressure
 against its side, and this  will generally  bring on its
action.
  The placenta  may be   retained  by  a con(rac(ed
uterus, of which  there  are two  kinds, one in which
 ihe uterus is as long as before delivery, but narrower.
This slate  will  depend  on  too speedy delivery.
We must patiently overcome the contraction  with 
        EFFECTS OF THE PLACENTA REMAINING.   245

our hand, and separate and bring away  the placenta,
as in other situations.  There is little hazard in this
case, as the ready contraction gives  U3 les3 reason to
fear  the ill effects of  hemorrhage, after we  have got
way the placenta.
  The other sort of contraction is that  in which the
uterus may be said to resemble  an hour-glass, called
therefore  the  hour-glass  contraction;  this  must  be
overcome the same way as the  other.  Whenever we
introduce our  hand to  bring away the  placenta, we
must take care to bring away  the whole; it has been
stated that a part of it has been found in the state of
scirrhous adhesion to  the uterus : now it certainly will
adhere, that often happens ; but of scirrhous adhesion
we know nothing.  Cases are not always stated cor-
rectly as they  are found, which  they should be.
However, if we set out  with  the intention of doing
any  thing, we  should  always do it completely.  It is
better to leave the whole than a part; for if the whole
is left, most probably  the uterus  will  contract upon it,
because it is a stimulus which the uterus is able to act
upon, while part of it cannot be acted upon with the
same facility.

  Sect. xi.  Consequences of a Portion of the Placenta
                     remaining.

  Pursuing the  subject, we come next to the  consi-
deration of that state which  arises  from a portion of
the placenta being left.  No great inconvenience seeme
to arise till the (hird or fourth day, when (he lochia!
discharge increases and becomes more offensive ; the
after pains, which generally cease about the third day,
remain beyond  that time, arising from the  tendency
in the uterus to throw off what it  cannot get rid of.
There is  occasionally a shivering fit, succeeded by
heat, but rarely  ending in perspiration.  Tbe pulse
                       x 2 
246    THE LONDON PRACTICE OF MIDWIFERY.

rises to 120 or 130, the patient becoming emaciated
and very pale, though when the fever is upon her she
looks as  if  painted : by  degrees  the hectic  flush
lessens; the pulse becoming smaller,  acquires a wiry
hardness, and  this goes on; (he woman  becomes
tender at the lower part of the belly when it is pressed
upon, though it  is not violent pain as in puerperal
inflammation ;  frequent  retching and  vomiting now
arise; and, if she lives long enough, hiccup  succeeds
to the last symptom, together with which the mouth
and tongue become sore;  she is at length worn out
by all this, and lays down her head and dies.
  The discharge becoming greater and more offensive,
is the best marked symptom, and  frequently causes
the death of the woman.   This does not strike those
people who happen  to  attend without being practi-
tioners in midwifery; they see the fever, which they
attribute  to the effects of lying-in, and they hope it
will soon get better.

            Sect. xii.  Inverted Uterus.

  Inverted uterus  happens most frequently in that
practice which is conducted by midwives, they being
more in the habit of pulling  away the placenta; they
in this way  invert upon the same principle that the
finger of a glove is inverted when a  siring  is passed
up  the  inside knotted to (he end of (he finger, and
then  drawn down withinside; by  which the tumour
which projected into (he cavity of the room, which
suppose  is the  abdomen,  would be  made to project
into the cavity of (he glove, which is (he vagina.
   In pulling at the  cord it will often  happen that the
placenta will remain attached  to the utenis, and the
operator is  not  aware of  what  has happened; now,
however this is produced, the effect is  in all  cases the
same; it may be attended with profuie flooding,  ou 
INVERTED uterus.
241
the uterus will contract as it is; it is lucky if a flood-
ing comes on, if it leads to an examination, when the
tumour will be felt in the vagina, and must be return-
ed, reducing the fundus first.  It should be done as
early  as possible.  The difficulty consists  in the os
uleri forming a sort of ligature behind,  which pre-
vents the return of  the uterus through it.  When the
os uteri is before  us, it is easily dilated;  but when we
have  to  work through a substance to it, the case is
changed.
   Sometimes hemorrhage  will take place early after
delivery; and whenever it does, we  should always
examine;  there is  no difficulty  in examining,  and it
ensures the safety of our patient.   If  we know  of the
case  directly as it has happened, we return it, and
there is  an end of it :  but if we neglect to ascertain its
existence, till the next day only,  we stand a very fair
chance of losing our  patient: it will be hardly pos-
 sible to reduce it, unless attempted directly.   The wife
of a man near Bloomsbury sent for a gentleman who
 lived near, as she was not clear that (he midwife  had
 done  every thing  that was proper ; the fact was, in
 the dragging (he  placenta down, (he uterus was in-
 verted,  and there  was a  flooding.   This  gentleman
 called in another practitioner, a man  of  great respec-
 tability, and  they adopted  such means as they thought
 proper,  and  went  away.  When they met the next
 day  the flooding  still continued,  and  one of them
 proposed an examination ; and the first thing he came
 to was  an inverted uterus in the  vagina : it could not
 be then reduced; the flow of blood continued,  and
 the woman  lost her life, entirely through their neglect
 of an  examination at  the only  time when it could
 have been useful.  This evidently shows the necessity
 there is of examining whenever  flooding arises after
 delivery.                                        .
    A very melancholy instance was that of a  lady us 
248   THE LONDON PRACTICE OF  MIDWIFERY.

the country, who was foolishly attended by a  very
ignorant midwife: like most  midwives, she thought
when she saw the head protrude,  it was her time to
pull out the body  after it,  and that she must pull at
the navel string as she  would at"a  bell-rope.   It was
the woman's first child; and  after  the placenta was
away, she asked  the midwife if there was not another
child?    She laid her hand upon the abdomen, and
said, No.  The  husband came up ; his  wife told him
she could not help saying she felt as uncomfortable a3
before she was delivered ; she thought something was
not right; he advised her to send for a medical gen-
tleman, which she did, who examined the midwife.
" Oh yes, Sir, indeed; every thing  has come away;
there  is the child, here is  the after-birth, and  all the
skins."  He then assured  the  woman  that all was
right; he  had,   he  said,  examined   the  midwife:
"You certainly   feel  uncomfortable,  which you ex-
pect to be after  delivery ;  I will order you  something
which shall  make you feel more easy."   The next
day he called ;   she  was better.   " Ah," says  he,
 ' I told  you, you would be better;"  and  she  conti-
nued to get better every day,  till, at  the end  of the
month, she had the misfortune  to find the  vagina
shut  up.   Another  medical man was sent for, who
desired her to  be sent up to  London, where  it was
 ascertained to be a chronic case of inverted  uterus;
 and, after taking a great number of opinions, she was
 sent  back  in a ruined state  into the country ; con-
 scious that one out of two things must be the couse-
 qucnce—either  she must see her husband give  up the
 greatest pleasures arising from life, or see him forming
 other connexions lessening and destroying his affec-
 tion for herself.
    It is then of  the utmost importance for  the  practi-
 tioner to be careful as to the extraction of the placenta
 by pulling  the  cord, and  to be very attentive to any 
INVERTED UTERUS.
249
bleeding after delivery.  We  should never  draw by
the cord till,  upon passing our finger into the vagina,
we perceive  the  root of the placenta;  then we are
sure it must be separated from the uterus.  If we are
called to a case where  we  have the least reason to
expect any thing of mischief, we should always exa-
mine for »  rselves, and  never go upon  report; and
that for  many  reasons: it makes people careless in
their inquiries; besides,  no two people  say exactly
alike upon  any subject; and hence the  great import-
ance of medical practitioners having an enlarged and
liberal education,  not merely as to their own  parti-
cular profession,  but such a  general  knowledge as
must necessarily strengthen and invigorate every mind
not  below  mediocrity;  for though the  majority of
cases require little skill  and less ability, yet in  the
course of practice every man must meet with new and
unexpected  difficulties, where  his  utmost  exertions
can alone save tbe life of his patient, for which he
must and will be  accountable, if it is lost through his
ignorance or  neglect, being no less than murder, and
that the more cruel  and detestable, because it must.
in such casesjbe wilful. 
250
                   CHAP. XIII.

     MANAGEMENT OP WOMEN AFTER DELIVERY.

    Sect. i.  77te Woman not to be moved immediately
                   after Delivery.

Most of the diseases that follow pregnancy arise
after delivery, and not during labour ; and it is parti-
cularly necessary  that the length of time that the wo*
man should lie after delivery be adended to.  As it is
highly improper that she  should be  moved early, she
should not be delivered in her clothes.   This however
is often proposed by the lower order of people, to save
inconvenience and expense; but it should never be
assented to by the practitioner, as it is a very dangerous
experiment to  raise the patien( to an erect posture, at
a time when she may remain perfectly safe in an hori-
zontal position. There are many instances of (he fatal
effects of neglecting such a precaution.
  A  gentleman  attended  a woman whose labour,
though good, was not very short; when the child was
born, and the  placenta come away,  the  friends of the
woman wished to  get  her up, that she might be made
clean and have the bed made.  This the gentleman
knowing to be improper refused, but at length yielded
to the importunity  of the woman, who got the patient
into an easy chair, and wheeled her towards the fire.
When (he bed was made, the  next step was to  lay
(he  woman in it again, but upon turning to the chair
they found her absolutely  dead; and  this required
little explanation.   It  is well  known that a person
who could not lose eight ounces  of  blood without
fainting  while in  an erect  position, will bear  twice 
          MANAGEMANT AFTER DELIVERY.        251

the quantity drawn in an horizontal posture : this was
the case  with the woman in question, whose  vital
powers left her as soon as she was raised up.
   In  another  instance the  gentleman  in attendance
was prevailed  upon, by the solicitations of the .persons
around, to allow the  patient to get up.  She did so
about an hour after delivery ; there was a little  gush
of blood, but  such as would  not  have produced the
least inconvenience in an horizontal posture, and she
sunk  down totally lifeless.
   A woman after delivery should remain perfectly at
rest for at least two  hours, and  then  should by no
means be raised upright, but be  very gently lifted
just enough to allow the  drawing away of the clothes,
which if they  give trouble, must  be cut away with
scissars, to prevent the risk of exhausting the patient
by over-exertion.

                Sect. 11.  Fainting.

   Fainting after delivery frequently happens, and may
arise  from many causes, most of which are of little
consequence ;  it is an  unpleasant occurrence, and
sometimes dangerous.   It may be merely the effect
of fatigue; a woman is  just able to bring the child
into  the world, and, after making perhaps the last
exertion she was capable of, sinks into  a faint.  Fre-
quentlv  she will  fall into  an hysterical  paroxysm,
 which'will easily be perceived by her  laughing, cry-
 ing, sobbing, &c. which  characterize hysteria.  If the
 fainting  proceeds  from either of the  above  causes,
 volatile  alkali rouses the patient, and nothing more is
 necessary; neither should  any apprehension be  felt
 for her safety.
   Fainting may be the consequence of the great agita-
 tion  of mind which the  patient has suffered from fear 
252    THE LONDON FRACTICE OF  MIDWIFERY.

of the approaching pains, and as she thinks, dangers.
In such cases nourishing things should be administered,
as a small quantity of good broth, with a table-spoon-
ful of wine in it; or some volatile  alkali.
  Whenever there is reason  to su?pect that the faint-
ing arises from a loss of blood, the  practitioner should
never  leave it to probability, but  instantly examine
(he (ruth of his suspicions, not only on the surface ly-
ing next  to him, but the upper part of the  further
thigh, as the blood will  sometimes run over the side
of the thigh  that is furthest off;  when  the  practi-
tioner, not perceiving any discharge  from that part
whence it is generally observed to flow, has  not the
least idea of bis patient's situation.  When upon exa-
mination it is found that hemorrhage has taken place,
(he placenta being delivered, it is to be treated in the
common way by acids, &c.
   In some rare instances it has happened, that imme-
diately after delivery the patient has sunk into a per-
manent syncope, from which  she never has recovered,
dying without a  groan.   When (here is reason to sus-
pect the approach of this state, the patient should be
made to swallow a large dose  of volatile alkali; it can
do no harm, and is generally  highly beneficial, let the
fainting originate from whatever cause ;  being a very
powerful  remedy, no other need be used ; though the
spiritus ammonios comp. and Unci, lavendulce may also
be administered; and hartshorn should always be kept
in a  lying-in room.
   After delivery it is  advisable to  apply  a certain de-
gree of pressure (o (he parts.   This circumstance has
been variously received and very generally misunder-
stood.  A certain degree of pressure is useful; if that
pressure is too  great, it will occasion worse conse-
quences than the want  of pressure altogether.  The
pressure required is, more properly speaking, a support,
and  is of the same kind  as we like  to feel  from a 
RETENTION OF URINE.
253
waistcoat in winter.  The intention to be had in view
in  making  it, is  just the same as after tapping in
dropsy ;  and pressure judiciously applied in both cases
will often prevent fainting.

            Sect. In.  Retention of Urine.

  In the country it sometimes happens that the prac
titioner does not see his patient any more, after leaving
her safely delivered. In such cases it will be necessary
for  him to  give general and explicit directions to the
attendants; the  most  material of which  is, that (he
nurse shall send for him,  if,  upon Irying,  (he patient
find herself unable (o make water,  at  the  distance of
eighteen or twenty hours after delivery.   If the patient
is neglected, the bladder  swells to an enormous size,
and at last  bursts.   If the urine  gets  into  the cavity
of the  abdomen it excites  peritoneal inflammation, and
destroys  life ;  if that portion of the  bladder nearest to
the vagina gives way,  she may  recover,  but  will be
rendered miserable to herself and family by the con-
stant dribbling of  urine.   When  the  practitioner has
been sent for, he  must not be  satisfied  with  the pa-
tient's  felling him that she has since made  water, and
that a  little escapes frequently ; all this amounts to
nothing,  and  must not excuse a moment's delay in
(he introduction of the catheter.   This should be had
recourse to  in  whatever situation of life tbe patient
may be ; whether she may  or may  not  be  able to
remunerate the practitioner for his  trouble;  for,
exclusive of  humanity,  nothing injures  the  reputa-
tion of a medical man more than losing a woman in
child bed.   It will generally  be necessary  to draw off
the water once or twice a day ; but, from distance in
residence,  this will sometimes be impossible.   In such
a case it is not very difficult  to teach  the  nurse bow
to perforin this operation, by showing her the parts, 
234    TIIE  LONDON PRACTICE OF  MIDWIFERY.

and pointing out the little orifice, at  the  same  time
telling her (he instrument must be passed up carefully
and slowly till the water flows from the other end of
(he tube.
  When in any case (he  introduction  of the  catheter
is  necessary, and  the patient  objects,  although  the
necessity of it is evident from tbe  tense  tumefied  ab-
domen, denoting fulness  of the bladder,  the practi-
tioner should not wait in hopes  that  (he urine  may
dribble away ; this ought never to satisfy him :  it is
better that he should give up altogether his attendance
upon  such  a patient,  first, however,  making use of
every possible  argument to succeed  in his attempt

      Sect. iv.   Effusion of Blood into  the cellular
             Membrane of the Labia Pudcndi.

