& N 
ESS A Y 
ON THE 
UTERINE HAEMO 
WHICH PRECEDES THE 
DE LIVERY 
OF THE, 
FULL GROWN FOETUS: 
ILLUSTRATED WITH CASES. 
By edwahd rigby. 
MEMBER OF THE CORPORATION OF SURGEONS IN LONDON. 
THE THIRD EDITION. 
PHILADELPHIA: 
PRINTED FOR THOMAS DOBSON, IN SE C O ND-S TREE T, 
TWO DOORS ABOVE CHESNUT-STREET. 
M DCC LX X XVI. advertisement. 
of the cafes on which the 
doßrine contained in the following 
pages, is founded, fell under my notice in 
confequence of being appointed to attend 
all the poor women in a large and popu- 
lous city, who have difficult and danger- 
ous labors. 
I thought it rig/jf to premife this, as 
were it not known what circumfiance 
gave me an opportunity of colleßing them,, 
the number of the cafes, when compared 
with the ffiort fpace of time in which 
they occurred mufi appear fo extraordi- 
nary, (exceeding, in fo great a propor- 
tion, the number ufually met with even 
in the moji extenjive private praßice) 
as poffibly, with forne readers, to render 
their authenticity doubtful, and confe- 
quently to invalidate the reafoning dedu- 
ced from them, iv 
ADVERTISEMEMT. 
Since the publication of the frjl edi- 
tion, I have had an opportunity of col- 
le&ing fxteen more cafes, and principally 
from the fame fource, from whence the 
former ones were obtained: thefe are 
now added to them± and they ferve f ill 
more fully to prove the juftice of the 
rcafoning which is made tfe of in the 
Ejfay, and to confirm the method of 
practice therein recommended. 
E* R. 
Norwich, 
Nov. 20* I 777-. A N 
ESSAY 
ON THE 
UTERINE HEMORRHAGE. 
NO Circumftance that attends parturition, 
expofes women to fo much danger, as 
profufe Haemorrhages from the Uterus, 
towards the latter end of pregnancy, and in the 
time of labor; the art of midwifery is likewile, in 
no inftance, more at a lofs in the ufe of means for 
the relief of the patient; an enquiry into the caufes 
of them, and an attempt to improve the pra&ice in 
fuch cafes, cannot, therefore, be ufelefs. 
The treatment of floodings, that come on before 
the Uterus has acquired any confiderable flze, muft 
be very obvious, and the confequences of them, at 
that early period of pregnancy; are feldom to be 
dreaded, as, if the patient lofe blood from the arm, z 
ESSAY ON THE 
be kept cool, and in an horizontal poflure, and 
fuch mild, aftringent, and anodyne medicines be 
adminiftered to her, as have been found, by ex- 
perience, to reftrain difchargcs of blood, they will 
very frequently flop entirely, and the woman go on 
to her full time; and if this fhould not be the cafe, 
but the Haemorrhage Ihould ftill increafe, it will 
feldom increafe to a degree that will endanger the 
life of the mother, without the fmall foetus and fe- 
cundines being feparated, and thrown off by it, 
after which the Uterus will foon contrail, and 
thereby clofmg the mouths of the bleeding velfels, 
the difcharge will gradually diminilh, till it be en- 
tirely Hopped: the furgeon has, therefore, in thefe 
cafes, nothing manual to do, for, notwithftanding 
it has been recommended by tMauriceau and De- 
venter,, and it is faid to be the practice of fome, to 
endeavour to bring away the foetus by art, even in 
the earlieft months, I am perfuaded, from experi- 
ence, that it is never neceffary, and were it even 
neceffary, I cannot conceive it poflible to do it with 
the hand. 
But floodings that precede the delivery of the 
full-grown foetus, when the Uterus is arrived at its 
greateft; ftretch, and the veflels have acquired their 
utmoft: magnitude, muft be ever highly dangerous, 
being more .profufe, and more difficult to fupprefs, 
in proportion to the increafed fize of the veflels; 
infomuch, that the number of inftances in which 
they have unhappily proved fatal, is very confider- 
able. 
Moft of the authors whom I have read on this 
fubjeft, defenbe thefe cafes as particularly embar- 
rafling, and feem alike to acknowledge, that they 
have always been at a lofs when fuch have occurred 
♦ Van Sweiten’s Commentaries, Sect. 1308—9- UTERINE HAEMORRHAGE. 
3 
to them, to determine, with any degree of certainty 
and fatisfa&ion, which of the two methods of prac- 
tice hitherto recommended, it has been mod proper 
to adopt; whether to endeavour to reftrain the dif- 
charge, by the means before mentioned for that 
purpofe, and leave nature, by her own efforts, to 
expel the child, as is the cafe in floodings of the 
early months, or at once to introduce the hand into 
the Uterus, and bring it away by art.-—This doubt 
about the propriety of waiting, or the necefiity of 
removing the contents of the womb, they fay, is 
ever owing to the uncertainty of knowing the quan- 
tity of blood that has been loft, and, if it were 
known, to the impoflibility of afeertaining the de- 
gree of lofs, that a woman might fuftain, without 
manifeft rifque of life. 
They all however agree, that when the difeharge 
becomes very profufe, and fuch a confiderable 
quantity of blood has been loft, as threatens the 
immediate death of the patient, that nothing but a 
fpeedy delivery will give any chance of preventing 
it; and have given us cafes, wherein the bringing 
away the child by art has been attended with fuc- 
cefs; they likewife inform us of others, in which 
waiting and purfuing the palliating means has been 
juftified, by the natural pains having cofne on, and 
the child having been timely expelled by them; 
moreover, where both methods have been ufed, a 
great number are related which, neverthelels, prov- 
ed fatal: but no particular reafons have been given, 
why the different methods of practice were ufed, 
why the fame methods in fome cafes have fucceed- 
cd, and in others, apparently ftmilar, have failed; 
nor have any hints been fuggefted to us, which 
might lead us, at the beginning of the complaint, 
even to a probable conje&ure, whether the Hae-  ESSAY ON THE 
4 
morrhage be of that kind, which requires the turn' 
ing the child, or not. 
We need not be furprized, then, to find, that 
upon a fubjed of fuch acknowledged uncertainty, 
there fhould be fome writers who give the moft op- 
polite advice; for as it is reafonable to fuppofe that 
the furgeon, who has loft a patient by too long wait- 
ing for the natural pains, will, in all future cafes, 
think it right to turn the child upon the firft attack 
of the complaint, fo it is equally natural to fuppofe 
that another, who has had feveral that have termi- 
mated fafely without turning, will think it feldom 
neceflary: thus, to inftancc* but two, * Chapman in- 
variably recommends the delivery by art, upon the 
firft coming on of the complaint, and \Puzos ad- 
vifes always to wait for the natural pains, which he 
believes will rarely fail of putting a fafe end to it. 