   An accident which now and then happens after de
tivery, is an effusion of blood into the cellular mem-
brane of tbe labia pudendi.   It is merely a mechanical
?ffect of pressure, and very rarely occurs. In one case,
where the parts had been previously  much strained,
the swelling was first observed by the  patient's finding
herself unable  to  close  her thighs  together.   This
blood, if left to itself, will first  coagulate round the
orifice of the  bleeding  vessel,  and  . afterwards the
whole quantity  of effused blood becomes fixed. There
are two ways by which the parts  may get rid of this
blood, if its quantity  is  considerable  ; either by the
skin sloughing  off, by  which part of the bood  may
?scape, or  by  the part inflaming and suppurating.
When the latter circumstance happens, and it  is de-
termined to open i(, (he  orifice made cannot be too
small, so that  the matter be allow ed to escape; for
the constitutional weakness at such  a time as  this.
will give a tendency to gangrene  in any part which is
divided.  Cold is the only application that is to be at 
EFFUSION
OF BLOOD, &C
255
all  regarded.   It has been recommended to  cut  and
scarify  the  part,  but  this is  objectionable,  because,
should the artery continue bleeding after (he openings
are made, (he sUuation of the patient at once becomes
serious, for we must necessarily be perfectly igno-
rant where the  ruptured vessel is, and consequently as
perfectly unable to stop it.  Should it ulcerate, the
treatment should be the same as that of an ulcer in any
other part of the body.

            Sect. v.  Lochial Discharge.

  Another object of inquiry is the state of (he lochial
discharge,  by  which is  meant that discharge which
follows the expulsion  of  the placenta, continuing for
several days,   and diminishing in  proportion as the
uterus contracts.  A  short  time after  delivery the
vessels which  before poured out red  blood, will (hen,
from (he womb  having contacted to a certain degree;
only oose forth serum.
  When small  pieces of the maternal part of the pla-
centa remain with fragments of the  membranes, &c.
and mix with  the lochial discharge, they constitute
what the nurses call  the green  waters;  and these dis-
charges generally subside in six or eight days, more or
less.   They will, however, often be reproduced by
very slight causes ; such as sifting upright, endeavour-
ing to walk,  eating  stimulating food;  or indeed any
thing which rnav increase the action of the heart and
arteries.   In  a  strong woman of tense fibre, the dis-
charge, will be of shoiter duration (ban  in  a weak
woman of  lax  fibre; if a woman is quiet it will not
continue so long as if siie is restless.   Where the quan-
tity is profuse, and i( flows for (oo  long  a period, (he
constitution becomes  weakened, and it is necessary
(o give bark with the vitriolic acid, or (he conserve of
roses. 
256     TnE LONDON PRACTICE OP MIDWIFERY.

  It is  requisite tha( the  practitioner t-hould be very
altentive in his inquiries into the taate of th s discharge,
particularly  with women in the middle and  lower
ranks of life, as they have generally great confidence
in its power an influence upon them.   If the patient
is provided with a nurse, it will  be better  to inquire
of her,  taking care,  however,  that the  patient may
distinctly  hear tbe word discharge.  The great object
to be had in view is to make the patient's  mind easy
by such attentions, for it is of little consequence whe-
ther  the discharge is rather greater or  less than com-
mon, as long as  the woman's  general state  is that
which it should be.   It is very  necessary then,  that
when the practitioner asks a question  of this kind, he
should be ready with an answer.   Thus, suppose the
nurse replies to it, " O,  very well, Sir ;" he may say,
"0, well, I am glad of it :" or,  if she  answers  that
(here is very little, he, having previously ascertained
by the  pulse that all is right, may say, " Ah, nurse,
now this I  dare say is what you have often seen,  that
where a labour ha3 finished in the regular manner that
this  has,  there are  very little cleansings;" she will
directly say, " O certainly,  Sir;  very true,  Sir."   As
often as we appeal to the experience of a person  who
is perfectly ignorant, so often  do we  succeed in our
argument or opinion.  If she  says the  discharge is  a
great  deal,  " Is it 1 what do you  call  a  great deal,
nurse?—Ah,  (his is pretty well;  and I dare say you
have generally observed lhat  those people who have
the best cleansings are up tbe soonest."   By appealing
to their experience all objections are at once removed.
and  the patient's mind is  thus made easy.

            Sect. vi.  Lacerated Perinaum.

  That intermediate part of the body situated between
the vagina and rectum is called perinceum ; and from 
LACERATED PERINEUM.
25*7
its peculiar situation is very liable  to  accidents from
the violence of pressure in labour; this will sometimes
happen with the most careful  practitioner:  it  will
now and then give way in a trifling degree, and  is in
such  cases  of no further consequence than from its
leaving the parts a little sore and weak for a few days.
The only laceration of consequence may happen back-
wards to  the  rectum,  by which the os externum and
rectum are laid into one, and the sphincter ani conse-
quently torn asunder.  This accident is, however, ex-
tremely rare, and  may  always be prevented by sup-
porting that part of the perinceum with the hand.
   In case of an actual laceration of the perinamm, the
first step  is to empty the bowels by a brisk  purge ; after
the  medicine has operated, the parts  should be per-
fectly cleansed from all faeculent matter, and then the
thighs should  be bandaged together,  by  which  there
is a probability of the parts uniting by tbe first inten-
tion, and in some  cases this  has succeeded.  Should
this fail, the only chance  is not to allow the parts to
heal except by uniting with each other.   If consider-
able inflammation takes place,  it must be reduced by
the  use of fomentations and cataplasms,  and of cool-
ing  laxative  medicines:  and,  if the  pain is  violent,
opiates  may be given.  When  suppuration  occurs.
bark must  be administered.   The dressings may be
 superficial.

                Sect. vii. After-Pains.

   Every woman who has been in  labour is  subject to
 what  are called  after-pains, though they do not always
 occur.  They come on at regular intervals, and  ni<-
 more or  less violent.  These pains are very rarely :db
 after  a first lying-in ; and  they are less when the la-
 bour has been retarded, allowing the uterus to  contract
 gradually behind the body of the child, than_\vliere the 
258    THE LONDON PRACTICE OF MIDWIFERT.

expulsion of the child has been hastened, the ulertti
then contracting suddenly but not perfectly.  In con-
sequence of these pains, and the fatigue which the
woman has sustained throughout the  labour, it is a
very general and excellent practice to give an  opiate
of from  twenty to  thirty  drops of laudanum,  and
afterwards  to  repeat it in such a diminished quantity
as shall allay the irritation, but not the contraction of
the uterus.
  An after-pain will perhaps  come  on an hour after
delivery, by which a large coagulum may be expelled ;
and after that others, by which smaller  coagula will
be separated ;  and then an after-pain as violent as any
of the rest, to throw off one of the smallest possible
size'.   To some women they are very distressing, and
are borne with less patience than the labour-pain3, as
these they know are for a good  purpose, while  the
pains after delivery afford no such consolation, and yet
are sometimes as violent  as the  worst  pains of labour
can  be.  These  pains  may  be moderated by warm
applications to the abdomen, and  by  small doses of
laudanum.

    Sect. viii.  General Treatment of a  Woman after
                      Delivery.

   Practitioners formerly had various ways of treating
 a woman after delivery.   Of these  the principal were
 the high or stimulating  mode of  treatment;  and the
 low or starving system.   The first was adopted  upon
 the  presumption  that  the woman had  been much
 weakened  by nourishing a child while  in the pregnant
 state, and  by the exertion of labour.  They gave her
 nothing but what was calculated to stimulate and  heat
 the constitution; and having observed that those wo-
 men got through the best who  fell  into  a gentle  heat
 and  perspiration,  they adopted the practice of giving 
GENERAL TREATMENT AFTER DELIVERY.   259
diaphoretics.  The woman was put  into a heated bed,
and covered  with  thick blankets, a fire was kept in
the room,  all  the  windows  were fastened, and  the
chamber made as air-tight as possible  In this state
the poor woman was not only plied  with all the com-
mon,  but some of the most uncommon  stimulants ;
farinaceous  mixtures  with spices and.spirits;  spiced
gruel with strong beer  and brandy, &c.  The  conse-
quence  of this was, that  tbe patient  was  unable to
leave her bed-room for a great  length of time, and
was  in  the  most imminent danger  of catching  cold
upon  the slightest change of temperature; and a pa-
tient so treated, frequently became  poor  and weakly
in her constitution, and suffered a premature old  age.
The inconveniences arising from this plan^ gave origin
to the low mode  of treatment, or,  to  speak in more
direct terms, to starvation.   According to  the  former
system,  the patient was carefully kept without a stool
for a week,  as the closed bowels  were supposed  to
promote perspiration  and warmth;  in  this,  on the
contrary, she was scoured out  with repeated  purga-
tives, as the exertion and straining of labour  were
thought very likely to produce fever.  The patient was
almost kept  without food, being only  allowed  barley-
water or gruel.
   The best  practice is to avoid both of these extremes,
and to treat the woman entirely according to her  situ-
ation ; if strong and healthy, she may be kept for a few
days  upon gruel, barley-water,  and toast  and  water;
and then, if she is perfectly  free from  fever, she  may
eat a little animal food.   But if of  a weakly constitu-
tion,  she may have animal food the first day; in the
former case no wine should be allowed, in the latter
both wine and whatever else may nourish  her  should
be administered.   In  general  no meat   should  be
allowed for the first three  days; bread pudding may  be
permitted, but if  there is tbe least tendency to  inflam- 
260    THE- LONDON PRACTICE  OF  MIDWIFERY.

mation  or  fever, nothing further.  With regard  to
medicine, much will  depend upon the patient; the
great object is to  keep her quiet; and if this cannot
be done without medicine, it must be given.   A saline
draught, either with or without spermaceti,  will gene-
rally be sufficient; and at night a small dose of the sp.
rethcr comp. which  may  be  increased  if the patient's
nights are restless.
  A tiring of the utmost  importance to be attended  to
is, let the rank or situation of the patient be what it
may, to give a purge on' the  third day.  It is  of little
consequence what purgative is used as long as an eva-
cuation is produced.  For many weeks before delivery
the bowels  of a woman are never emptied  of their
solid  contents ; and  the quantity  that thus accumu-
lates  is  sometimes very astonishing.   Should  the purge
not operate, an enema should  be  exhibited the same
evening; after which not a day should  be allowed to
jsass  without  a stool being procured, and  this strict
*attention should  continue for the first fortnight.
   The  time of lying-in  is  by  many women, particu-
larly in the lower orders  of life, considered as a period
when good  living and jollity should be universal; and
such  women think that their husbands.are then  bound
to  feed them and  their friends better than  at other
times;  and as nurses are not much distressed on  see*
ing good living  about them, nor  have any  particular
objection to a little brandy, they and  their mistress
 seldom fall out  about that  A woman who will thus
 eat  and drink what she likes while her nurse helps-her
 through, contrary to all  the  injunctions  of the  ac-
coucheur, requires some management, for  she cannot
 often be  reasoned out of such  bad practices.  So that
 if, upon inquiry, the nurse says, " Oh no, Sir,  mis-
 tress has taken no cordial," while you  can smell the
 fumes down her throat,  the only  alternative left is to
 purge her.  The practitioner may order her first wH»* 
SORE NIPPLES.               261
he  pleases, and if  the  next  morning she complains
that she  has been a  good deal purged,  he may say,
" Well, I will order  you something else,  but keep the
medicine  (part of which only  has  been taken) by you,
in case it should be necessary to take  more of it;"
and then he  may directly  order  her another purge,
varying  in taste and form.  The  next day, as  usual,
the patient will be full of  complaints;  which the
practitioner may answer by inquiring, if she thinks she
ate any thiDg  during the day that  might disagree with
her;  observing,  that he will give her  something to
set her stomach  to  rights; and then order her ano-
ther purge, not  forgetting to vary its appearance.  In
this way the patient may be kept safe in spite of her-
self and the nurse.
   Milk-fever  rarely  or  never happetfs  where proper
care has  been  taken  to preserve a  regularity of  action
in  the intestines. Where  the bowels are neglected,
and there is a disposition to  inflammatory fever, the
milk  being formed   in   considerable quantity, will
greatly increase that tendency to fever.

               Sect. ix.  Sore Nipples.

   Women are liable to have sore nipples, a complaint
which is  often met with, and very troublesome, and
most  probably arises from their artificial mode of liv-
ing.  Many women   use considerable pressure   upon
their breasts,  and under such  circumstances it is na-
tural to expect that the nipples being pressed in, may
be absorbed altogether, or,  if  this  does not take place,
they will give  way  upon  the  child  sucking,  and be-
come  sore and painful.   If this has occurred in a pre-
vious  lyingi-n, the parts may  be  strengthened by ap-
plying to  them   astringent  remedies two or  three
months before labour.   When, however, soreness  of
the nipples has taken place, the best way to protect is
                        z 2 
21)2*    TnE LONDON  PRACTICE OF  MIDWIFERY.

to use an artificial teat, by which the child can suck
equally well,  and the nipple itself  being undisturbed,
wiH soon  heal.   The way  in  which  one  of these
instruments is prepared, is to procure a fresh teat from
a hiefer, and scooping out the inside, steep  the  skin
in spirits for  an  adequate length  of time, and then
fasten it on to the  glass instrument: glass is prefer-
able} because by seeing the milk we may be assured
fhat  the child is properly nourished.  A woman is
capable of giving milk with a flat  or even a concave
surface, by drawing it out with a  glass  tube  that  has
a small ball to  it, by which  a vacuum is produced,
immediately the glass is removed ; the child being put
to the breast will keep it out by sucking till satisfied.
   Where the nipple is sore, it will either  be  from su-
perficial ulcers,  or cracks in the skin, either  of which
give excessive pain and distress; and it often happens
that, after all manner of things have been ineffectually
applied, the nipple will heal of  itself.  Wine, alum-
 solution, rose-water,  and all similar  applications,  give
 very great pain, though they seem  to be the most be
 neficial of any that are in use.  Indeed, it is extremely
 difficult to know what will answer best.   If  emollients
 are applied,  less  pain will  be the  immediate  effect;
 but they make  the  parts  more tender, which,  when
 the child sucks, will  frequently bleed; and this is un-
 pleasant for several  reasons.  The child probably swal-
 lows the blood,  and it sometimes  happens, that  being
 sick, it  vomits  it up again, to the great terror of the
 nurse, the mother,  and all around  them.  If  the sore
  is superficial, it will be much aggravated by  slicking
  to die woman's clothes: in this case a little  cup made
  of wax  is a good  protection.  The limpet-shell will
  answer the same purpose, the edge being covered with
  sealing-wax; or a walnut-shell may do  equally  well.
  A fresh ivy-leaf laid on  after every suckling is very-
  useful :  die fine glaze will  prevent its sticking, and* 
PHLEGMASIA D0LENS.            263
as it preserves the parts from the clothes,  it is  very
pleasant.   A careless woman,.who does not attend to
these apparent trifles, will frequently have  the newly
formed skin torn off from her nipple, by  its fastening
to the coverings of the breast.   Sometimes the inflam-
mation extends  to a considerable distance  round the
nipple.   No plan answers  so well  in  all sore breasts
as the false teat, as  any application will then heal the
nipple without further trouble.

      Sect. x.  Swelled Leg of Lying-in Women, or
                  Phlegmasia Dolens.

   A disease sometimes occurs just after lying-in ; and
 is rightly termed  the  swelled leg  of  lying-in women.
 There are many improper terms  for  this complaint,
 one of which is oedema lacleum ; this  is  quite wrong,
 for it is  not oedema, neither has it any thing to do with
 the milk.   It never arises before  the third  day, and
 rarely after  three weeks from delivery.  Tbe disease
 occurs in women  that have had hard labours, or easy
 labours ;  in strong constitutions, and in weak consti-
 tutions ; in women  delivered on the right side,  or  on
 the left  side; where there is milk in  abundance,  and
 where there is none  at  all;  where  the  lochial dis-
  charge is great or  little;  and whether the  patient lias
 been upon  a  free or more abstemious plan of diet.
  So  that  there  seems to be  nothing,  either in the
  nature  or constitution  of the woman,  which  shall
  either cause or  prevent it; neither  would it appear
  to be affected by the labour, as it seems to arise alike
  under all circumstance?.   It is said to depend upon a
  translation   of  the  lochial  discharge,  but  this  is
  veiy absurd; it  is like  supposing  that  fever depends
  upon obstructed perspiration,  from which belief we
  should not  expect to  find fevers in  a hot climate,
  *bere  people perspire much;  nor any thing but fcvtt 
264    THE LONDON PRACTICE OF MIDWIFERY.

in a  cold  climate, where  they perspire  little.   Wc
know that,  during disease, the healthy actions art
suspended, and knowing this to be the  case, we. may
as well suppose that the suspension of these healthy
actions is the cause of the disease; it  were quite as
reasonable to believe, that loss  of appetite in a fever
causes fever, and that the return of it  brings health;
in fact, these are merely symptoms of a  deranged state
of functions, and not causes of the complaint.
   The  disease generally begins  with  shivering, the
swelling being perceived  either general or partial hi
the leg; sometimes arising over the  whole limb at
once, and at other times  beginning in the ham.  It
seems to  have some  connexion  with  the absorbent
glands, as it frequently commences in the groin, from
which part the swelling  will continue  to  extend  till
the whole leg and thigh are as large as the body : in
this way the leg will be extended to the greatest pos-
sible  degree, without  any  redness or  inflammation;
but it will not bear moving; if the patient is  desired
to move the limb, it gives her great pain.  Swellings
in general will  pit, but this  does not;  and it  usually
occupies one side only  : this is observed by Mr. White,
who states that even the labium of one side shall be
tumid, while the other  is quite unaffected.
   The swelling alluded to is of a peculiar character; if
the hand is drawn across the limb, it does not give the
uniform sensation which is commonly felt in swellings,
but resembles an infinite number of irregularities dif-
ficult to be described.  The best idea that can be given
of it is to suppose a block,  in shape resembling a leg,
covered with, brass nails of various sizes, and  these
covered with skin stretched over it.
   The  disease is acute, and the symptoms  of fever will
sometimes be considerable,  and then it  is by no means
surprising  that the secretion of milk is lessened, or the
lochial discharge diminished; as the circulation is de- 
TREATMENT OF PHLEGMASIA' DOLENS.     20
(ermined to other parts.   In ten or twelve days  the
hardness of the swelling ceases, and the state of  the
disease  is changed to true  oedema, and the limb  re-
mains weak  for several months.  Such a limb will al-
ways* be more affected by cold than  the other; after
any exercise,  as  dancing,  it will  be more stiff  and
weak the next morning than the other.   This disease
sometimes attacks both  sides in succession; it  never
occasions suppuration : though Mr. White mentions  one
instance, it is doubtful, however, from his description,
whether it  was this sort  of dwelling, for oedema some-
times resembles it very closely.
   It is extremely difficult to determine the cause of this
alteration of parts,  or  change  of organization!   Mr.
White attempted to explain it,  by supposing .that an
absorbent  vessel gives way at its  entrance into  the
gland, and that the lymph still passing upwards, over-
flows, and enters into the cavities of the cellular mem-
brane,  and there  coagulating, gives  the unequal  feel
observed in this disease.  This is by no means a satis-
factory explanation, and we are still ignorant of the
nature of the disease. No opportunity has yet occurred
of examining the leg of a patient labouring under the
influence of this singular complaint.
   Dr. Denman believes this disease to arise first in the
inguinal glands,  by the absorption  of some irritating
principle in the discharge, the consequence of an  un-
healthy secretion from the uterus.  The leading symp-
toms being a sense of extreme  weakness and excessive
irritability, he recommends the patient to be supported
by cordial medicines and a liberal use of wine;  a light
sudorific  draught, containing aq. ammon. acet.  Iss.
with syr. papav. alb.  3ij- to be taken every  four or six
hours,  to which  a few  drops  of tinct. opii  may be
added to allay pain if occasion require: the  belly to
be kept regularly open, not  purged, by small doses
of magnesice sulphas.   The  best application  to the 
2B6    THE LONDON PRACTICE OF MIDWIFERY.

limb consists in a liniment  composed  of a dram  01
camphor dissolved in  an ounce  of olive-oil, with five
or ten grains  of powdered  opium, used  night  and
morning, and covering  the limb afterwards with loose
flannel.  Great relief has often been received by sur-
rounding the whole limb with a soft poultice, compos-
ed of a peck of bran, four ounces of olive-oil, half an
ounce  of  tinct.  opii, and  a  sufficient quantity  of
hot water :  this may be renewed twice a day.  When
the acute symptoms  are  past,  and the swelling re-
mains, recourse  may be  had  to decoct cinchonas,  or
cascarilloz, Or proper doses of the chalybeates, with the
use  of a  volatile or stimulating liniment to the limb,
assisted by a flannel bandage. 
FOOD OP INFANTS.
267
                   CHAP.  XIII.

              Sect. i.  Food of Infants.

IVliLK is surely intended for the  nourishment of the
child : we see the female not only of our own species,
but of all other animals, is  furnished with it.  There
is no necessity, however, that  milk should be ready for
the child directly as it is born :  nature rarely provides
it till some days have elapsed.  In the mean time the
best nourishment that the child can receive is  a  little
thin water-gruel, sweetened and mixed with some oily
substance, as butter.   The lower classes of people ge-
nerally  give  the child a mixture of butter  and  sugar;
while in the higher ranks they give oil of sweet almonds
with syrup of roses.   These tend  to  make the meco-
nium come away.
   The  proper nourishment of a child is its mother's
milk.   In a state of nature a child should take nothing
else, neither should it in civilized life.  But, from va-
rious causes, a  woman may  be unable  to suckle her
own child ; in which  case, the next best thing  for the
infant is the breast of another woman, of the same age
as its mother, or as  near as  possible; for there is a
great difference between the milk of a woman who has
lain in  one month,  and that of one who has lain in for
 eight or nine mouths.   But wet-nurses are only to be
 had recourse to in  cases of absolute necessity: in ge-
• ueral,  society  suffers  from this class  of people;  for
though the foster-child may  go on very well, yet the
 child of the  wet-nurse is by this means deprived of its
 proper  support, brought  up  by hand, perhaps under
 the care of one who has little regard to its welfare,  and
 in  such circumstances it very frequently dies. 
 268     THE LONDON PRACTICE OF MIDWIFERY.

   Now and then a woman may be induced to suckle
 when she wishes to avoid it:  the  practitioner, when
 her pretences for evasion are  merely  frivolous, may
 often, by dexterously  throwing  out  a  few  hints,
 frighten her into  it.   He  may, for instance, say that
 certainly the  constitution does not suffer much from not
 suckling,  neither is the backing of the milk very dan-
 gerous considered in itself: if this is not enough, that
 his opinion,  notwithstanding, is, that  those  mothers
 who suckle their children are generally the longest liv-
 ers, and are  not so liable  to cancer, or to     Here,
 perhaps,  she will interrupt him, and exclaim,  " Lord,
 Sir, what do  you  say ? cancer !" To which the practi-
 tioner may  answer, " Oh no,  Madam,  I  only  mean
 that those complaints are  more frequent when a lady
 does not suckle."  The word cancer  is generally suf-
 ficient.   There are some  women, however, who would
 not give  up their amusements for  all the  children in
 Europe.   These women  will weigh the  comparative
 importance of things, placing their balls and  routs in
 one scaie, and their infant in the other;  the pleasure
 preponderates, and the child kicks the beam : but many
 of this class of females will be induced,  from the fear
 of cancer, to do  their duty towards the infant by giv-
 ing it suck.
   Supposing  that neither the mother's  milk, from  an
 imperfect state of nipple, or other causes, nor that of
 another woman,  can be  procured  for  the support of
 the child, we must have tecourse to substitutes.  Fa-
 rinaceous decoctions may  be mixed with a sixth  part
 of milk,  previously skimmed and boiled,  to  deprive
it  of  its  thickest and heaviest  parts;  one fourth  ol
 milk may be  mixed with three  fourths  of a decoction
 of pearl-barley, or of grits, carefully strained,  and not
 very  thick,  or   the  arrow-root  mixed with  water.
 Sugar may be added to  (ake  off the insipidity.   The
manner of the child's taking this  should be by suck- 
FOOD OF  INFANTS.
269
ing; for which purpose a piece of leather or skin may
be fixed to the spout of a glass vessel called a sucking-
pot, so  as to resemble  a nipple.   In the  natural
mode of sucking, the child takes its support in  small
quantity and slowly, and  with some difficulty,   so
that it  will not  suck after its  hunger  is  satisfied.
Besides, in sucking, the saliva is  secreted, and carried
down with the  nourishment  which the child  takes,
while in swallowing it  frequently happens that none
is taken down with the  food.  The saliva  being both
useful and necessary to a good digestion, is another ar-
gument in  favour of the child's receiving its  food  by
suction.
   It often happens that parents are not contented with
this, but will give the infant solid food; in such  cases,
the most proper is that  sort of bread which  is  called
rusks, or tops and bottoms :  it is French bread sliced
and baked over again.   In  this there  is neither alum
nor j alap,  ingredients that certainly  are used in form-
ing the bread in this town, notwithstanding the several
penal statutes to prevent improper and unwholesome
mixtures.  This  bread does not disagree  with people
who are used to it: those who are most disordered by
it are generally persons who  have  come up from the
country ; and the complaint it occasions is usually at-
tributed to the water.   The bakers use jalap instead of
yeast, to assist in fermenting the mass.
   Whether the child has common bread, or any other
material, the victuals should be passed through a sieve
and made the consistence of cream.  If this is attended
to there will be  no  danger of  pieces sticking  in  the
child's throat, and endangering suffocation, instances
of which sometimes happen.   A case of this occurred
not long since in the grandchild  of a  venerable  pre-
late • when come into the church  to  be  christened,
the nurse gave it some Savoy  biscuit, part  of iwhich
                        a a 
 270     THE LONDON PRACTICE GF MIDWIFERY.

 got into  the windpipe,  and the  child  instantly died,
 without any one conceiving the cause of its death  The
 worst kind of food for an infant is what is called thick-
 milk, as it is principally composed of water, and flour
 lha( has not undergone any fermentation.
   When, as is frequently the case, in  bringing up a
 child by hand,  costiveness arises, it  is easily  re-
 medied by sweetening the food with  manna instead of
 sugar.
   When  the child sucks, it may be laid to the breast
 within twenty four hours after delivery ; not that it will
 get much nutrition during the first day, but the action
 of fucking will dispose the vessels leading from  the
 glandular structure of the breast in the nipple,  to yield
 the milk as soon as it is  secreted, and the breasts will
 not become too full and tense.  If the child is  not put
 to the breast till it is quite hard, the nipple itself  will,
 by stretching, almost disappear, and the child be  una-
 ble to get at what is left, on account of its nose.  A want
 of proper  attention  to this  rule,  more particularly
 amongst the lower order of females, who often wish to
 defer applying the child until the  third day, has very
frequently been the cause of inflammation and suppura-
 tion in the glandular structure of the part;  a  disease
 almost unknown to tbe  patients of intelligent  and at-
 tentive  practitioners.
   Where a woman has a  full  breast of milk  without
 Suckling, the accumulation is checked most effectually
 by purging;  and at the same time the breasts should
 be rubbed well with oil  of almonds, in  which  a  little
 camphor is  dissolved,  for the friction  will  promote
 absorption, while the  oil will iclax the skin.   The
 woman  should be purged  every second  day till all the
 milk is  gone.   Those  women  who do  not  ruckle
 Jheir children, generally keep their breasts too  warm ;
 when they  are kept cool and lightly covered,  there is 
FOOD  OF INFANTS.
271
less determination of blood to them, and consequently
less milk secreted.

        Sect. ii. Symptoms of Health or Disease.

  It has been said that children have no symptoms by
which  we can know their complaints; but this is not
the fact.   In th> first place, the figure of a young child
is to  be attended  to: this requires little explanation:
by  it is meant, that universal  roundness which is seen
in all parts of the  child; it is so completely rounded,
that there is no such thing as an  angle in the whole
figure;  whether the limbs are bent  or straight, every
line forms  a portion of a circle.  No muscle can  be
discerned through  the skin, all the spaces being  filled
and plumped out with a  gelatinous  fluid,  which after-
wards becomes fat; the joints cannot be found, except
by  observing the flf xions of the limbs.  Whenever the
joints of a young child can be seen, it is not in health;
there must be either some local or  general disease, or
the food is improper, and  not converted  into healthy
nourishment
  The  next circumstance is  what regards the  pro-
portions of  parts.   The body of a young  child in
health will form a  figure which  is  uniformly convex,
though rather more protuberant  at the abdomen than
at other parts   If  the anterior part of  the  chest  is
elevated while the sides are sunk in, it  is a sign of
ill health ; or if  the abdomen projects  forwards too
far, it denotes the same thing;  or if, on the  contrary,
it is  concave,  it  is  a  sure   sign  of disease.   The
fatness or leanness of a child  must ah/ays be attend-
ed to.   Fatness implies  the  nourishment being in an
over-proportion to  tbe exercise taken,  while  leanness
is the opposite to this.   The head  of a child ought to
be  proportionally larger than  that of  an adult, yet 
 2 72     THE LONDON PRACTICE  OF MIDWIFERY.

 there may be an increased size, which points out dis-
 ease.

                 Sect. hi.  Gestures.

   The gestures of a healthy child are  all easy  and
 natural,  but in  sickness they  will often denote the
 nature of the disease.  The legs  being drawn  up to
 the  abdomen,  and accompanied  with  crying,  are
 proofs of disorder and  tenderness, or  pain,  in the
 abdomen, which, upon trial, will be found increased
 by pressure.
   In health the hands of a child are very rarely  raised
 above  the mouth :  hut under some circumstances,  and
 particularly an accumulation of  blood in the head, in
 the  beginning  of phrenitis, and acute  hydrocephalus,
 the child  is never easy except when the hands are ap-
 plied to the head and face.
  Another gesture indicative of disease is a constant
 unceasing desire for picking something or other.   The
 child will begin to pick its own skin till there is a hole,
 and then  continue  to  pick on: perhaps it will pick
 away its  eye-lashes, or a hole in its cheek or nose; it
does not seem to  regard whether it picks itself or ano-
ther child.   This propensity is always connected with
 a diseased state of the abdomen.  If the bowels are
 cleared by a powder composed of calomel etpulv. rhei,
 orpulv. scammonii cum calomelane, proportioned  to the
 age of our little patient, or a dose of plain calomel at
night, and a senna  draught the following morning, the
 child will cease  picking in twenty-four  hours; if it is
 again neglected for  a week, the accumulation will again
 take place, and the infant will be just as eager in pick-
ing as before.
  Starting  from  sleep, or when awake, is another
 circumstance of gesture requiring attention ; though
this  may sometimes happen from the  most  trifling 
GESTURES  OF INFANTS.
273
causes, it  is frequently connected  with  approaching
disorder in the brain or head.  The state of the eyes
also should be attended to; in health they are  clear
and bright, but in disease  they become dull, though,
after long-continued  irritation,  they  will  assume  a
degree of quickness which is very  remarkable,  and a
sort of pearly brightness which is better known by ob-
servation than it can be from description.
   The direction of the eyes should also be attended
to.  When a child is first  brought to the light, both
eyes are scarcely  ever directed to  the  same object j
this  happens without any tendency 10 disease,  and
merely  proves, that  regarding one  object with both
ey*"s  is only  an acquired  habit.   There are  many
people grown up, who are able to look,  very  atten-
tively, at any object  that  they please  with  one eye,
whilst the other is wandering,  or placed with its  axis
in another  direction:  sm h  people can make  use  of
either eye  with  equal readiness, but are  not able  to
direct both eyes to the  same object.
   Children are often  seen to throw their  eyes up-
wards, which generally indicates a  torpor  of some  of
the  muscles,  and is often a  consequence of opiates
having been given
   When the child has come  to that age when the
eyes  by  habit  are directed  to the same  object, and
afterwards it loses that power, it is a fiequent prelude
to diseases affecting the head ;  as  hydrocephalus and
phrenitis.  With regard to the eye, the state  of the
pupil may  vary : it  may  not contract  properly, re-
maining too much dilated, which denotes an unusual
degree  of irritation.   At  the  approach of inflamma-
tion of the brain, the  pupil of the eye is sometimes
bo contracted,  that, supposing the  eye was steadied, a
needle could not  have been  passed through without
pricking the iris :  and while the eye is in this state  of
irritability, most of the other senses are affected in  a
                       a a 2 
-.74    THE LONDON  PRACTICE OF MIDWIFERY.

 similar way ;  any sudden  noise, as  the  clapping ot
 hands near the child's ear, will make it startle more
 than when in health.  In the  latter stage of this  dis-
 ease, and of hydrocephalus, an opposite state,  or  that
 of dilatation of pupil,  is generally observed ;  thougl:
 this state by no means  belongs to phrenitis or hydro
 wphalus  exclusively.