It is faid that an eminent lecturer in midwifery, 
in London, direds his pupils not to be too hafty in 
checking the difeharge, as he imagines fome cafes 
that have fallen under his notice, have, by fullering 
the veifels to unload a little, turned out better than 
others have done, in which means were ufed to re- 
flrain it upon the firft attack. 
Another (who is lately deceafed) not lefs capable 
of the fubjed, acknowledged himfelf 
totally at a lofs what to advife, and faid, that fur- 
geons muft, in a great meafure, be left to their 
own diferetion, when fuch cafes occur; but fpeak- 
ing in general terms, he thought it right at firft to 
endeavour to check the Haemorrhage, and wait for 
nature’s aftiftance by pains, and if they fhould not 
come on, the flooding fhould increafe, and the wo- 
♦ EfTay on the Improvement of Midwifery, chiefly with 
Regard to the Operation. 1733- 
| Memoire fur Pertes dc Sang. UTERINE HEMORRHAGE. 
5 
man grow weaker, it was then right to have re- 
courfe to delivery by art. 
It is hardly neceffary to obferve, that contradic- 
tory as chefe directions are one to another, they 
mull all in their turns be improper, as they are 
guided by no fixed rules; and if no information 
be, therefore, to be had, than what can be collect- 
ed from books, and no other directions are to in- 
fluence our practice, than the vague ones we have 
mentioned, it will ever be uncertain, it mult fre- 
quently be unfuccefsful; for we mull either wait 
undetermined what to do, till the dilcharge becomes 
very profufe, and fo much blood is loft as renders 
what we then do probably ufelefs, or we rauft do 
it before much lofs has been fuftained, at a time 
when the patient appears to be in no danger, and 
when we cannot have the fatisfaClion of knowing 
that nature will not be able herlelf to expel the 
child, and that the turning is abfolutely necelfary; 
the timid praClitioner, encouraged by no certain 
guide, and cautioufiy afraid of giving his patient, 
unneceffary pain, we may reafonably fuppofe, will, 
for the moft part, be guilty of the firft error; 
while another, who is more precipitate, through a 
deftre of preventing the danger of delay, will as 
often make ufe of painful means, when the efforts 
of nature, aflifted by more gentle methods, would 
probably be equally fuccefsful; and, at the 'fame 
time, he will iikewife unneceffarily expofe his pa- 
tient to the danger, which a too early delivery may 
perhaps occafion. ' 
To remove the uncertainty and embarraffment, 
which have hitherto attended the praClice in thefc 
cafes, and determine on more fixed and rational 
principles, when it is fafe to wait for nature’s en- 
deavours to expel the child, and when it is ablo- 
lutelv neceffarv to bring it away by art, would. 6 
ESSAY ON THE 
therefore, certainly be an important improvement 
in midwifery. 
For this purpofe two things appear to be indif- 
penfably neceffary; firft, to know the reafon why, 
in cafes that have began exactly alike, where the 
difeharge, pulfe, and faintnefs have appeared the 
fame, and there has been no remarkable difference 
in the age, ftrength, and conftitution of the patient, 
and the fame treatment, has, likewife, been made 
ufe of, they have, neverthelefs, in the end turned 
out quite differently, why in fome, the difeharge 
is reftrained by ufing the common palliating means, 
and the labor terminates fafely by waiting for na- 
ture to empty the womb, and in others, notwith- 
flanding the ufe of the very fame methods, it in- 
creales t® a degree that expofes the woman’s life 
to the mofl immediate danger, and thereby renders 
the turning of the child neceffary: and, fecondly, 
to be able to procure this information as early as 
poffible after the coming on of the Haemorrhage, 
fo as to enable us to determine with certainty, be- 
fore too much blood has been loft, whether it be 
right to endeavour to reftrain it by the means be- 
fore-mentioned, or to proceed at once to delivery. 
A knowledge of the true caufes that produce 
floodings, will give us all the information, which I 
liave confidered as the firji requifite towards an im- 
provement in the practice; for though it has been 
little noticed by thole who have written upon the 
fubject, they certainly arife from two very differ- 
ent caufes, which are very different in the danger 
they produce, and which require a very oppoftte 
method of treatment. 
Floodings have, indeed, heretofore been confi- 
dered as arifmg from two different caufes, one 
alone of which was fuppofed dangerous; a diftinc- 
tion having been made, by fome authors, between UTERINE HAEMORRHAGE. 
7 
the difcharge which came from the Vagina, and 
that which proceeded from the Uterus, and when 
it came from the Uterus, they alfo diftinguiflied 
whether it came from the bottom or the orifice of 
the womb, by which was only meant, whether it 
was occafioned by a reparation of the Placenta, or 
whether it was owing merely to a rupture of the 
veffels of the Vagina or Os Uteri, produced by the 
diftenfion of labor: this diftimftion, to thofe who 
are the lead converfant with practice, muft appear 
trifling, as no bleeding of confequence enough to 
deferve confideration, ever comes from the latter; 
and that, which is the object of the prefent enquiry, 
always proceeds from the Uterus. 
The reparation of the Placenta from the Uterus, 
before the delivery of the child, and the confequenc 
opening of its veffels, muft, therefore, be looked 
upon as the proximate caufe of every confiderable 
difcharge of blood from the womb at that time: 
but this premature reparation of it may be produced 
by very different caufes, and it is a knowledge of 
this difference that will, in my opinion, remove the 
difficulty of afeertaining the reafon, why the fame 
apparent complaint fhould, very often, fo widely 
differ in its termination, and at the fame time re- 
move alfo the uncertainty of treating it. 
There is no particular part of the Uterus, to 
which nature feems conftantly and uniformly to fix 
the Placenta, it is, neverthelefs, for the moft part, 
fo fituated, that if the woman be healthy, and no 
accident befal her, it does not feparate till the full 
term of pregnancy, nor then before the entire ex- 
pulfion of the child, after which it becomes dif- 
engaged from the Uterus, and is thrown oft', mak- 
ing room for its entire contraction, which ftiutting 
up the mouths of the veffels, effectually prevents 
any confiderable lofs of blood: for which purpofe. 8 
ESSAY ON THE 
it is plain, it mull be fixed to fome part of the 
womb which does not dilate during labor, namely, 
to the fundus or Tides of it. 