                   Sect. iv.   Skin.
   The elasticity of  the skin is considerable, and very
 useful  to the animated  body, by  adapting itself to
 various  changes of  bulk and  position ; and this  pro-
 perty is more observable in some parts of the body
 than in others, and particularly in the scrotum, which
 iu disease is always relaxed and loose, but as  soon as
 health returns becomes more firm  and  tense.   The
 muscles  themselves,  while healthy,  are exactly  the
 length of the parts between which they  lie, however
 varied be the position of the parts.   Thus the deltoid
 muscle fits the shoulder,  and,  whether  the arm hangs
 down by the side, or rests  upon some  object,  the
 muscle keeps equally  well in contact,  and  appears
 to fit quite as close, although  the distance  between its
 extremities is  so  much less in the one instance than in
 the other.  In disease the  case is very different; the
 muscles seem to be too long,  they lose their power o'
 adaptation, and become, what is termed, flabby.

                  Sect. v. Respiration.

   Tbe respiration of a young child, when atteuded tc
 in health, is formed of equal  inspirations and  expira-
 tions.  When these  operations  are  unequally  per
 formed,   the  child breathes  with  difficulty.   When
 respiration ia attended  with a noise  in the throat,  it
 denotes  the  presence of phlegm.  When a  peculiar
 kind of  wheezing noise is heard,  there is reason to
 apprehend the existence  of a  very  dangerous disease, 
              RESPIRATION  OF INFANTS,          275

inflammation of the trachea.  Another kind of sound
is peculiar to the  hooping cough, where,  from  re-
spiration  being impeded, the child becomes  purple.
The secretions  also should  be  attended to; the flow
of saliva is increased during dentition; and this is  a
very salutary provision of  nature, a  local evacuation
from  an  inflamed  part.   A dry  mouth  always  in-
dicates fever-
  It is of considerable consequence  to  observe  the
stools.  In health a child  has  commonly two,  three,
or four,  in the twenty-four  hours.   When  the first
stools, which  are  generally black,  have passed  soon
after  delivery,  those  which  follow   have but  little
smell;  their  colour may  be  either yellow,  green,
white,  or clay colour:  they  may  be  tinged  with
blood, or may be mucous or watery   The treatment
will be entirely regulated by the colour, consistence,
and  manner  of  discharge  of these  stools   In  a
healthy  child the faeces  are generally  squeezed out3
but in disease they  will be  thrown  out  with  consider-
able force, which  is always a sign of great irritation.
The  stools  of  a  healthy young  child  have  little
smell; those of a  child that has  the  infantile fever
have  a  peculiar  smell:  it  is  very  unpleasant,  and
 gives the sensation of faintness.
   Crying will be different according to the cause,  and
 must be attended  to carefully.
   The heat of the  body must be attentively observed:
 if too low,  it denotes a  want of vital  energy; if too
 great, it may first indicate the presence of infantile
 fever, where, as soon as it has formed  itself,  the  skin
 during the paroxysm will be as  red as scarlet, and the
 heat  so intense, as fully to justify saying that it  is
 burning  hat.
   The tongue of all  sucklings  being uniformly of a
 white colour,  there is no necessity to examine  it, un-
 less aphthae are suspected.  As to the pulse of a very 
276   THE LONDON PRACTICE OP MIDWIFERY,

young  infant, little judgment can be formed from  it;
for merely pricking the finger with a pin will, in a few
seconds, occasion the pulse to be too quick for the pul-
sations to be numbered.
  There are many other circumstances  respecting the
child's  appearance, which cannot  be described, but
which  convey much information to an experienced
practitioner. 
277
CHAP. XIV.
DISEASES  OF INFANTS.
           Sect. i.  Inflammation of the Eyes,

 The diseases  of children may be divided into  two
 kinds, those born with the  child,  and those acquired
 after its  birth.   Imperforation of the rectum,  urethra,
 or vagina, occasionally occurs, and  requires  surgical
 treatment; and sometimes the child  is,  what  the
 nurses call,  tongue-tied,  though by no means  so
 often as they  represent it: when this  happens,  the
frcenum  lingual will require division,  which is  to be
 done carefully  with a pair of very  sharp scissars.
 The  most convenient time is when  the  child is cry-
 ing ;  the tongue is then raised towards the middle or
 upper part of the mouth,  and this little operation  can
 be performed in an instant; it does not appear to  oc-
 casion much  pain, and, if  proper attention  is paid to
 avoid the veins  under the tongue, there will never be
 any bleeding of consequence.
   When first children come into the  world, they  are
 covered  with a  white mucilage, which is no  disease,
 and is to be  washed off by  a  little  warm water  and
 soap  with  a  flannel; a little brandy or  other spirit is
 generally put into it : it certainly does no harm, and,
 by exciting a gentle stimulus or glow upon the skin,
 may sometimes  prevent the  child from  taking  cold  by
 the change of  temperature it  has  so lately experi-
 enced.
   Inflammation of the eyes is sometimes very trou-
 blesome  to infants,   The  mucous membrane  of  the 
 278    THE  LONDON PRACTICE OF MIDWIFERY.

eye is liable to be inflamed from  a variety of causes ;
among  which  may  be  enumerated  the use  of too
much brandy in washing the child ; the keeping it
too near the fire; the air of the room,  and dirt and
sand, where  cleanliness  is  not  attended  to.  When
inflammation takes place, the vessels  will, as in the
adult, appear more numerous and of greater size than
in the healthy state.  The treatment should  be the
same as that  of ophthalmia in any other stage of life  :
a weak  solution of zinc,  sulph. or cupri  sulph.  in aq.
distillat. is a  successful remedy.   If this  does  not suc-
ceed used as  a lotion, it may be safely injected between
the eyelids, three or  four times a day.
  An increased secretion from the tarsal cartilages of
the eye  will  sometimes be very  troublesome,  by con-
fining the eyelids during sleep,  and the matter still
secreting  within,  distending  them.   When  the in-
flammation  is great,  a  leech on each  temple  near
the angle of  the eye will be very useful.   The  eyelids
must be gently separated, and the matter pressed out.
A most useful  application  in this  state of diseased
eyelid  is made by mixing hydr.   nitro-oxyd. 3j,
(rubbed down  to an  impalpable powdei)  with  ung.
cetacei "fj  ; when properly prepared, it  will form an
orange-coloured ointment, and  the  particles  of the
precipitate should not be visible :  a very small quan-
tity of  this  is to be rubbed between the  fore-finger
and thumb  for  a few moments,  until it becomes an
oil, which is  to  be  cautiously smeared over the mar-
gins of  the  eyelids  every night.   Fresh butter, pre-
viously  washed in two or three waters  to  deprive  it
of  the little salt usually  mixed in the dairy, may be
substituted for  the  ung. cetacei.   A  quack-medicine,
called  Singleton's Golden Ointment,  which has met
with an extensive demand, and is sold at the  rate of
more than a  guinea an ounce, is exactly like  this in
appearance and effect.   An ointment  of similar qua- 
DISEASES  OP INFANTS
279
fities is  made by mixing ung. hydr. nitrat. 3j. with
ung.  cetacei, or adip. proeparat.  3iij- and applied as
before directed.   The  principle on  which  these  re-
medies act, is to  bring on a  more  healthy secretion
of the sabaceous  glands of the tarsal cartilages and
eyelids,  and they  h.ve long been used by  the  most
successful oculists  in London.

                 Sect. ii.  Jaundice.

   The greater part of the diseases of children are con-
nected with an  irregular action of the bowels, a very
common diseased  state in infants,  producing  the jaun-
dice.  When it  occur-  soon after birth,  it most  pro-
bably arises from  a  viscid meconium or  mucus inter-
cepting  the  free  passage of  bile into the intestines,
and  will often go  off spontaneously ; but is  generally
removed by  a tra spoonful  or a dessert-spoonful of
castor-oil,  which  is.  certainly, the  best  remedy.   A
little ipecacuanha  wine  or powder  has  been recom-
mended  to  excite  vomiting,  which,  no doubt,  by
agitating the stomach  and  surrounding  viscera, will
often succeed ; yet vomiting being,  in truth, an un-
natural action, ought not to be resorted  to unless re-
lipf cannot be obtained by the  above  means.  A state
of bile unusually viscid may also  be  a  cause of jaun-
dice in early infancy, and there is  no impropriety in
giving  two  grains  of calomel mixed with  as  much
sugar, which,  being put into the child's mouth  dry,
is carried  down  with  the  saliva, and,  in this  way,
has  been  known  to remove  the complaint.  Gentle
friction  with thp  hand  upon  the abdomen,  over and
about the situation of  the liver, will  assist the  effects
ef remedies.  It sometimes, though  rarely,   happens,
that the  ductus communis choledochus  is impervious
where it should open  into the duodenum, and forms
a permanent  cause of disease, which then  terminates
fatally :  dissections have proved this. 
 280    THE LONDON PRACTICE  OP MIDWIFERT.

         Sect.  hi.  Indigestion and green Stools.

    In  very young children symptoms  of  indigestion
 will sometimes occur, by  too  much  air being  gene-
 rated  during the passage of the food  along the intes-
 tinal  canal; in  fact,  no  air   whatever  should  be
 evolved; but as there is at all times some  little fault
 with regard to a  child's  food, either in quantity or
 quality, more  or less air is always formed.  This is
 easily remedied by  a carminative united with  a few
 grains of volatile alkali, and any distilled water;  the
 dill-water with sp. ammon.  comp. is a good formula,
 and will be found  effectual where there is no  other
 complaint than  wind.  Our intention in such   cases
 should be to stimulate the stomach to contract  upon
 the wind,  by which it  will  be expelled, when a tem-
 porary cure is  at once obtained.  As all solid  food,
 when given to  young children  brought up  by  hand,
 will produce a degree  of flatulence, it is proper that
 a small quantity of spice  should be  mixed with  the
 food, so as gently to  stimulate  the stomach : for this
 purpose very little  is sufficient; if much is  given, it
 does mischief.
   After a child has had symptoms of flatulency  for
 some  time, green stools will frequently be the con-
 sequence.  This ha$ been supposed to arise  from the
 existence of an acid; but this is very dubious, for the
 medicines which  succeed the best  in curing the  com-
 plaint,  are not  calculated  to produce any  change in
 an acid.  There are two kinds  of green stools : one
 sort appears green when it  has  stood  some time, but
is  yellow when  it comes away;  the  other  is green
when passed.  The colour however, in both cases, is
most probably  owing  to  the same  cause, an undue
mixture of bile.  Let the colour  of the faeces be  what
it may, when the food is natural, little lumps are seen,
and  these  are  portions of curdled milk. This does 
DISEASES OF INFANTS.            281
hot show that the stomach is imperfect in its digestive
powers, for it is no ill change in the milk, inasmuch
as all milk in every stomach must curdle before it is
digested.   Coagulation is a chemical effect of the gas-
tric liquor, but digestion is an animal  process; both
assist in the reduction of the milk, and  both appear to
be dependant upon the powers of animal life.
  Sometimes  the stools  become  more  frequent;  the
number, instead  of  being three or four  in the  twenty-
four hours, increases to twelve or fourteen.  They may
be mucous and tinged with blood, and thrown  out  by
Sudden jerks; the belly is tender to the touch,  and the
legs drawn up  to the abdomen.   In bowel-complaints
of this kind the irritation is sometimes  so great, that
the  motion throughout  the whole intestinal canal is
instantaneous, and  the child has no sooner swallowed
any nourishment than it  has a stool; so quick indeed,
that it  is  impossible that the  food could  have passed
through the intestines in  the short interval that elapses
between the  swallowing  and the motion.   The child
in a little  time does not sleep at  night,  becomes more
and more restless from the pain  in the bowels, and in
some instances convulsions supervene,  and the child
dies emaciated and entirely exhausted.
  The  principal  causes  of bowel-complaints in infants
are, either the irregular or deranged action in the liver,
forming an unhealthy bile,  that  stimulates the prima'
vice  too much,  and produces purging; or the gene-
ration of acidity during the digestion of the breast-milk
or food,  which also increases  the peristaltic motion of
the intestines, and diffuses a general state of irritability
to the abdomen :  a considerable sourness is often per-
ceptible in the stools  under these circumstances ;  an
increased  and altered secretion  from the liver soon
follows, and constitutes  that state of things which the
practitioner is called in to relieve.
   A dose of calomel, with a little rhubarb, should be
                        e b 
282
THE LONDON PRACTICE  OF MIDWIFERY.
given first,  and repeated,  after the lapse of four  or
six hours, or until by the appearance of stools we are
persuaded  that it has  gone  through  the bowels; a
little cretaceous mixture, with a very small portion of
Unci,  opii, may then be givpn, every  three  or four
hours, until relief is obtained, which,  in  slight cases,
may  soon be  expected;  some  practitioners  advise
emetics in the early state of bowel-complaints, with a
view of emptying the stomach, and producing an anti-
peristaltic motion  of the intestines,  but the cause is
below the stomach :  however, ipecacuanha is the best
and the safest that can be given.  Tartarized anti-
mony is sometimes dangerous, and (here are instances
recorded  where children have died under  its opera-
tion,  even when given iu very small quantity.   In one
case two grains were dissolved in an ounce of water,
of  which  half  a tea-spoonful was given every quarter
of  an hour till it produced vomiting,  which,  when it
took place, never ceased till the child died.  Such vio-
lent effects never happen  from ipecacuanha; two or
three grains of which may be given to an infant every
quarter of an hour, till  it vomits.  If the child is
sucking, it need not  be kept from the  breast;  for
when it throws the milk off  its stomach  there is no-
thing to fear.   An hour after the emetic has operated
the child  may take  a mixture of magnesia and rhu-
barb,  which will open  the bowels.   The dose,  for a
child four months old,  should  be four grains of rhu-
barb, and six or eight of magnesia, in half an ounce of
peppermint or dill water.
   Where the complaint has been  allowed  to run on
 t'dl the stools are very  frequent,  watery,  and bloody,
accompanied  with  great  irritation  throughout the
 whole extent of the canal, the greatest expedition must
 be used ;  for loss of time will be the loss  of life to the
 child.  The necessary  steps will be, first, to wash out
 die lower part of  the intestines by au injection formed 
DISEASES OF INFANTS.
28S
Of any animal  or vegetable  mucilage: barley  decoc-
tion, water gruel, water with cow-heel  boiled in it.
or any kind of broth.  This will act with great advan:
tage upon  the  intestines as  an  internal fomentation,
and may be repeated once or twice within the twenty-
four hours.  After this  injection  has been given as
often as is necessary, another of a different kind should
be exhibited, with a view to quiet the irritation in  the
lower intestines.  A very good formula  for it  is two
drams  of olive-oil, rubbed with the yolk of an egg;
and added to this barley-water, linseed-lea, or arrow-
root decoction, in such a proportion as all together to
make about three or four ounces, to which should be
added from five  to eight drops of laudanum.  This
should be administered  with  the utmost care and  gen-
tleness; and may be repeated six or eight  hours after-
wards  if the irritation continues.   The belly should be
fomented  with warm water,  or an  infusion of chamo-
mile-flowers  with  poppy-heads;  or, instead  of the
latter, laudanum  may  be mixed  with the infusion.
If the child is very young, the  quantity of the foment-
»*;~« j^y ke increased by warm water, and the  child
immersed in it;  care Vting  taken  to wipe the  infant
quite dry, when it comes out  of the bath;  and then  a
plaster,  containing  aromatic ingredients,  may be ap-
plied to  the abdomen.  That found to be most benefi-
cial  in such cases is emp. ladan. ^jss. emp. plumbi 3'j.
pulv. opii 3j.  ol.  mcnth. 3j.  camph.  3j.; which ingre-
dients being mixed and spread on  thin leather, should
be applied over the  anterior surface of  the abdomen.
The following case is a striking instance  of the good
effects of this plaster.
   A child had the complaint  in the bowels, of which
we have been treating, to a very great degree;  almost
every medicine had been given, and a consultation was
called; when a very eminent  practitioner (Dr. Clarke)
proposed the use of opiates: he was told that they had 
^■Z I     THE LONDON PRACTICE  OF MIDWIFERY.

been tried in every form, but  could not be  made to
agree ; he then advised a plaster of the kind we have
just described, which was adopted.  At ten  the same
evening the consultation  was  held again", when the
child was found to be asleep.  The next morning, Dr.
Clarke  was sent for  in  great  haste;  the child was
thought to be dying, was quite lethargic, and had not
awakened  since  the plaster was first  applied.   The
plaster was now  removed, and  by  twelve o'clock the
child was awake, and fell to  sucking without  the  least
interruption from pain, or  further complaint.   It is,
however, necessary to do  something afterwards,  even
in a case like this; the  bowels must be  kept gently
open, aromatic mixtures may be given, and all irritating
food should be avoided.
   In such urgent and pressing  cases, every thing that
is prescribed  must be gone through in  two or three
hours.   To affect (his,  however, the practitioner must
stand by and see that it is done; for if he leaves it  to
the attendant, they very often neglect his orders.
   Iu nineteen oases out of twenty this disordered state
of bowels depends entirely upon the food : h«««« «ne
necessity of the practitioner himself inquiring into its
nature, and endeavouring to regulate  the quantity as
well as the quality.

               Sect. iv.  Infantile Fever.

   A frequent disease, and  one peculiar to children,  is
infantile fever.   The period when  it most  generally
occurs is just at the time of vveaning, when  the  child
is made to live upon a different kind of food from that
to  which  it has been  accustomed.   Dr. Cheyne,  of
Edinburgh, has published  an essay  on  bowel-com-
plaints,  and   chiefly  the  atrophia ablaclatorum,  or
weaning brash, which is connected with infantile  fever.
He gives  a faithful and candid account of the various 
DISEASES Of infants.
28o
remedies  employed, details  the appearances on  dis-
section  in the unfortunate cases,  and terminates his
inquiry  into  the relative merits  of different remedies,
by a decided preference to small and repeated doses of
calomel, half a grain every  night and morning:  this
has  been found  to  relieve   and remove diarrluea in
children, which most frequently  proceeds, in his opin-
ion, from a diseased secretion of  the  liver.   The ex-
perience of other practitioners will  certainly  corro-
borate  his statement.  It is  to be  lamented that Dr.
Cheyne has  not communicated his sentiments in a less
expensive form,  which  would have diffused  informa-
tion  more extensively, since sludents  and  early prac-
titioners,  to whom this work will  be most useful,
cannot  always conveniently indulge in the luxury of
beautiful  type and large-paper margin,  which  are?)
certainly, rather to be tolerated in books of established'
reputation  than  in  essays:  these remarks, however,
are  not exclusively  due  to the  work  in question, and
writers on practical subjects  should consider that  they
derogate  from  their  own  merit,  and subject them-
selves to the suspicion of motives widely different from
general utility, by unnecessarily increasing  the expense
of their publications beyond the limits of moderation.
   Infantile   fever  is known to happen between six
months and seven years of age.  It is in almost every
instance produced  by the food  being  improper, either
in quantity  or  quality,  or  both ; or given at an im-
proper time.  The  child is  perhaps  on the lap while
the nurse is taking her tea, and cries for want of good
nursing; the  nurse soon   puts  an end  to  that, by
 chewing  a  bit of bread and  butter, and with her finger
 •md thumb cramming it  into the child's mouth ; or,  ii
 she  is at  dinner, she gives it a bit  of fat meat to suck,
 and wets its lips with a little porter, or whatever she
 may be drinking; and the lower class of  nurses, and
 other females, suffer infants to taste a little gin: this
                         b b2 
286    THE LONDON PRACTICE OF MIDWIFERY.

is what they call giving the dear creature a little of any
thing that's going.   This renders the health uncertain,
and the child is liable at any time to fall into this  fever
from the disorded state of its bowels; the most tri-
fling causes produce it.
   One  very  frequent cause of its  production  is, that
in  fashionable  families,  at a  time when Nature in-
tended that an infant should sleep,  it is awakened and
brought down to be dandled and stared at by the com-
pany  after dinner;  and if tbe child is  able to run
 about and talk, so much the worse  for it:  for  then
 every person thinks that, in compliment to  the father,
 he is obliged to assist  in making  the child sick: one
 will give it a  plum, another a  sweet cake, a third a
 little wine, a  fourth a fig, &c.   When this practice i
 frequently repeated,  it is natural  to expect  that  the
 bowels must suffer;  and when at  last the   fever is
 raised, a medical man is called in  to allay it: they tell
 him that  the  child  went  to  bed  quite well, and
 awaked in the morning with  a burning  heat and as
 red as  fire.
    It is highly  important to attend  to the proper treat-
 ment of this fever:  saline draughts and antimony are
 of no manner of use.   The disease depends  upon the
 state of the belly ; but it is also necessary to attend to
 the symptoms which  accompany  it: and  the picking
  which was  before described  is  particularly  to be ob-
 served ; it continues as  long as the  disease remains.
 The child, when the fever is upon him, appears more
 pert and lively, while the interval  brings on a lethargic
  stupid state.   The  paroxysm  returns, and he is more
  lively  again.  The appetite is various : sometimes it i«
  lessened,  but  is frequently increased very much ; and.
  when the disease is worst, the desire  for food  is  ex-
  cessive, the child eats voraciously,  and is never easy
  but when swallowing.  Insatiable thirst generally at-
  tends  this complaint.   The paroxysms vary in nunr- 
DISEASES OP INFANTS.           Qfof
her ;  there  are generally three or four in the twenty-
four hours, the child being either  of a fiery red,  or as
pale as ashes.   The alvine discharge is very irregular;
sometimes there are not two stools in the twenty-four
hours, and  at  other times  there  are half a  score.
When the disease is suffered to go on for a length of
time,  the paroxysms will gradually  subside, leaving
the child in  a  deplorable state of weakness, sometimes
producing marasmus: the flesh is evanescent,  the fat
is absorbed, and the child is rendered a most miserable
object.
   The treatment consists in clearing  out  the  bowels ;
and this should  be thoroughly effected ;  for when we
imagine that this end is  accomplished, often if we  give
another purge we still  find an astonishing quantity of
very  offensive horrid-looking sordes   will  be  voided.
To a child of three years old,  four or six grains  of
calomel  may  be given, and to one of (welve  months
old, three grains.  This  by some practitioners will be
considered  as a large dose for so young a child ;  but if
a smaller dose is given, the effect is  trifling and  un-
certain ;  and though a full dose should  occasion vo-
mitting, it is still useful by clearing out the primoz vice.
 Tbe  best way is  to give the calomel at night  mixed in
 a  little honey or  jelly,  and some infusion of senna,
 with a few drops of tinclura jalapoz and  a little syrup
 of roses, very  early the next  morning;  or, if  in the
 daytime, a plain calomel-powder first, and the senna-
 draught  three hours afterwards: and this method of
 giving calomel U, in  general, preferable to combining
 it with cathartic ingredients, as scammony, &c.  After
 this  the digestion may be assisted by the sp. ammon.
 r.o. with aq. anethi.  The purgative must be  repeated
 every now and  then,  till the fever is quite subdued ;
  when this  is  the case, the food must be regulated both
  in quality  and quantity.  Bitters should  then be given
  in such "form as both  to open and strengthen at the 
288    TUE  LONDON PRACTICE OF MIDWIFERY.

same  time:  cascarilla   with canella  in  infusion $
or rhubarb with the mineral alkali.  Great benefit is
also derived from the use of bark  and steel:  an  infu-
sion of cinchona 1y  with tinct. ejusdem com. 3j. twice
a day, for a child at the age of six or seven years, will
be proper; or vin.ferri 3j. ad 3jss. in a little of any of
the  aromatic waters,  with  syrup to make  an ounce
draught, twice a day, will be useful to recruit the sys-
tem after the removal of primary causes.
  By these means the  digestive powers  are strength-
ened ; and, whilst the steel  is taking, a grain of ca-
lomel should  be given every night: it has  the good
effect of unloading the mesenteric glands, and cleans-
ing out the intestines;  it should be continued for about
a month.   In a smaller dose, instead  of purging, it is
apt to salivate.  During the  progress of this complaint,
and, indeed, in all  the disorders  of  children,  consi-
derable attention ought to be paid to keep the  skin  in
an equal and comfortable state, which is best effected
by  putting on  a  flannel  jacket  next the  skin; the
temperature  kept up will be  more  equal, and  many
bowel-complaints avoided,  for the sympathy between
the skin and intestinal canal is very great at all periods
of life, but more  particularly in  infancy  and early
childhood.  By this plan of treatment the disease may
generally be  cured ; but  when  it  is neglected,  or im-
properly treated, it  is very  apt to degenerate into
marasmus.

               Sect. v.  Spina Bifida,

   Sometimes, instead of the spinous processes of the
bones composing the back being  joined to each other,
forming the  spinous process  extending  in an uniform
line  down the  back, they  remain  separated  to  some
distance, so that nothing covers the spinal marrow at
that  part except the theca vertebralis and skip..  Some- 
                DISEASES OF INFANTS.           289

times there are symptoms of this disease at birth,  and
sometimes  not, when the  child is  born  with  every
appearance of health,  till the  space between the  ver-
tebra: of the back becomes  a tumour, which  is filled
with a watery fluid.   In some  cases the external  sur-
face of the. tumour inflames and sloughs off; and in
others a small crack appears, through which the watery
fluid  continually oozes.  This  disease  is  called the
spina bifida,  it has been advised to press upon tbe tu-
mour, or to tap it and evacuate the fluid ;  but the best
way of proceeding is to leave it entirely alone.*

            Sect. vi.  Abdominal Tumour.

   In these three  diseases, abdominal tumour, worms,
and hydrocephalus, there  are  symptoms common to
all, and there are also certain symptoms which cha-
racterize each, and being  attended  to, will enable us
to discriminate in the more difficult cases.   The  most
simple  is that of abdominal tumour;  it  occurs com-
monly snnn aftpr wcailMg, when tile child  has begun
to take food of a nature very  different from breast-
milk, and chiefly when there happens to  be a quantity
of undigested  aliment in the bowels.  The  predispo-
sition seems to consist in a fine skin, and a  weak con-
stitution tending to scrofula.
   A certain state of this disease is easily cured; but if
neglected it leads to a state of  general debility, and is
frequently  followed by  rickets  and curvation of the
limbs.
   The symptoms are, that the  child,  from being ac-
tive,  becomes  torpid,  and is  frequently disposed to
sleep much, which  often  gives the belief of  water
being accumulated in tbe  head; and, during the pro-
gress of the disease, the ossification  throughout  thp

  * Mr. Astley Cooper has published a very valuable paper on this
complaint in  the 2d vol. ofthe Mcdico-cuirurgical Trnn3act'onsj 
 290    THE LONDON PRACTICE  OF MIDWIFERY.

 body stands still.   The pupil of the eye is uncommonly
 dilated, and  the  general  disposition to excitement  is
 diminished.   Neither  the ear  nor the eye is so sus-
 ceptible of impressions as in a state of health.   The
 bowels are irregular, generally  costive.
   What principally distinguishes this  complaint from
 hydrocephalus is,  that there is no pain in the head; the
 flesh of the body  and limbs wastes away ;  the appetite
 varies,  and sometimes is  suddenly lost.  The  size of
 the belly is partly owing to flatus, and partly to accu-
 mulation in the  intestines; and there  is generally an
 enlargement of the mesenteric glands, many instances
 of which  have been found  upon dissection.  The dis-
 ease  appears to  be complicated with   a  considerable
 defect and derangement of the absorbent system.
   The  treatment most successful consists in evacuating
 the bowels by a dose of calomel, &.c. and repeating it
 after an interval  of two or  three days.  The strength
 of the system is  to be supported  by  a decoction  of
 cinchona with sodae subcarb. morning  and  noon, and
 half a grain of calomel every  n'^'nt,  «r  pverj/  other
 night;  instead  of which,  frictions with  ung. hydr,
fort.  3ss.  omni  node, upon the abdomen, have been
 found to  produce  a beneficial  change.  Bitters, and
 other tonics,  are of great utility;  but the  principal
 difficulty in the employment of them arises from their
 unpalatable taste.

                 Sect. vii.  Worms.