In this cafe, then, when a flooding comes on be- 
fore the delivery of the child, it is obvious, that 
the reparation of the Placenta muff be owdng to 
fome accidental circumftance, to violence done to 
the Uterus by blows or falls, to fome peculiar laxity 
of the uterine veffels from badnefs of habit, or fe- 
ver, or to the influence of the paflions of the mind 
fuddenly excited, fuch as fear, anger, &c. 
But from the uncertainty, with which (as before 
obferved) nature fixes the Placenta to the Uterus, 
it may happen to be fo fituated, that when the full 
term of pregnancy is arrived, and labor begins, a 
flooding nece(Jarily accompanies it, and without the 
intervention of any of the above accidental circum- 
itances; that is, when it is fixed to that part of the 
womb which always dilates as labor advances, name- 
ly, the Collum and Os Uteri, in which cafe, it is 
very certain that the Placenta cannot, as before de- 
feribed, remain fecure till the expulfion of the 
child, but muff, of necelfity, be feparated from it, 
in proportion as the Uterus opens, and, by that 
means, an Haemorrhage muff unavoidably be pro- 
duced. 
That floodings, which arife from thefe two differ- 
ent caufes, which I will diftinguifh by the names of 
accidental and unavoidable, though they may appear 
exactly fimilar in their firft fymptoms, fhould ter- 
minate very differently, if left to nature, aflilfed 
only by the palliating means before mentioned, 
cannot feem ilrange ; nor can it be a doubt that 
of thefe two kinds of floodings, only one of them, 
namely, that which is produced by an accidental 
Reparation of the Placenta, can be relieved by the 
life of thefe palliatives; and that the other, in UTERINE HAEMORRHAGE. 
9 
which the Placenta is fixed to the Os Uteri, and 
the flooding is therefore unavoidable, cannot poflibly 
be fupprefled by any other method whatever, than 
the timely removal of the contents of the womb : 
lor fuppofing the difcharge to be for a while reftrain- 
ed by bleeding, medicine, cool air, &c. it will in- 
evitably return when nature is fo far recovered as 
again to bring on labor: in the firlt cafe, if the 
Haemorrhage have been checked by the ufc of the 
above means, it is not impoflible but labor may 
come on, and the child be fafely expelled by the 
natural pains, before it returns ; or, if it Ihould 
return, it may not encrcafe in quantity ; as in this 
cafe, very probably, the feparated part of the Pla- 
centa, which occasions the difcharge, remains near- 
ly the fame; whereas, in the other cafe, in which 
the dilatation of the Os Uteri produces the fepara- 
tion of the Placenta, every return of pain muff be 
a return of the bleeding, and it mult become great- 
er and greater, as the Uterus opens more and more, 
and the Placenta is in proportion detached, till it 
increafes to a degree that exhaufts the patient, and 
flic dies before nature has been able to expel the 
child. That fuch mull, inevitably, be the progrefs 
and event of floodings arifing from fuch a caufe, if 
left to nature, is too obvious to be further infilled 
on. 
That this attachment of the Placenta to the Os 
Uteri, is much oftener a caufe of floodings than 
authors and practitioners are aware of, I am from 
experience fully fatisfied; and fo far am I convinced 
of its frequent occurrence, that I am ready to be- 
lieve that moll, if not all, of thofe cafes which re- 
quire turning the child, are produced by this un- 
fortunate original fituation of it; and, moreover, 
(which is perhaps of as much practical importance 
to know) when the Placenta is not fo fituated, the io 
ESSAY ON THE 
events of the annexed cafes authorife me to fay, 
that if the patient be properly managed, nature 
will, for the moft part, terminate the labor fafely, 
without any manual affiftance of the furgeon.* 
And independent of the proofs which experience 
gives, it feems reafonable that in the latter cafe it 
Jhould be fo; for thofe who are much converfant 
with the difficult part of midwifery, muft have ob- 
served, how much more nature is able to do for her 
own relief than is commonly imagined, and how, 
unexpectedly, ffie will fometimes effcft, what art 
has been a long time in vain attempting; if we add 
to this, that when any dangerous circumftance af- 
fects the Uterus, nature ever makes fome effort to 
remove it, need we be furprized, that in thcfe cafes, 
when the Placenta is not at the mouth of the womb, 
and there is, therefore, no impediment to its dila- 
tation, and the expulfion of the child, ffie ffiould, 
for the moft part, fafely effeCl both? 
There are not, indeed, wanting relations of 
cafes, in which the Placenta has been found at the 
♦ I have the fatisfaction of adding two very refpeftable au- 
thorities in further confirmation of what I have juft faid, the 
one is of Mr. Charles White of Mancheftcr, and the other 
of Mr. John Aikin, of Warrington, gentlemen well known 
both as furgeons, and as writers; Mr. White, who has had 
the moft extenfive praftice in midwifery, as there was a time 
when almoft all the difficult cafes not only in Manchefter, but 
in a very populous neighbourhood, through a large circuit of 
many miles, fell under his care, and who is therefore well 
qualified to judge upon the fubjcft, tells me, “ That the di- 
ftinftion I make between floodings which are accidental and 
thofe which are unavoidable, perfectly agrees with his experi- 
ence in fuch cafes, and that he is very clear that few, if any, 
of the former require turning and delivery by art.” And Mr, 
Aikin, whofe practice is alfo conflderable, fays, “ That he has 
never had occafion to ufe forcible dilatation and turning ex- 
cept where the Placenta has been found at the mouth of the 
Uterus,” UTERINE HAEMORRHAGE. 
11 
mouth of the Uterus, but it was ufually fuppofed 
to have been feparated from fome other part of it, 
and pufhed down into that fituation by its own gra- 
vity, and the force of the natural pains, and fome 
have even denied the pofiibility of its ever being 
originally fixed there. 
Mauriceau* has a chapter on this fubjeft, and 
La Mottey relates three caies of it; but they both 
fuppofe that when the Placenta prefents it is ever 
wholly detached, and coniidering it therefore as a 
foreign body, direct that it fhould be always im- 
mediately brought away. 
Dionis \ fays, tc That the after-birth fometimes 
loofens before the membranes, which contain the 
waters, are broke, and when the infant turns it- 
felf, it is to be found at the internal orifice of the 
womb.” 
Ruyfch 5 fays, tc It is well known, that the Pla- 
centa Uterina fometimes prolapfes or fubjides before 
the foetus in the time of parturition. 
Deventer || relates, that when the Placenta is de- 
tached from the Uterus, it is ufually found at the 
orifice, to which it defeends by its weight, “ Ou 
fon poids I’entraineand in another place he calls 
it, “ la chutc,if the falling down of the Placenta. 