   By what means the nidus, from which round worms
 are hatched, finds  its way into the intestines,  we are
 ignorant.   But though we know nothing of  the gene-
 ration of these worms, yet we know that they are often
 very troublesome.  Some  people  suppose that the
 worms themselves  never produce any symptoms; they
 say that the symptoms all arise from the impaired state 
DISEASES OF INFANTS.
291
of the bowels: but surely when there are a number
of worms,  they  must  produce some  symptoms  from
their immediate irritation.
   The  irritation  attending  worms will often  excite
fever and pain till  they are destroyed.  A child old
enough  to describe what he feels, will say that he
perceives something moving in his belly ; and at times
a twinging and  griping pain.  Another symptom of
worms  is a  grinding  of the teeth  in sleep, also rub-
bing of the nose,  which does not happen in abdominal
tumour.
   It is a certain symptom of the  intestines being loaded
with foul matter when  a semicircular  zone of a dark
colour is perceived under each eye.
   The  treatment  of  worms consists  in completely
clearing out the bowels.  If the  child  is four years
old, he may take four  grains of calomel at night for  a
dingle dose ; and, if it does not produce vomiting or
much  inconvenience, he may  take  six grains the next
night.   A small dose  of half a grain  will irritate and
always do harm, producing griping; while a full dose
stimulates the glands,  and at the same time causes  a
large quantity of  foul  matter  to  be evacuated.   A
draught of infus. sennce  and  linct.  jalapce the next
morning'will assist in clearing the bowels, and this dose.
is to  be repeated after the lapse of two or three days.
   The object to be kept  in view is.to make the situa-
 tion of the worms as  uncomfortable  as possible; this
 is best done by evacuating the bowels of their contents,
 when the  worms  will often  be carried away  by the
 stream ; and, unless they are thus expelled, the dis-
 charge by stool is of very little use.  The purges being
 given  on every third  or fourth day,  on the interme-
 diate  days a mild cordial mixture  should be taken.
 Frictions over the abdomen are useful, either simple ox
 medicated.  The digestive powers should next be in-
 creased by  an infusion  of cascarilla or calumba, to 
 292    THE LONDON PRACTICE OF MIDWIFERY.

 which  may be added the fossil alkali.   A very good
formula is quassice3j. soda  subcarb. gr. x. aq. fervent.
 ^ij. tinct. cardamom. 3j.  This is to be taken in three
 portions, morning, noon,  and evening, by a child from
 five  to  seven  years of age,  and  continued till  the
 strength returns; and then  steel is proper:  the  best
 preparations of it are the fer. sulph. which  may be
 dissolved in any of the distilled waters, and  by the
 addition of a little syrup is made palatable; and the
 rinum Jerri.
   The ascarides are another  species  of  worms: (hey
 are generally  found in  the lower intestines, and pro-
 duce less  general  derangement, though considerably
 more local  irritation:  when  in the rectum they  are
 excessively tormenting,  and produce a similar degree
 of itching in the  nose.   They frequently excite piles,
 in  consequence of the  accumulation  of  blood  which
 attends their irritation.   There is no occasion in  this
 complaint  to weaken the constitution by  strong  ca-
 thartics.  An infusion  of the  semina absinth, thrown
 up as a  clyster,  will certainly  destroy  them: and by
 repeating this remedy from time to  time, the rectum
may  be  completely  cleared.   The  efficacy of   the
 injection is improved by mixing with it a little olive
 oil.

          Sect. viii. Hydrocephalus Internus.

   Hydrocephalus internus is a disease to which young
children appear  to  be very subject.   It  is sometimes
well marked, and  at others not  known  till  it is  too
late to receive any  benefit.
   Acute hydrocephalus is always owing  to inflamma-
tion of the brain, and this is usually accompanied with
general fever.   The child  becomes very quick and
active in its perceptions; the  eyes  are  particularly
brisk  and bright, and  the whole frame  is more irrt« 
DISEASES OF INFANTS.           293
table than  usual:  all this may, and frequently  does,
occur without there being any suspicion  of the child's
ailing any  thing   In a short time, if great  attention
is paid, the cheeks will be observed to acquire a florid
colour, as if rouged :  and all the senses  are  rendered
remarkably acute; so much so, that in  two  or three
days  from the beginning of  these symptoms, if the
child, while asleep in his cradle, is gently touched, he
Starts ; if,  when awake, any person clasps bis  hands by
the child's ears, he  will  start violently.  The eye is
also affected;  where the pupil is much  contracted, it
is often indicative of a bad  fever.   These symptoms
may  continue  for a few days, when the  child  will
have fits of screaming, and will be continually moving
its hands about its head,  though with no determinate
motion.  The fit of  screaming will perhaps last  for an
hour, after  which the child will  become sleepy  and
dull, and the irritability will  then appear as deficient as
it was formerly superabundant.  The fever  also  will
be less  considerable, and after every  fit the consequent
torpor will be greater than before.  When at length the
pressure upon the brain  begins  to affect the pathetic
pair of nerves, the motions  of the eye become  inter-
rupted,  and  strabismus arises.   Imperfection in the
senses of seeing, hearing, and feeling, next follow, and
the case becomes chronic.
  This  is  neither more nor less than inflammation of
the brain ;  in proof of which we find coagulable lymph
poured out into the ventricles, upon the optic thalami,
and upon the origin  of the various nerves, as well as
between the  membranes of  the brain.  It is  probable
that the fits of screaming arise at the throwing  out of
the  fluid,  as after that the fever and pain  subside;
and after  the  symptoms  now described have recurred
for a length of time,  the child dies.   In many  cases,
however,  of  hydrocephalus, symptoms  of this com-
plaint  arise  without the inflammatory  stage having
r                      c c 
294    THE LONDON PRACTICE OP MIDWIFERY.

been  so perceptible,  or  its principal symptoms have
abated before  relief is sought for;  an accumulation of
water is found in the ventricles of the brain, and often
between the pia mater and tunica  arachnoides, form-
ing small  but distinct elevations  of the  latter mem-
brane, which  bad  excited symptoms of hydrocephalus
terminating latally, when no  excess of fluid has been
found in the ventricles
  The treatment in  acute  hydrocephalus,  when there
is much  flushing in the face,  and  evidently great in-
crease of arterial  action in the brain, should  be  the
early   application  of six  or  eight  leeches  to  the
temple-, or cupping at the   back of the neck, the
bowels to be briskly acted upon by a dose  of calomel,
and kept  in a  laxative state : small doses of pulv.
antimonialis,  combined  with calomel,   given every
four hours in a little honey or jelly,  with a spoonful
of saline mixture ; this  determines to the skin,  and
assists  in  relieving the  inflammatory  stage.    The
child's   diet  to  be  barley-water, tcast  and  water,
light pudding, and what is called  the  antiphlogistic
regimen.   When  this  complaint  is  not  successfully
resisted  by  these means,  symptoms of  great debi-
lity and compression of  the brain  come  on in a few
days, or  they may  be  in  actual existence when the
practitioner is first called in : if, for example,  there is
much   stupor, with a  continual tendency to doze,
and in this state the eyes are  in part closed,  so as to
elevate  the pupil to the  upper  eyelid,  leaving the
under part only visible, giving a  death-like appear-
ance  to the countenance,  and there should be occa-
sional or frequent flushings, that remain only  a  short
time, succeeded  by  the symptoms of stupidity  and
torpor, the child raising  its hands feebly to the upper
part of the bead, and moving them about the head,
either  with  or without  dilated  pupils, the case be-
comes more  chronic, and   the abstraction  of blood! 
               DISEASES OF INFANTS.            295

improper,  a  serous effusion  having already  taken
place.   The plan then to be  pursued consists  in  an
attempt  to excite  absorption,  and to  support  the
strength of  the system.  The  application of a very
large blister to the upper  part of the head, reaching
longitudinally from the occipital  to the frontal  bones,
and  laterally, from  one  temporal bone to the  other,
should  be  immediately  resorted  to:  some  practi-
tioners prefer the application of  a blister to each leg,
with  the view of producing  a counter stimulus;  but
in this state of  things they  are  not  so extensively
useful.   The  ung. hydr. fort,  must be used with
great  freedom, and  does not affect the  mouth in a
way that might be expected : to a child of three years
old, 3j. should be rubbed in  upon the legs, abdomen,
or back (changing  the surface  at different times), at
night, and  the same  quantity in the morning.   Beef-
tea,  good  mutton  or veal broth, should be  given;
and decoction, with extract  of  bark dissolved in it,
is one  of  the  best  medicines  after the bowels  are
cleared, which  often  have a tendency  to costiveness.
Upon the whole,  this  disease is  very frequently  cured
by a liberal use of mercurial  frictions after the failure
 cf all other remedies.

                 Sect. ix.  Scald Head.

   The scald  head is a very  common disease.  It is
sometimes  the offspring  of  mere  filthiness.   If the
 head  is not  kept clean,  the  scurf, which  is  always
 formed  and separated on the  head of an infant,  will
 produce  a pustular  eruption.   This, however,  will
 sometimes arise where even  the greatest attention is
 paid to cleanliness,  and  generally in those children
 that have been subject to runnings from the ears and
 groin, and who have  tender  skins.    Pimples  like
 chicken-pox  are perceived, and  afterwards dry up.
 When the  disease has a little advanced  they run  into 
^9G    THE LONDON PRACTICE OP MIDWIFERY.

each  other, and by the surface of contact still spread-
ing, the pustules next to  them will join also.   In this
form the disease is infectious
  Another species  of scald head,  which  is much
worse, and  more  highly infectious,  is, when there is
an aggregation of very small pimples  which can only
be seen by the help of a magnifying1  glass.
  The treatment in either case will  be, first to cutoff"
all the hair as close as possible; if the head .an  bear
shaving, it  will be better;  the surface of the  head
should  then  be washed  with warm milk  and  water
and  a  sponge,  with the   intention  of  completely
sopping the scales till they are reduced to  a sort  of
pulp.    If  there are  separate collections  of scales,
they  may  be peeled off, by  gently  raising them  with
a  blunt knife.    When   the head  is  once entirely
cleared from  the  scales, they must  not be  allowed to
form again, and  for this purpose  the head must be
well washed  twice a day.   If the  child  can bear it,
iiie best application  to cleanse  it is soap and water,
but it  is very  painful.   A  solution  of  zincl  Zed^.
may be made in  water,  in  the proportion of a  grain
to an  ounce; in  this cloths are to be  wetted,  and
then laid  over  the diseased parts  of the  head, and
dried bv a hot iron being passed  over them.   These
may remain on  some time,  and afterwards a plaster
with sulphur should be laid  upon  the part.   A very
painful mode of treatment for this eruption is  the ap-
plication of a plaster of cobler's  wax laid over the
head,  and then violently torn off again,  to draw out
the  diseased   roots  of  hair,  which by many  are
believed to be the  cause of all the mischief.   But this
is a  most severe and violent application, and ought
not  to be practised.   The  immediate cause of this
disease appears to be a diseased secretion  from the
cutaneous glands;  and although, in  a general sense,
unctuous applications are exceptionable,  yet an  oint-
ment  composed  of  calomel, vel hydr. prai. alb. .y. 
DISEASES OF INFANTS.           29?
adipis praipar. recentis  lj.  M. forms a  useful re-
medy ; the affected part to be smeared with  it three
or four times  a day,  and lightly covered  with linen
under the cap.
   If the  surface is large, it should not  be  allowed to
heal  without  the child  being  considerably  purged,
either with the tartarized  infusion of senna,  or with
jalap and calomel.   If this is neglected, the  child  is
sometimes attacked  by  inflammation  of the  brain.
This is easily  accounted for.  The carotid artery is at
first a single  trunk, although it afterwards  divides;
one division going to supply the  external parts  of the
head, the other the  internal:  and as the accumulation
of blood  which was  circulating in the branches  of the
external   division of  the  artery is  lessened,  conse-
quently  the  balance of  circulation must be  trans-
ferred to the  other branch, or  to that which supplies
the brain.  Inflammation of the eye  will  frequently
arise from  the  same cause, and  sometimes  total
blindness, so that the child should be kept  low and
moderately purged  : if the disease should not easily
yield to  this  treatment,  and  more  particularly  if
mercurial pieparalions are not used externally, much
advantage will  be obtained by giving half a  grain  of
calomel   every  night,  with  a  little sugar,  or pulv.
 tragac.  comp.

                Sect. x.  Convulsions.

   Young children  are  very liable  to convulsions,
 which arise  from  different  causes;   dentition  very
 often produces them.  It  is then the effect of the in-
 flamed and tumefied state of  the gums; when this  is
 the case, lancing the gums will  at  once afford relief.
 They are not  unfrequently  the consequence of foul
 bowels; they often accompany  hydrocephalus, and,
 indeed,   are  more  frequently  rather  a  symptom
                      c c 2 
T;98   THE LONDON PRACTICE OP MIDWIFERT.

of visceral  or cerebral disease,  than  an idiopathic
affection ;  they  may  also precede  the  eruption  of
small-pox,  &c.   Another cause is what is  called
nervous irritation; so  termed merely that we may be
satisfied that we have got a name; and  that  we may
satisfy others that we  know something about  it, while
the fact is, that we really know nothing of it. A woman
will say, "But  what is it,   pray tell  me,  my dear
Sir, that has given my poor  child these convulsions;
is it his teeth ?"—No."  Is it its  poor  little belly r"
—No."—" Then what do you  think  it  is,  Doctor ?
—"Why, upon  my word, Madam, as far as I have
been   able  to judge, 1 think it arises  from nervous
irritation."—" Do you, indeed ?  ah, well, now I am
satisfied, as I know what it is."
   If  we  are  called  in during  the fits,  dashing  (he
 child with  cold  water will frequently stop them;  and
 sometimes a warm bath has succeeded  where  a cold
 one has failed.  A full dose of castor-oil should be
 given as soon as possible, to carry through the bowels
 any irritating cause,  and half a tea spoonful of  linct.
 assqfoetid.   mixed with an  equal quantity of  water,
 a few minutes after the oil, which will often  relieve.
 Clysters of tepid  mist,  assafoetidce  are  proper, al-
 though the convulsive motion  of the  viscera some-
 times prevents their  being  long  retained.  Throwing
 up an opiate by the rectum, some  time after  the
 castor-oil has been given, may  be useful, and at any
 rate will do no harm,  as it does  not produce any  of
 those effects which  it does when  taken  into the
 stomach.   In teething-time the bowels  should always
 be kept open,  and  abstinence  from  animal:   food
  observed.
    There is a disease, a species  of convulsions,1 at the
  name of which some  medical men choose  to sneer;
  the  complaint  is  inward  fits: a name is of  little
  • onsequence as long as it designates the disease, and 
DISEASES OF INFANT",
299
this  name certainly does very well.  The inward fits
attack suddenly, accompanied with  a purple  colour of
the lips,  cheeks, &c. ; this lasts tor a time,  when the
child comes out perfectly well.  They seem  to be the
effect of a spasm of some part about the heart.  The
exciting cause  is often irritation in  the bowels, which
is  frequently relieved by the means used in other con-
vulsions. If cordial medicines are given, the paroxysms
wilkbecome shorter, or the paroxysms becoming worse,
the patient dies purple.   The foetid clyster should not
be omitted in these cases.

       Sect. xi.   Cynanche Tracheaiis, or Croup.

   This disease is an inflammation of the secreting sur-
face of the trachea, and extending down to the bronchia,
and is accompanied with a peculiar wheezing, or hoarse
noise, caused by the rushing of air, during inspiration
and expiration, over a rough unequal  surface.  It is
very rapid in its progress, and, from the importance of
the  parts affected in carrying on a function indispensa-
bly  connected with life, requires a prompt and decided
practice.
   The cause being an increased action in  the blood-
vessels  of the  trachea  and  its  vicinity, requires  the
 early abstraction of blood : ten  or  twelve leeches
 should be applied, as soon  as possible, over  and about
 the  thyroid cartilage,  and  repeated  the   next  day,
 unless there are evident signs of alleviation  ; bleeding
 from the arm,  and,  more  especially, opening  the
 jugular vein, where symptoms  are very  urgent, is
 highly necessary, and ought to precede or obviate the
 necessity of leeches, otherwise  a  stratum  of coagu-
 lable lymph is  thrown out upon the surface of the
 trachea, and  partly or totally  impedes respiration.
 After   taking   away  as  much   blood  as  may  be
 considered  prudent,  that is, when the active febrile 
300   THE LONDON PRACTICE  Or MIDWIFERY.

symptoms  are  diminished, a blister is to be put upon
the part where  the leeches had  been, by which the dis-
ease  is  most   frequently  combated  with  success.
The bowels are to be opened by a dose of calomel and
a small draught of infus. sennce et tinct. jalapoz.  The
saline medicine, with a solution of antimon. tartarisat.
should be  given in this stage so as to excite perspira-
tion.   The warm bath is a  most excellent addition to
this  plan  of treatment:  occasional  emetics  of pulv.
ipecac, vin. ipecac, or  acet. scillae,, are lo  be  resorted
to, which, by the action of vomiting, assist in  dislodg-
ing  portions   of  the  membrane lining  the trachea.
The food  should consist  of barley-water, giuel, and
light farinaceous substances, and be as  little stimulat-
ing  as possible.   Large  and  quickly repeated doses
of calomel have been  given to excite a change of se-
cretion in  the  affected  part,  and  determine to the
salivary glands : this  treatment  will be  often bene-
ficial, but should never preclude the free  use of early
and  repeated  bleeding,  from which  most  relief is
certainly to be  expected in  this distressing  complaint.
When the violence of  the  fever has  abated, the  sys-
tem suffers under the effects of debility;  a more nou-
rishing diet, as  beef  tea,  mutton, or  veal  brotii,
is  to be  allowed;  and the  decoction of bark, or
any light tonic, with a small quantity of sod.  subcarb.
will be proper.