Giffard** has more than twenty cafes, where the 
Placenta was found at the Os Uteri, but he plainly 
♦ Difeafes of Women with Child and in Child Bed, tranflat- 
ed by Chamberlen, i?Sa- 
f General Treatife of Midwifery, tranflated by Tomkyns, 
1746. 
$ Treatife of Midwifery, tranflated from the French, 1719. 
§ Practical Obfervations in Surgery and Midwifery, Englift* 
Tranflation, 1751. 
II Obfervations importantes fur le Manual des Accouehemens, 
traduites du Latin, 1734. 
** Cafes in Midwifery, 1734, 12 
ESSAY ON THE 
fuppofes that it had not been originally fixed there., 
for he fays, “ It is cuftomary in floodings to find 
the Placenta funk down to the mouth of the womb.’** 
Smellie, in his firfl volume of Midwifery, more 
than once*mentions the pollibility of the Placenta 
being fixed to this part of the Uterus, and in his 
third volume, defcribes feveral cafes in which it was 
there fituated ; but there are no practical inferences 
drawn from them, nor, in his directions about the 
management of floodings, are there any rules given 
relative to this fituation of it. 
There is a fimilar cafe related by Dr. D'Urban, 
in his elegant Latin Diflertation on the Haemorrhagia 
Uterina, which he evidently confiders as a moll un- 
ufual one ; for, fpeaking of the Placenta being 
there fituated, and thereby producing the flooding, 
he faySj “ fingularem Hannorrhagia hujus caufam 
fuiffe.” 
Dr. Hunter, in his beautiful engravings of differ- 
ent views of the gravid Uterus, lately publilhed, 
has one, in which the Placenta was found at the 
Os-Uteri, and had been the caufe of a fatal flood- 
ing.* 
More authorities might ftill be produced, to prove 
that the Placenta has been often found in this fitua- 
tion, but thefe are fufficient; and I have not the 
* Since I wrote the above, I have Teen Levret's Treatifc on 
Midwifery, written in French, and publifhed at Paris a few 
years ago, and on the fubjeft of floodings, he has a chapter 
to prove that the Placenta may be fituated on the Os Uteri 
without having been previoufly feparated from fome other 
part, and pufhed down there, he illuftrates what he fays by 
four cafes, two of which were under his own care, another 
was communicated by a friend,, and the laft was an account of 
a difleftion of a gravid Uterus publifhed in the Hiftory of the 
Royal Academy of Sciences at Paris in 1723, in which the 
Placenta was found there fituated, and had been the caufe of 
an Haemorrhage which proved mortal. UTERINE HAEMORRHAGE. 
13 
leaf! doubt, but in all of them it was originally fixed 
to the Os Uteri; it is poffible, indeed, if the womb 
open with unulual facility and quicknefs, and the 
woman, through a peculiar conllitutional ftrength, 
be able to fupport the lofs of blood which mull ne- 
ceflarily be produced by it, that the Placenta may 
become wholly detached; and its having bepn fome- 
times found lying loofe there, is, undoubtedly, the 
reafon why it has been fuppofed to have been fepa- 
rated from fome other part of the womb, and to 
have fallen down into that lunation: the impollibility 
of fuch a circumllance, will, however, be very- 
evident, if we confider the anatomy of the gravid 
Uterus; for the Spongy Chorion,* which, by an 
nniverfal adhefion, conne&s the membranes to the 
Uterus, and which is an expanfion of the furface 
of the Placenta, mud effectually prevent the latter 
from changing its place, whilft the former remains 
unleparated, which I am convinced from fcveral 
diffeclions it always does till the cxpulfion of the 
child; indeed, there muff be a partial reparation of 
this membrane, in the fpace between the Placenta 
and the Os Uteri, to allow of the difcharge of 
blood into the Vagina, but there muff be an entire 
reparation of it, above as well as below the Placenta, 
to admit of its falling down, which, I Ihould fup- 
pofe, could never take place before the delivery of 
the child. 
It may appear extraordinary, that a circumllance, 
attended with fo much danger, and which feems to 
* This fine cellular fubftance, which is the connecting me- 
dium between the Uterus and the Chorion, and through which 
an infinite number of velTels ramify, was described by the late 
Dr. M'Kenzie, under the name I have ufed, but it is fome- 
times called the Membram Cribriformis, and I find Dr. Hunter, 
in his anatomical plates of the gravid Uterus, gives it the 
name of Dscidua. 14 
ESS AY ON THE 
be fo frequent a caufe of the Uterine Haemorrhage 
fhould have hitherto been fo little noticed, for 
though, in the cafes which have juft been alluded 
to, the Placenta was found at the Os Uteri, yet it 
was, in very few of them, fuppofed to have been 
originally fixed there, and I make no doubt but it 
has often happened when it has not been known at 
all to the furgeon, as I am induced to believe that 
in the greateft number of thofe inftances, in which 
the women have died undelivered, the floodings 
have been produced by this attachment of it: but 
this is eafily accounted for, when we confider, that 
it is very rarely that a furgeon has an opportunity 
of opening the gravid Uterus after death, that there 
are very few fymptoms in the courfe of the com- 
plaint, which might lead a perfon unapprized of its 
frequent occurrence, to fuch a conjedure, and that 
in the early part of labor, when the Uterus is high 
in die Pelvis, and the Os Tineas is very little open, 
it is not difcoverable by the ufual mode of examina- 
tion : we may alfo add, that in thofe few cafes 
where there has been fufficient ftrength to admit of 
its being completely open, the Placenta muft have 
been found loofe; and, moreover, which is perhaps 
the principal reafon, that the number of floodings 
which happen, when compared to the number of 
labors, is fo fmall, that very few muft come under 
the notice of thofe who are engaged only in private 
practice, not enow probably in their whole lives to 
draw their attention fufficiently to the fubjeft, or 
to make them competent judges of it. 
Admitting, then, that floodings are produced by 
thefe two different caufes,* and that they require a 
* La Motte relates a cafe of flooding, in Ms 214th obferva- 
tion, produced by a caufe different to either of thofe I have 
mentioned, and which, probably, would be more dangerous •UTERINE HAEMORRHAGE. 