               Sect. xh.  Marasmus.

  We have before stated, that the infantile fever and
ubdomen tumidum may terminate  in marasmus, which
is  a disease in which there is a peculiar loss of tone
and energy of the system, and  generally  an enlarge-
ment and  obstruction  in  the mesenteric  glands ; in
which there is  a  most perfect  absorption  of fat, and
the body  is  at length left, as nearly  as possible, a 
DISEASES OF INFANTS.           301
skeleton.  It is a very common disease, and may gene-
rally be observed in its progress by slow degrees, being
almost always owing to improper food, either as  to
quality or quantity.
  The skin of the child seems to be too large for the
covering of the muscular parts ; the muscles themselves
being too long for the distance  between their origin and
insertion.  A continual tendency to picking is a regular
attendant  of marasmus; and  though the child is not
nourished by the food taken, there is a continual crav-
ing for it,  which most probably arises from the consti-
tution feeling the deficiency  of nourishment, while the
stomach takes in food without  being capable of digest-'
ins^ a particle.
  ^Weakened as the  child must always be  by this dis-
ease, it is still capable of being remedied ; but some-
times there is a loss of tone and energy, from which we
can  never recover our patient:  for when  the exhaus-
tion of substance has proceeded  to a certain degree, it
dees not admit of relief.                     tj .
  Calomel purges, with infusion of  senna, win oe ne-
cessary to clear out the bowels ;  after which it  is  in
vain to attempt immediately to strengthen the stomach,
that organ being  too much debilitated to bear such
treatment.  Such medicines, however, may be given  as
may afford temporary strength and support, as spices
and cordials.   A most essential point to gam is, break-
ing: that  perpetual desire for food which always attends
this disease.   If the  stomach is. kept constantly loaded,
it is impossible for it to gain strength.  The  only way
to recover the stomach is to keep it  nearly empty;  it
signifies very  little what the child swallows,  since the
absorption of nourishment  is  not in due proportion to
the food taken.
   When a person is weakened by disease, and it is ne-
cessary to "restore  his strength, it  is generally  at-
tempted  by giving the essence  of good things,  as 
3f)2    THE LONDON PRACTICE  OF MIDWIFT.RY.

gravies, jellies, &c. as combining the  most support in
the least space.  This is the wrong way to treat this
disease;  it will only exhaust the remaining  power of
the stomach.   The nutritive quality of ass's  milk, so
singularly  efficacious,  not  in  this  only,  but  in all
diseases  of great  weakness, consists  in its want of
nourishment;  it is the lightest and  the  most diluted
of all the sorts of milk used; and yet, in cases of ex-
treme  debility, it  is  supposed  to  be  the greatest
strengthener.   Now it is very proper  for us  to  make
use of this general prejudice to forward our views in
regard  to  practice ;  and therefore recommending
ass's milk will be  agreeable  to our own  intention,
and to the wishes of the child's friends; although they
are  perfectly mistaken  as  to the  reason  why it  is
useful.   It will sometimes be of use,  while giving the
ass's milk, to mix with it  a little arrow-root powder;
it has the  good effect of preventing  so  firm a coagu-
lation of  the  milk  as  would  otherwise  take place  in
the  stomach, which is  sometimes incapable  of digest*
iilg a  strong  coagulum:  this is  proved by what
frequently happens  in  children  when they  are  sick ;
they will then sometimes bring off from their stomach
a long fragment of what, in  fact, is  merely  cheese
made in the stomach, and remaining without the sto-
mach having the power  of digesting it, and is  at last
brought up.
   The ordinary drink may be  barley water,  the great-
 est attention being paid  to the interruption of the con-
tinual desire  for food; for till  this is overcome nothing
 can be done.  The same reasoning applies to  the ab-
 domen tumidum and worms;  we must  never  oppress
 the stomach  beyond what it is able to bear.

    With this we conclude our  account  of the diseases
 of children ; and earnestly advise  those medical men
 who have not had  much experience in them,  to lose 
DISEASES OF INFANTS.
303
no time in obtaining a practical knowledge of their va-
rieties.
  The little  sufferers are unable  to  tell us what ails
them, and it  is not unfrequently that the most able and
experienced  practitioner is deceived in his conjectures.
What then must be tbe perplexity of him, who is nearly
ignorant of  the diseases of children ?  He acts with
uncertainty and indecision; the friends of the child dis-
cover his want of experience, and justly apply to those
who are more intelligent in their profession. 
 
INDEX.
                          A.

 Abdomen, light pressure upon, after delivery, Page 14?
 Abdominal tumour, 289.
 ■:------------------causes and treatment of, ibid.
 Abortion, or premature labour, 98.
 ---------not peculiar to the human species, ibid.
 --------different causes of, 99.
 ---------symptoms preceding, 103.
 ---------different modes of occurrence, ibid.
 -------- remote effects of, on the constitution, 105.
 ---------treatment to be employed in preventing, 109
 Advertisements, insidious, concerning pregnancy, 10£.
 \ffections of the head and chest, 97.
 After-pains, cause of, 257.
 -----------moderated by opiates, 2»58.
 Ambrose Pare, method of, in turning the  foetus, 198.
 Amnion and chorion, membranes of the foetus, 62.
 --------liquor of the, a secretion, 63.
 -------------------- qualities and use of, 64.
 Animation, suspension of, at birth, 75.
 Application of the vectis, 168.
 -----------oi the forceps, 172.
 Applications, cold, in uterine hemorrhage, 240.
 Arrest and impaction of the head, 167.
 -------------------utility of the forceps in, 161.

                          B.

 Bed, how to be made convenient for delivery, 137.
 Bladder, inflammation at the neck of, 88.
 _______and rectum, evacuation of, in labour, 136.
.-------fulness of, a cause of difficult labour, 157.
 -------stone in. 158.
                         Dd 
INDEX.
Bleeding often necessary to prevent abortion, IOC.
---------early in croup, good effects of, 299.
Blood, circulation of, in the  foetus, 71.
------coagulation of, more rapid in dying animals, 28 J
------effusion of, into the labia pudendi, 254.
_________________treatment of, ibid-
Breathing, suspension of, immediately after birth, 75
Breech and feet, presentation of, 194.
----:-----------how  to be delivered, 195.

                        C.

Caesarean operation, why and how  performed, 177.
-------------------fatality of, in England, 178.
--------------------cases in which it is admissible, 179.
Calomel, small doses of, in bowel-complaints, 285.
Cancer of the uterus preceded hy scirrhus, 40.
--------------:-----treatmentto retard and relieve, 42.
Celsus, practice of, in turning the foetus, 197.
Cessation of menstruation, consequences and treatment ol.
    SO.
Changes of the  uterus by impregnation, 78.
---------------os tinea? in pregnancy, 12S.
--------immediate, in the child after its birth, 71.
Chest and head, affections of, 97.
Cheyne, Dr. his essay on bowel eomplaints, 284.
Child, different states of, when born, 74.
------to be applied to the hreast early, 267.
------or mother, which to be preferred, 182.
Children, gestures of, Us be observed, 272.
Chorion and amnion, membranes of the foetus, 6i;
Circulation of blood in the fcetus, 70.
-------------------in the umbilical cord, 72.
Climates, told,  small quantity of menses in  5.
---------warm, copious menstruation in, ibid.
 Clysters, utility of, iu disordered bowels, -283.
Coagulation of blood more rapid in dying animals, 2S1.
Cold, utility of, in preventing abortion, 107.
-----applications in  uterine hemorrhage, 239.
Complex labour, 202.
 Conception, observations on, 46.
------------si,<rns of, 82.
 Conduct, propriety of, to be strictly observed, 1.-21 
INDEX.
Confidence  of the patient, importance of, in  difficult la-
    bour, 152.
------------------------how to be obtained, 153.
Consequences of pressure on the navel-string, 73.
----—------of the placenta remaining, 242.
Convulsion, puerperal, 208.
-------------------causes and effects of, 209.
-------------------organic affections of brain in, 211.
------;-------------appearances after death in, 212.
----'--------------- preceding symptoms of,ibid.
-------------------utility of evacuations in, 214.
---_______________- caused by irritable state of nerves.
    2!5.
-------------------treatment of, from plethora, 217.
____________________________________irritability, 218,
Convulsions remaining after delivery, 220.
----------in children generally a symptom, 297.
--------------------treatment of, 298.
Cord, umbilical, to be preserved from pressure, 193.
-------------presentation of, 202.
Corpus luteum and ovum, 61.
Costiveness often attendant on pregnancy, 87.
Cracking of the skin of the abdomen, 98.
Cramp, and pain of the lower extremities, 95.
Croup, orcynanche trachealis, cause of, 299.
 ------treatment of, ibid.
Cullen, Dr. his opinion, on the. cause of menstruation, 9.
 Cynanche trachealis, or croup, 299.

                            D.

 Danger in protracted delivery, 163.
 ____;:__-of delay in retention of urine, 253.
 Dangerous officiousness of midwives during labour, 144.
 Death or life of the  foetus, how ascertained, 180.
 Decidua and decidua reflexa, membranes.  65.
 Deformed  pelvis a cause of difficult labour, 176.
 Deformity and  weakness causes of difficult labours, 148.
 Delivery bv the forceps, 172.
 _______- convulsions that remain after, 220.
 _______treatment of women after, 250. 
INDEX.
 Delivery, fainting after, causes of, 251.
 _____________■    ----treatment of, 252.
 Diarrhoea and hemorrhoids in pregnancy, 88,
 --------in children, treatment of, 284.
 Diet proper for a woman after delivery, 259.
 ----what improper  for children, 285.
 Difference of puberty in various climates, 6.
 Different states of the child when born, 74.
 Difficult labour three species of, 148.
 .____—__-----predisposing causes of, ibid.
 ____.---------address in the management  of, 149.
 ______________caused by weakness and deformity, ibid
 ______------—-----------passions of the mind, 152.
 ,__________■-------------• rigidity of os uteri, 154.
 .,_______i—.«——_——.——        ■■   vagina, »56.
 ______.-----.......■■-----distended bladder, 157.
 ___                      atone in the bladder, 150.
 ------—--------------tumours of the soft parts, ibid,
      —---------~------rupture  of  the  membranes,
    160.
 ------------------------a large head, 162.
 -.-------------------improper management, 163.
 Difficulties in labour seldom existing, 136.
 ----------in preternatural  labour, creation  of, 147.
 Dilatation of theos uteri, 129.
 -----------------------sometimes rapid,  140.
 ---------------vagina mechanical, 130.
Discharge, menstrual, 1.
.--------------------parts concerned in, 2.
 --------------------various opinions concerning, 8.
 --------------------a secretion, not merely blood, ibid
 --------------------does not coagulate, 4.
 .--------------------influenced by diseases, 6
 --------------------probable cause of, 10.
 ■--------------------irregularity of, 12.
 .-----------•---------obstructed, 13.
 ------■               treatment to regulate, 20.
 --------------------painful, called  dysmenorrhea, 25.
 ----------mucous, from the vagina during  labour, 133.
----------lochial, 255.
Disease and  health, symptoms of, in infants,  271. 
INDEX.
Diseases of infants, 277.
Division and tying the navel-string, 145.
Dress, convenient, of the woman in delivery, 140.
Dropsy of the ovarium, 43.
-------------uterus, supposed, 44.
Ductus  arteriosus, use of, in foetal circulation, 72.
Duration of labour, uncertainty of, 139.
Dysmenorrhcea, or painful menstruation, 28.

                          E.

Early application of the child to the breast, 270.
---.— bleeding in croup, good effects of, 299.
Effusion of blood into the labia pudendi, 254.        .
,______________——---_——_—.----treatment of, tbid
Elasticity of the skin. 274.
Enlarged nymph®, 34.
Evacuation of bladder and rectum in labour, 1S2.
Examination per vaginam, 120.
_----------during labour, reasons for, 139.
Expulsion of the placenta, by the uterus, 145.
Extraction of the placenta, 146.
.------------------------in twins, 205.
Extremities, lower, present in preternatural labour, 193.
------------upper, presentation of, to be altered, 196.
Eyes inflammation of, in infants, 277.
-1----------------------------treatment of, 278.

                          F.

Fainting after delivery, causes of, 251
-------:--------------treatment of, 252.
False pains, bow distinguished, 134.
Febrile  state, oedema, and varicose veins, 96.
Feet and breech, presentation of, 194.
„_______________how delivered, ibid.
Fermentation supposed necessary in generation, 49,
Fever, milk, general causes of, 261.
..----- infantile, causes of, 285.
.--------------treatment of, 287.
First stage of labour, 126.
Flaccidity of 03 uteri dengerous, 236. 
                        INDEX.

Flooding in premature labour ; see in Abortion,  100.
---------in advanced pregnancy, 231.
---------caused by partial separation of placenta, 225.
         delay of midwives in, 227.
         natural means by which it is restrained, 220.
         treatment-of, 231.
         necessity of horizontal posture in, 233.
         delivery to be assisted in, i>3 i.
         restrained by contraction of the uterus, 237.
Fluor albus, or leucorrhcea, treatment of,37.
Foetus, circulation of the blood in, 69.
■■---—situation of, in the uterus, 109.
-------to ascertain whether living or dead, 180.
-------opening the head of, reasons for, 183.
-------turning of, to facilitate labour, 188.
                  ■sentiments of Hippocrates concerningj

                  - practice of Celsus in, ibid.         .  t,
                  ■ most convenient time of, 198.
                  - opinions of  Baudelocque, Hunter, and
197.
    Clarke, 191.
------------------how to he  best effected, ibid.
------------.------difficulties when long delayed, 200.
Fontanelle, anterior and posterior, 126.
F'»od of infants, what most proper, 267
Foramen ovale pervious in the foetus, 72.
Forceps, utility  of, in arrest and impaction, 163.
------------------on various occasions, 165.
--------origin of, 167.
--------superiority of, over the vectis, 169.
--------principle of action of the, ibid.
--------first used by Chamherlen, 172.
--------application of, ibid.
Fourth stage, >'.nd conclusion of labour, 131.
Fulness of  hi'ddera cause of difficult labour, 157.
Funis timuiiicaii.-i and placenta, 66.
----------------connexion with placenta, 67.
----------------presentation of, 202.

                          G.