15 
treatment fo widely different, we cannot be at a 
lofs when fuch occur to us, and we have difcovered 
the particular caufe from which they arife, how to 
aft; as, in the one cafe, we fliall be encouraged to 
wait, and make ufe of fuch means to reflrain the 
difcharge, as will be more particularly mentioned 
hereafter, and in the other, we fliall hclitate to have 
recourfe to delivery by art: for it is very obvious, 
that the want of fuccefs which has fo often attend- 
ed the turning the child, when fuch has been 
thought neceffary, is to be attributed to the opera- 
tion having been too long delayed, rather than to 
than that which arifes from the accidental caufe, as it would 
continue as much during the prefence as the abfence of pain, 
nor would it ceafe till the child and Placenta were removed, 
which, unlefs the progrefs of the labor was quick, might pro- 
duce a Ibfs of blood fufficicnt to deftroy the woman; the cafe 
I allude to is a rupture of one of the umbilical veffels, owing 
to the cord being feveral times twilled round the child’s neck, 
and to its texture being remarkably weak and knotty: but as 
this is fo very extraordinary an inflance, that it, perhaps, may 
never occur again, and as it would be, moreover, impoflible 
to know the caufe of it till the labor was finiihed, I think it 
deferves not to be confidered amongll the general caufes of 
the Uterine Haemorrhage. 
Another circumftance may likewife happen to prevent the 
expulfion of the child by nature, even when the flooding is not 
.produced by the attachment of the Placenta to the Os Uteri, 
I mean, when the Pelvis is fo badly formed that the head can- 
not pafs in the ufual time: Mr. Aikin has favoured me with a 
cafe fomewhat like this; “ He was fen't for to a woman who 
had flooded pretty much, the membranes were broken and the 
Funis was coming down into the Vagina, he immediately intro- 
duced his hand to turn, when he found the head in the paffage; 
which by a pain was forced pretty low, and he thought the la- 
bor would foon be over, but after waiting two or three hours 
the head continued where it was, and the flooding returned at 
times; the woman being now very weak and the child certain- 
ly dead, from the obflruction of the naval-firing, which was 
pulhcd down, he opened the head, delivered, and the patient 
did well.” 16 
ESS AY ON THE 
any real danger that attends the cautious perform- 
ance of it; as it it be not attempted, as ufually 
happens, till the woman be well nigh exhaufted, it 
mult certainly be a doubtful matter whether the 
lives through the operation, or if Ihe furvive that, 
whether the debilitated Uterus will be able to con- 
tract itfelf when its contents are removed, fo far as 
to put an entire flop to the difcharge: the changes 
under fuch circumftances being, then, fo unfavour- 
able, no wonder that the molt cautious and fkilful 
turning of the child has fo feldom been attended 
with fuccefs. 
The fuccefs of turning depending, therefore, en- 
tirely upon its being done before the patient has 
loft too much blood, it is a matter of the utmoft 
importance to obtain an early knowledge of the 
necefiity there is of doing it, or in other words, to 
know at the beginning of.the difcharge, whether 
it be produced by the Placenta being fituated on 
the Os Uteri or not; which is the fecond circum- 
ftance I before confidered as effentially neceffary to 
enable the furgeon to practice with certainty in thefe 
cafes, and concerning which I fliall now endeavour 
to give fome directions. 
There is, perhaps, fome difference to be obferved 
in the time and manner that floodings, produced by 
thefe different caufes, come on ; probably, that 
which is occafioned by the Placenta being fixed to 
the Os Uteri, will, for the moft part, not come on 
till the full term of parturition, when the Uterus 
begins to dilate from the approach of labor; the 
other, which is owing to fome accidental reparation 
of the Placenta, may, on the other hand, come on 
before labor begins, and indeed at any time during 
pregnancy, and poflibly, were we to be very nice 
in our enquiries, it might be accounted for by the 
patient’s having received fome external injury, hav- UTERINE HAEMORRHAGE. 
17 
ing fuffered by a fever, or undergone fome fudden 
and confiderable fright, &c.—but as thefe, with 
other fymptoms that might, very likely, be enume- 
rated, are, at heft, but vague and equivocal: and 
as alfo, though'the Placenta be fituated on the mouth 
of the womb, it may, neverthelefs, fometimes be 
feparated by the fame accidental means which de- 
tach it, when otherwife fituated, the only certain 
knowledge refpeCting its fituation, is to be derived 
from an examination of the Uterus by the touch. 
For this purpofe, however, the ufual method with 
one finger will not always fuffice, but the hand muff 
be introduced into the Vagina, and one finger in- 
fmuated into the Uterus;* for in feveral of the fol- 
lowing cafes it will appear, that though the women 
were frequently examined in the ufual way, the 
Placenta was not difcovered till the hand was admit- 
ted for the purpofe of turning the child: if this 
be done flowly and cautioufly, and the hand be pro- 
perly lubricated, it will feldom give the patient 
much pain, but if it fhould give fome pain, as it 
is to obtain information fo effentially neceffary to 
her fafety, that ought never to induce us to omit 
doing it, or to do it imperfectly: if the Placenta 
be at the mouth of the Uterus, it will be imme- 
diately felt by the finger, and may be diftinguifhed 
from the membranes, by its greater thicknefs, and 
* I have lately had an opportunity of feeing an accurate 
copy of Dr. Young’s very excellent Leisures on the Theory 
and Practice of Midwifery, and though he takes no notice of 
this fingular fituation of the Placenta, he advifes in floodings 
always to examine the ftate of the Uterus, by introducing the 
hand into the Vagina; the reafon he gives for it is, that the 
coagulated blood which is ufually found in the paflage, renders 
it impdflible to feel the Os Uteri with fufficient diftinctnefs by 
the finger alone: if, then, it be right when the fituation of 
the Placenta is not an object of enquiry, the propriety of my 
recommending it above mull be very obvious. i8 
ESSAY ON THE 
from coagula of blood, by the irregularity and 
roughnels of its interior furface, which will then 
prefent to the finger. 
It muff be acknowledged, indeed, that it may 
fonietimes happen, that, at the very firfl coming on 
of the complaint, if the difcharge be fmall, and 
more cfpecially if it be the patient’s firfl child, and 
the parts be clofe and unyielding, the admiffion of 
the hand into the Vagina, as I have directed, will 
be attended with the utmofl difficulty, and, per- 
haps, be almofl impracticable;—in this cale let us 
wait (but let it be with the patient) till the difcharge 
increafes, or has continued long enough to relax 
the parts, for certainly, if the woman be able to 
bear loling a little blood, which at firfl fhe may 
fafely do, the examination will be thereby rendered 
more eafy, and the turning the child, if neceffary, 
be more practicable and fafe. 
Suppofmg, then, that the Placenta fliould, from 
this enquiry, be found at the mouth of the womb, 
the furgeon will be at once convinced of the dan- 
ger that muft unavoidably attend delay, from the 
impoffibility there will be of affording the woman 
relief by any other means than the timely removal 
of the child, and will, on that account, not hefitate 
to deliver before too great a lols has been fuftained. 
In recommending early delivery, I think it right, 
however, to exprefs a caution againfl the premature 
introduction of the hand, and the too forcible dila- 
tation of the Os Uteri, before it is fufficiently re- 
laxed by pain or difcharge; for it is, undoubtedly, 
very certain, that the turning may be performed too 
foon as well as too late, and that the confequences 
of the one 'may be as deflruClive to the patient as 
the other. lam particularly led to obferve this, as 
1 have lately been informed, from very good autho- 
rity, (namely, a gentleman to whom one of the UTERINE HAEMORRHAGE. 
19 
cafes occurred,) of three unhappy inftances of an 
error of this fort, which happened, fome years ago, 
to three furgeons of eftabliffied reputation, who, 
from the fuccefs they had met with in delivering fe- 
veral who were reduced to the laft extremity, were 
encouraged to attempt it where but very little blood 
had been loft, in hopes that their patient’s conftitu- 
tions would fuffer lefs injury, and their recovery be 
more fpeedy; which, till the experiment was made, 
was a very reafonable fuppofition; the women died, 
and they feemed convinced that their deaths were 
owing to the violence of being delivered too foon, 
and not to the lofs of blood, or any other caufe. 
It becomes, then, neceffary to endeavour to af- 
certain, with a degree of accuracy, the precife time 
when we may proceed to deliver, without fear of 
incurring the ill effeds either of precipitancy or de- 
lay. 
It has been advifed, never to introduce the hand 
till nature has fhewn fome difpofition to relieve her- 
felf, by the dilatation of the Os Uteri to the fize 
of a fhilling, or a half crown, and this rule is cer- 
tainly founded on a rational principle, for when it is 
fo much dilated, there is no doubt but the turning 
may be eafily and fafely affeded; but from fome of 
the annexed cales it appears, that a dilatation to 
this degree fometimes does not take place at all, 
and that even when the woman is dying from the 
great lofs of blood, the Uterus is very little open; 
the reafon for which feems to be, that when the dif- 
charge has been confiderable, and more particularly 
when much blood has been fuddenly loft, fuch a 
faintnefs is brought on, that though the Uterus be 
totally relaxed, and might therefore be opened by 
the moft gentle efforts, yet nature is unable to make 
ufe of thofe efforts; and, moreover, if there be 
flight pains, the adhefion of the Placenta to the in- 20 
ESSAY ON T^E 
ternal furface of the mouth of the womb, counter- 
ads their influence, and thereby hinders its giving 
way to a power, which would otherwife, probably, 
very eafily open it. 
It appears, then, that this rule, if invariably ad- 
hered to, would, in fome cafes, be attended with 
danger, as we might wait for the opening of the 
Uterus, till it was too late to relieve the woman by 
turning the child ; and for this reafon it feems right, 
that we fhould fometimes be as much influenced by 
the Os Uteri being in a flate capable of dilatation 
without violence, as by its being really open; when 
this is the cafe, therefore, if the woman’s fituation 
demand fpeedy afliftance, we fhould not hefitace to 
attempt delivery, even though to the touch the 
Uterus feem quite fhut, more efpecially as in mak- 
ing the attempt, we lhall know, before we can pof- 
fibly have injured the Uterus, whether it be fafe to 
proceed;—if the womb readily give way, and the 
hand pafs with eafe, we may be certain no harm will 
follow, and may, on that account, confidently pro- 
fecute the turning; but if, on the contrary, there 
immediately come on a contradion of the Os Uteri, 
that, in a purfe-like manner, tightly furrounds the 
fingers, it will prove difficult, and we ought there- 
fore to defift, and wait till the part be more relaxed 
by pain or difcharge, as difficulty, in thefe circum- 
flances, is the truefl criterion of danger. 
As an encouragement that we may fafely fuller 
a woman, under fuch circumftances, to lofe more 
blood, the contradion may certainly be looked up- 
on as a proof, that there flill remains a confiderable 
portion of animal flrength, and that fhe has not 
been fo much affeded by the lofs, as we before ima- 
gined; and if we can fo far moderate the difcharge, 
as to prevent the blood from being too fuddenly 
1011, which, in fuch a cafe, it mufl be our endeavour UTERINE HEMORRHAGE. 
21 
to do, a very confiderable quantity may come away 
without endangering the life of the patient. But 
in waiting for a further relaxation, we ought by no 
means to leave the woman, not even if the flooding, 
from the mean's we have ufed to moderate it, be 
totally fupprefied ; as when the Placenta is here 
fituated, the Haemorrhage will fometimes return fo 
fuddenly and profufely, that if the furgeon be not 
at hand immediately to bring away the child, the 
woman periflies in a very little time.* 
* The cafe of the King’s coachman’s wife, related by Smel- 
lie in his anfwer to Douglas, is a ftriking proof of the danger 
of leaving a patient in fuch a fituation. The woman had 
flooded feveral times from the middle of the feventh month to 
within a fortnight of her full reckoning, at which time it in- 
crcafed much, the had flight pains, and the Os Uteri was found 
open to the fize of a fixpence, beyond which was a foft fub- 
flancc that felt like thcPlacenta; as the dilatation was, he thought, 
inefficient to admit of delivery, he determined to wait; the 
advice of another phyfician was taken, who concurred with 
him that it was proper to wait till “ thofe pains fliould Bring 
on right labour,” they therefore left the patient; but in a few 
hours after he was again fent for, when he found her in fuch 
extreme faintnefs, that ffie expired foon after his arrival: the 
body was opened, and the Placenta was found at the Os Uteri. 
—lt is obferved, indeed, that a trial was then made to open the 
mouth of the womb, but it was not effected without much dif- 
ficulty and a laceration, fuch an accident happening however 
after death, (wheii every ftrong membranous partis equally in- 
capable of contraction and extenfion,) is no proof that if the 
mod favourable opportunity had been watched for, and a gra- 
dual and repeated endeavour to open it had been before made, 
k would not have lucceeded: their determining to wait “ till 
right labor fliould come on,” and leaving their patient without 
apprehending its bringing on an incrCafe of the difeharge, 
proves their not having thought about the Placenta, and their 
not being aware of the unavoidable confcquence of fuch a fl- 
tuation of it; and I have related the cafe as much to prove 
this, as to exemplify the danger of leaving a patient under fuch 
circumflanccs. 22 
ESSAY ON THE 
To fleer fafely, then, between the two danger- 
ous extremes, it appears neceffary that, on the one 
hand, we fhould never deliver till the dilatation of 
the womb can be effected by eafy means, and, on 
the other hand, when it has been fufficiently relax- 
ed by difeharge, if the woman have fuffered much 
by it, that we fhould no longer defer it, notwith- 
flanding, from the abfence or inefficacy of pain, the 
Os Uteri fhould remain unopened: yet, after all, 
as turning feems to be only neceffary when the Pla- 
centa is fixed to the mouth of the womb, and that 
circumftance can feldom be known till the hand be 
introduced into the Vagina, and one finger be in- 
fmuated into the Uterus, I fhould imagine it not 
very likely that we fhould often be in danger of in- 
juring the patient by premature delivery, as when 
the hand paffes eafily into the Vagina, I fhould fup- 
pofe there will be feldom much difficulty in its ad- 
miffion into the Uterus. 