Generation, diseases in the female parts of, 81.
—--------different theories of, 49. 
Generation, peculiarity  of, in various vegetables and ani-
    mals, 50.
---------Haller's opinion concerning, 51.
—------•— fepallanzani's experiments on, 52.
---------John Hunter s experiments on, ibid.
-----      Harvey's sentiments concerning, 54.
---------Buffon's hypothesis of, 57.
---------Paiacelsus's experiments on, 58.
   -------Leuwenhoeck's notion of, ibid.
           theory of, not perfectly understood, 60.
General treatment of a woman after delivery, 258.
Gestures of children to be observed, 272.
Green stools, and indigestion in children, 280.
—---------causes and treatment of, 281.

                          H.

Head and chest, affections of, 97.
-----ossification and form of, 126.
-----opening of, in the  foetus, 179.
-----reasons for opening before delivery, 183;
----manner of opening, 184.
----scald, general causes of, 296.
----------treatment of, 295.
Health and disease in children, symptoms of, 271.
Heartburn, sickness, and vomiting, 86.
Heat of the skin, increase or diminution of, 274.
Hemorrhage, uterine,in advanced pregnancy, 224.
-------------------causes of, 225.
____-----------delay of midwives in, 227.
.-------.-----------natural means of restraining, 22»
_______—   ---  -  -  treatment of, 231.
___________________delivery to be assisted in, 235.
_________________  after delivery of placenta, 238.
.__________________from inverted uterus, 216.
Hemorrhoids and diarrhoea in pregnancy, 88.
Hippocrates, sentiments of, on turning ihe fetus, 197.
-----------practice of, in embryotomy, ibid.
Horizontal position necessary to prevent abortion, 107.
__________________________in   uterine   hemorrha^

     238;________________— after delivery, 250. 
INDEX.
 Hydrocephalus internus, symptoms of, 292.
 _______r             treatment of, 296.
 Hymen, imperforate, treatment of, 34.

                          1.

 Jaundice, in infants, causes and treatment of, 279.
 Ice, great utility of, in profuse menstruation, -4.
   ,fe_________------ uterine hemorrhage, 231.
 Impaction and arrest of the head, 164.
 __________________. utility of the forceps in, ibid.
 Imperforate hymen, treatment of, 34.
 Improper management a cause of difficult labour, 163.
 Indigestion and green stools in infants, 280.
 ___________________________________causes ana treat
    mentof, 281.
 Infantile fever, causes of, 284.
 ------------- treatmenfrof, 286.
 Infants, food of, 267.
 -------respiration of, to be observed, 274.
 -------diseases of, 277.
 Inflammation of the neck of the bladder, 88.
 -------------of the eyes in infancy, 267.
 -----------------------treatment of, 278.
 Inflation of the lungs in suspended respiration, 77.
 Instinctive knowledge of animals about labour, 119.
 Instruments used in midwifery, 167.
 Inverted uterus, general cause of, 246.
 --------------reduction of, 247.
 ______________dangerous hemorrhage from, 247.
 Irregular  contraction of the  uterus  in  difficult  labour,
    151.
 --------menstruation, 11.
 Itching, excessive, in the parts of generation, 36.

                          K.

 Knowledge, instinctive, of animals about labour, 119.

                          L.

Labia pudendi, diseased, 34.
Labour, causes of,  114.
 -------ridiculous opinions concerning, 113. 
INDEX.
Labour, division of, into four 6pecies, 118.
-------signs of, 119.
-------natural, first stage of, 126.
--------------second stage and progress of, 129.
--------------. third stage and progress of, 130.
>--------------fourth stage and conclusion of, 131.
--------------symptoms accompanying, 132.
--------------treatment of, 136.
-------pains, cause, and effects of, 138.
--------things to be attended to in, 137.
-------difficult, three species of 148.
--------------predisposing causes of, ibid.
-------facilitated by turning the foetus, 184.
-------premature, reasons for, 188.
-----------------how obtained, 190.
-------preternatural, and first division of, 195.
-------complex, 202.
-------attended  with convulsion, 208.
Lacerated perinaeum, 256.
------------------prevention of, 257.
Large head a cause of difficult labour, 162.
Legs, swelled, in lying-in women, 264.
Leucorrhcea,  or fiuor albus, treatment of, 37.
Life or death of the fcetus how ascertained, 180.
Lochial discharge, 255.
Lower extremiiies present in preternatural labour, 193.
Lungs, inflation of, in suspended respiration, 76.

                           M.

Marasmus, or wasting of the body, 300.
 ---------treatment of, 301.
Mechanism of human and comparative parturition, 127.
Membranes of the ovum, 62.
__________not to be ruptured during labour, 73.
__________rupture of, a cause of difficult labour, 161.
Menorrhagia, or profuse menstruation, 23.
____________causes and treatment of, 24.
Menstrual discharge, parts concerned in, 2.
______-------------various opinions concerning, S,
_____._____________a secretion, not merely blood, ibid.
~ __________________does not coagulate, 4.
                         Ee 
INDEX.
Menstrual discharge, small quantity of, in cold climates, •>
----------■---------copious in warm climates, ibid.
------—-----------probable cause of, 11.
—----------------irregularity of, 12.
—------------------obstructed, 14.
-------------------treatment to regulate, 20.
Menstruation, 1.
—---------— connected with puberty, 6.
------------ profuse, or menorrhagia, 23.
-------------■ painful, 28.
 -----------period of cessation and treatment of, 30
Milk of the mother best nourishment for the infant, 267
——- fever, general causes of, 261.
Midwives, dangerous officiousness of, in labour, 144.
---------bad management of, in difficult labour 149.
Miscarriage, or Abortion, 98.
----------not peculiar to the human species, ibid.
-----------different causes of, 99.
----—----symptoms preceding, 103.
-----------different modes of occurrence in, 104.
----------insidious advertisements to procure, 102.
----—-----remote effects of, on the constitution, 105
Mollities ossium, a cause of deformed pelvis, 176.
Moon, its supposed influence on menstruation, 7.
Mother or child, which to be preferred, 182.
Mucous discharge from the vagina during labour, 133

                          N.

 Vatural labour divided into four stages, 125.
--------------first stage of, 126.
—;------------second stage and progress of, 129.
—------------third stage and progress of, 180.
----■----------fourth stage and conclusion of, 131.
  ------------symptoms accompanying, 132.
------—;-----treatment of,  136.
Navel-string, consequences of pressure on, 73.
-----------division and tying oT, 145.
Nipples, sore, management of, 261.
Nourishment most proper for the child, 267.
Nymphs, enlarged, 34. 
INDEX.
                         o.

Obstructed menstruation, various causes of, 14.
-----------------------treatment of, 20.
OSdema, varicose veins, and febrile state, 96.
CEdematous swelling of the labia pudendi, 35.
Opening of the head of the foetus, concerning, 180.
-------------------------------reasons for, 183.
-------------------------------operation of, 184.
Operation, Cesarean, why and how performed, 177.
-------------------fatality of, in England, 178.
-------------------cases  in   which it  is  admissable.
    179.
Opiate plaster, a case of its good effect, 283.
Opiates, utility of, in difficult labour, 151.
-------small doses of, to allay irritability, 242.
Os tinea?, change of, in pregnancy, 122.
Os uteri, means by which it is dilated, 129.
 -------rapid dilatation of, in some cases, 140.
 -------irregular contraction of,  a cause of difficult la
    bour, 154.
--------flaccid in dangerous flooding, 236.
 --------sometimes closed by the placenta, ibid.
Ossification of the head, progress of, 128.
Ovarium, dropsy of, 43.
Ovum and corpus luteum, 61.

                           P.

 Pain of, and cramp, in lower extremities, 95.
Pains, labour, cause and effects of, 133.
■-----false, how distinguished, 135.
 ----- after cause of, 257.
 Painful menstruation, 28.
 Par6, Ambrose, method of, in turning the foetus, 197.
 Passions of the mind causes of difficult labour, 152.
 Patient, confidence  of, important in difficult labour, ibid
 ---------------------how to be obtained, 153,
 Parts of generation, female, diseases of,  34.
 Parturition, human and comparative, mechanism of, 12' 
Pelvis, greater breath of, in the female, 126.
-----general structure and capacities of, 127.
-----deformed, a cause of dilficuli labour, 176.
Perinaeum, reasons for supporting during labour, 144.
---------lacerated, 256.
—---------------prevention of, 257.
Phlegmasia dolens, description of, 263.
----------------probable cause of, 265.
~-----------■---- treatment of. ibid.
Placenta and funis umbilicalis, 6.6.
-------structure and uses of,ibid.
             ;---of, in certain animals, 67.
"-------cautious extraction of, 146.
         expulsion of, by the. uterus, ibid.
-------datngerof forcible extraction of, 146.
-------sometimes over the os uteri in flooding, 256.
         to be delivered in floodings, ibid.
         hemorrhage after the extraction of, 237.
-------remaining, dangerous consequences of, 24S.
----------------treatment of, 241.
----------------portion of, dangerous, 245.
Placentae in twins, caution in the delivery of. 205.
Plaster, opiate, a case of its good effects, 283.
Polypous tumours, 39.
Portion of placenta remaining, danger of, 246.
Position of the foetus in the uterus, 111.
-----------;-------various opinions concerning, ibid.
-------horizontal, necessary to prevent abortion, 107.
            --------------in   uterine   hemorrhage.
233.
               to be continued after delivery, 250.
Predisposing causes of difficult labour, 148
Pregnancy, spurious, 31.
------------------causes and treatment of, ibid.
---------signs of, 32.
---------changes of the uterus in, 78.
           peculiar symptoms, 84.
~--------divisions of, from its symptoms, 85.
Premature labour, reasons for, 189.
r~----------- how obtained, 190.
Presentation of the funis umbilicalis, 202. 
INDEX.
Presentation of an upper extremity, 196.
---■----------a lower extremity, 193.
—---■---------the breech, 194.
Pressure, light, upon the abdomen after dalivery, 147.
Procidentia uteri, causes and treatment of, 37.
Profuse menstruation, 23.
Prognosis in abortion, 104.
--------in difficult labour to be guarded, 152.
Propriety of conduct to be strictly observed, 121.
Protracted delivery, danger of, 164.
Puberty signified by menstruation, 6.
-------different periods of, according to climate, ibid.
Puerperal convulsion, 208.
-------------------causes and effects of, 209.   .
■-------------------organic affections  of the brain in.
    211.
-------------------appearances  found after death in,
    212.
-------------------symptoms preceding, 213. •
-------------------general utility ofevacuants in, 214.
-------------------caused by  an irritable state  of the
    nerves, 215.
-------------------treatment  of,  in  plethora  and  in
    irritability, 217.
Purgative usually given on  the third  day after  delivery.
    260.

                          R.

Reasons for examination during labour, 139.
Recovery of suspended animation at birth, 75.
Rectum and bladder, evacuation of, 132.
Refreshment, the kind of, necessary in labour, 141.
Respiration of infants to be observed, 274.
Retention of urine, danger of delay in, 253.
Rigidity of os uteri  a frequent cause  of difficult  labour,
    154.
------of vagina sometimes occurs, 155.
Rupture, early, of the membranes  a  cause of difficult la-
    bour, 160.
------of the uterus, 221.
------------------spontaneous and accidental, 222
------------------always fatal, ibid. 
                          s.

Scald head, general causes of, 295.
----------treatment of, 296.
Schirrhosity of the uterus, 40.
.----------treatment of, to obviate and retard cancer, 11
Second stage of labour, progress of, 129.
Sickness, vomiting, and heartburn, 86.
Signs of labour having commenced, 119.
Situation of the foetus in utero, 111.
Skin, elasticity of, 274.
----heat of, in health and disease, 274.
Smell of putrefaction with dead foetus, 181.
Sore nipples, management of, 201.
Soreness of the skin  covering the abdomen, 98.
Spina bifida, 288.
Spurious Pregnancy, 31.
-------------------causes and treatment of, 32.
Stone in the bladder a cause of difficult labour, 158.
Suspension of breathing immediately after birth, 75.
Supporting the perinaeum, reasons for, 143.
Surprise of a woman in labour, how avoided, 138.
Sutures of the bead,  how formed, 128.
Suppression or retention of urine, 88.
Swelled leg of lying-in women, description of, 263.
-----------probable cause of, 265.
.-----------treatment  of, ibid.
Swelling, oedematous, of labia pudendi, 35.
Symptoms of health, and disease in infants, 267.

                          T.

 Third stage of Labour, 130.
-----day after delivery, purgative given on, 260.
Treatment of natural labour, 136.
_________and causes of rigid os uteri, 155.
---------of uterine hemorrhage, 231.
-----------women after delivery, 250.
Tubercle of the uterus, 40.
 Tumour, abdominal, 285.
 ------------------treatment of, 289.
 Tumours, polypous, 39.
 --------of the soft parts causes of difficult labour, 1S.
 Turning thefcetusto facilitate labour, 188. 
INDEX.
Turning the foetus, practice of  Celsus in, 197.
—;---------------sentiments of Hippocrates concerning.
  ibid.
-----------------most convenient time of, 198.
-----------------opinions of Baudelocque, Hunter, and
  Clarke, ibid.
-----------------how to be best effected, 199.
—----------------difficulties   of,  when   long  delayed.
  ibid.
Twins, or more children, how discovered, 205.
-----management in the delivery of, ibid.

                          U.

Umbilical cord and placenta, formation of,  66.
 --------------to be preserved from pressure,  195.
Uncertainty of the duration of labour,  140.
Upper extremity, presentation  of, to be changed, 196.
Urine, retention or suppression of, 88.
----;---------danger of delay in, 253.
Uteri procidentia, causes and treatment of, 37.
—— os, rigidity of,  a cause of  difficult labour, 154.
----;-------------causes and treatment of, 155.
Uterine vessels concerned in menstruation, 2.
-------hemorrhage in advanced pregnancy, 224.
------------------caused by partial  separation  of the
     placenta, 225.
                  ~ delay of midwives in, 227.
                     natural means lo restrain, 229.
                     treatment of, 231.
 .-------------------utility of horizontal position, 232.
 -------------------delivery to be assisted in, 236.
 -------------------after extraction of placenta, 238,
 -------------------treatment of, 239.
 Utero-gestation, period of, 113.
 Uterus, polypous tumours of, 39.
 -------tubercle of,  40.
 -------schirrhosity of, and treatment, 41.
 -------changes of,  by impregnation, 78.
 -------retroverted, 90.
 ------------------causes and effects of,  100.
 ,------------------catheter to be used during, 95.
 ——-—sympathies of, tending to abortion, 102. 
INDEX.
s
Uterus, irregular contraction of, a cause of difficult labour.
    151.
------rupture of, 221.
----------------spontaneous and accidental, ibid.
----------------always fatal, 222.
------contraction of, restrains flooding, 287.
------irregular contraction of, after delivery, 241.
------inverted, general cause of, 246.
---------------reduction of, ibid.
---------------dangerous hemorrhage from, 247.

                          V.

Vagina, examination by, in labour, 120.
---------dilatation of, mechanical, 130.
--------occasional rigidity of, 156.
Varicose veins, oedema, and febrile state, 96.
Vectis, or lever, its principle of action, 167.
------■---------application of, ibid.
 --------------why inferior to the forceps,  169.
 p--------------objections to the use of, 170.
Vessels, uterine, concerned in menstruation, 2.
Volatile alkali, utility of, in fainting, 241.
Vomiting, sickness, and heartburn, 86.
---■-----frequently occurs in labour, 132.

                          W.

Warm climates, copious menstruation in, 5.
Warmth,  artificial,  promotes  the  menstrual dischaiK'-
    ibid.
Wasting of the body, or marasmus, 300.
--------------------treatment of, 301.
Weakness and deformity, causes of difficult labour 148.
Women, treatment of, after delivery, 250.
Worms, treatment of, 290.
THE END. 
1 
 
MexL. H








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