In introducing the hand for the purpofe of turn- 
ing, when the Os Uteri has been carefully dilated, 
if the feparated part of the Placenta be immediately 
prefenting, it is beft to endeavour to pafs the finger 
through the fubflance of it, and by degrees with 
other fingers to enlarge the opening, till the hand 
can get through it into the cavity of the Uterus: 
the obvious reafon for this is, that by this means 
not more of the Placenta may be feparated, than is 
neceffary for the introduction of the hand, and con- 
fequently that as little increafe of bleeding as pof- 
fible may be produced by the operation; but if it 
be impracticable, as 1 have more than once found 
it, and it muft ever be when the middle of the Pla- 
centa prefents to the hand, from the thicknefs of it 
near the Funis, it muft be carefully feparated from 
the Uterus on one fide, and the hand paffed till it 
gets to the membranes, which being eafily broken, UTERINE HAEMORRHAGE. 
it is admitted into the bag, the floating foetus is 
turned, and the delivery finiflied, as in preternatu- 
ral portions of the child; except, that in this cafe 
the extraction fhould be more flow, that the Uterus 
may not be unable to contract, by being too fud- 
denly emptied: a moderate preflure from the hand 
of an afliftant, upon the Abdomen, as the child is 
coming away, will likewife be of ufe to aflift the 
contraction. The Placenta being at the Os Uteri, 
and being ufually feparated more by the introduction 
of the hand, commonly comes away immediately, 
but if a part of it fhould remain adhering, and the 
difcharge continue, it fhould be carefully removed, 
and as it is fo near, it may very eafily be done. 
If, on the contrary, it be clear from this careful 
examination of the Uterus, that the Placenta is not 
at the mouth of it, and that the coming on, or in- 
creafe of labor, will not of neceflity increafe the 
difcharge, provided it be not very profufe, (for let 
it be remembered, that I am fuppofing the exami- 
nation to be made early, and before any confidera- 
ble quantity of blood has been loft:,) it certainly will 
be proper to wait for the natural pains, and, in the 
mean time, to ufe fuch methods as are likely to re- 
ftrain the flooding, which are, the admitting a free 
circulation of cool air into the room, keeping the 
patient in an horizontal pofture, giving her anodyne, 
with TinCtur: Rofar: &c. and fupplying her fre- 
quently with fuch cool and Ample nutritious drinks 
as will fupport her without quickening the circula- 
tion; from purfuing this method it will often hap- 
pen, that the difcharge goes oft' entirely, and if the 
woman be not arrived at her full term, and fhe be 
kept very ftill and calm, that it does not return be- 
fore labor comes on. But if it fhould ftill continue, 
or return frequently, it will be right, if pofiible, 
to bring the Uterus into a ftate of contraction, by ‘24 
ESSAY ON THE 
exciting fome pain, which may often be done by 
gently irritating the Qs Uteri with the finger; if 
this fucceed, and the mouth of the Uterus be there- 
by fo far dilated, that the dihended membranes may 
be felt, they mud be immediately pierced by palling 
a probe along the finger, as upon the difcharge of 
water thus produced, the womb, neceffarily contracts 
to a certain degree, and the flooding proportionably 
abates ; this is, for the mod part, foon fucceeded 
by flight pains, which if the child prefect fair, have 
very foon an effect upon it, and pulh it down.* 
In the then relaxed and inelaftic date of the Ute- 
rus, it is adonifliing how much it is influenced by 
a trifling degree of pain, dilating and giving way to 
the mod gentle throws; infomuch that, in thefe 
cafes, the child ufually pafles with half of the ordi- 
nary efforts of nature: it is likewife remarkable, 
that the difcharge commonly abates upon the com- 
ing on of pain which pvoyes the propriety of en- 
deavouring 
* This is the method of practice recommended by Puzos in 
his Memoire fur Penes de. Sang, which if confidcred as relating 
only to cafes produced by an accidental reparation of the Pla- 
centa, is certainly an excellent one, and thefe are the only ones 
that focm to have occurred to him, for he appears not to he 
aware of the Placenta being fome times fixed to the Os Uteri, 
in which cafe, it is plain, his advice mull he dangerous. The 
fucccfs that attended the management of his cafes., which were 
certainly produced by accidental caufcs, may, J think, ferve to 
llvengthen what I have ventured to declare as my opinion, that 
when fuch is the cafe, it will, for the molt part, terminate fafe-, 
]y by the foie alfillance of nature. 
t The Fundus, and fides of the Uterus being in a ftate of con- 
traction during the prefetfee of pain, profs upon the Placenta, 
and leflen the flux of blood into the womb; moreover, when 
the water is efcapcd, the child’s body comes in contact with 
the Uterus, and the Placenta may likewife be profiled upon by 
it, fo as to have its veflels flopped, and thefe are, without 
doubt, the reasons why it is obferved that the flooding ufually UTERINE HAEMORRHAGE. 
25 
deavouring to excite it by the means before-men- 
tioned, when the other methods ufed to reftrain 
the flooding do not fucceed, and irom this circum- 
hance, too, the early examination with the hand in 
the Vagina, and one finger in the Os Uteri, is not 
only uleful when the Placenta is there fituated, but 
from the ftimulus it excites, is of fervice to bring 
on pain, and facilitate labor when it is not fo fituat- 
ed. 
But if, notwithflanding, this mode of treatment, 
the difcharge Ihould not leffen, if the evacuating 
the waters ihould not abate it, and if, moreover, 
labor pains, fufficient for expelling the child, ihould 
not fucceed, and the flooding ihould Hill increafe, 
fo as to endanger the life of the patient, I ihould 
imagine it hardly neceflary to fay, that even in this 
cafe, as well as when the Placenta is fixed to the Os 
Uteri, the only certain method of hopping it ihould 
be ufed, namely, the delivery of the child by turn- 
ing; for though I have never yet met with a cafe 
that under fuch circumhances has required it, and 
believe fuch very rarely happens, yet I would not be 
fuppofed to fay fuch an one cannot occur, as the 
reparation of the Placenta may, for initance, be 
produced by fuch violence done to the Abdomen, 
and the Haemorrhage may be fo profufe, that no- 
thing but a fpeedy delivery by art will put a hop to 
it. I only mean, that when we are called in early 
to flooding cafes, if we judge only by the quantity 
of blood that has been loh, which may be fmall, 
and the prefent hrength ot the woman, which may 
abates whilft the pain continues, but this muft obvioufly be 
only when the Placenta is fixed to any part but theCollum and 
Os Uteri, in which cafe the rqverfe muft happen, as thofe 
parts are dilated during pain; it may be of ufe to attend to 
this circumllance, when we cannot fo foon as vve could wifh, 
ipake a manual enquiry into the caufe of the flooding. 2 6 
ESSAY ON THE 
be confiderable, we muft frequently be deceived in 
our judgment of the cafes, and be in danger of 
ufmg a wrong method of treatment, but that the 
knowledge of the caufes which produce them, will 
in the one cafe, for the moji part, juftify our wait- 
ing; and in the other, will invariably prove the 
propriety of turning the child. 
The want of fuccefs which has fo often attended 
turning in flooding cafes, has, however, induced 
fome people to believe there is danger in the opera- 
tion itfelf, and that, independent of the time and 
manner of its being performed, the mifchief in 
part arifes from that: among others, Puzos raifes 
objections that have a tendency to difcourage it; he 
draws, indeed, a very nice comparifon between the 
influence that natural, and artificial labor have upon 
the Uterus, and feems thence to infer, that the in- 
jury done to it by the latter, is very often the reafon 
why it is unable to contract itfelf after the child and 
Placenta have been removed: there can be no doubt 
but that the womb ever fuffers more from art than 
from nature, as the latter is more gentle, flow, and 
regular in her efforts to expel the child, than the 
former is to bring it away; but he certainly goes 
too far in attributing fo much mifchief to the ope* 
ration by art, as if the want of contractile power 
in tlie Uterus were owing to the mere mode of de- 
livery, it would very often turn out fo in preterna- 
tural labors, where the improper pofltion of the 
children renders the introduction of the hand to 
turn them neceflary, in which too the Uterus being 
more rigid than in flooding cafes, more force is 
requifite to effect it, and confequently more violence 
is offered to the womb; but every one’s practice 
in th(*fe cafes contradicts it; furely the obvious rea- 
fon then for the want of fuccefs is, in moft cafes, 
what has been before obferved, that the delivery UTERINE HEMORRHAGE. 
has been too long deferred, and the woman too 
much exhaufted by the great lofs of blood. 
It has been likewife urged by fome, as an addi- 
tional objection to turning, that in thefe cafes there 
is, for the moft part, fuch an infenfibility of the 
Uterus, that as nature is, on that account, unable 
to expel the child, Ihe will, for the fame reafon, be 
unable to contract-the womb, if delivery be effected 
by art, and, independent of the injury which turn- 
ing may do to the Uterus, that all attempts to flop 
the difcharge, will, for this reafon, be ineffectual; 
but I fhould fuppofe this want of fenfibility to be 
owing to the fame caufe, the lofs of blood; for 
when the Placenta prefents to the Os Uteri, (which 
is the cafe we confider as'requiring turning,; no 
wonder nature is unable to expel the child, as every 
effort fhe ufes to dilate the womb for that purpofe, 
muff feparate the Placenta, produce an increafe of 
bleeding, and proportionably lelfen the vital power; 
fuch an idea, therefore, which feems to be an un- 
juft one, ought never to induce us to omit ufmg 
the only certain method of flopping the flooding, 
and thereby of preventing that infenfibility, which 
a further lofs of blood alone occations. 
To many practitioners, moreover, the introduo 
tion of the hand to turn the child, is a very difa- 
greeable operation, and if they have not been much 
ufed to it in cafes where the Uterus is but little 
open, it appears a very difficult and formidable one: 
it were to be wiffied, that even this circumftance 
had never an improper influence upon furgeons, 
efpecially thofe who are young in practice, and that 
they were never induced to omit, or too long delay 
this operation, becaufe they feel unwilling to do it. 
But it is not fo difficult as many imagine, for 
even in preternatural cafes, where the Uterus is 
ftrong and rigid, and gives way reluctantly, if the *8 
-ESSAY ON THE 
hand be flowly and gradually introduced, it will 
feldom be found impracticable, provided the Pelvis 
be not badly formed; and in floodings it is effected 
with peculiar eafe, which fhould be a further en- 
couragement to attempt it in fuch cafes; for as the 
Uterus neceffarily becomes fo relaxed after a confi- 
derable lofs of blood, it very readily gives way to 
the ad million of the hand, that tight contraction of 
its neck, which in other cafes is fuch an impedi- 
ment to the introduction of it, being here feldom 
to be met with; and it may be added, that in pro- 
portion as nature, from the lofs die has fuftained, 
is lefs able to bear violence, happily, a proportion- 
able lei's force is requfite. 
If, therefore, the operation may be performed 
without much difficulty to the furgeon, if the cau- 
tious performance of it be attended with no danger 
to the patient, and if the becoming early acquaint- 
ed with the neccffity there is for it, give us an op- 
portunity of doing it before the woman has loft too 
much blood, and before the Uterus has thereby 
been too much deprived of its fenfibility and power 
of contraction, if, likewife, that early knowledge 
may be obtained by purfuing the directions I have 
given, the turning the child, in the cafes I have 
mentioned, cannot, furely, be too much urged to 
practitioners; as it is highly reafonable to expcCt 
more frequent fuccefs, when it is done under more 
favourable circumftances, if it be certain, that fuc- 
cefs fometimes attends it, when the patient is in 
appearance at the laft extremity. 
It will, however, frequently happen, that we ffiall 
not be called in till late in thefe cafes, when the 
woman will probably be in appearance dying, and 
indeed, fometimes the fluor is fo rapid, that in a 
very little time lb- much is loft, that the patient 
finks immediately; but, as was juft obferved, un- UTERINE HEMORRHAGE. 
29 
expected fuccefs having fometimes attended turning, 
even under the moft unpromifmg circumftances, it 
is certainly always our duty to do it, and by that 
means give the woman the only poftlble chance, I 
know there are arguments to be ufed, which may 
feem to juftify a furgeon’s relinqui filing his patient 
under fuch melancholy circumftances; that as peo- 
ple fo frequently judge by the event only, he may 
incur blame, and his reputation undefervedly fuffer, 
if it terminate badly, as it is moft likely to do; thefe 
may be tolerable arguments in trade, but they are 
very unjuftifiable ones in morals, which direct us 
always to do what is in itfelf right, independent of 
the opinion of the world, and the confequences 
that may follow it. But I cannot fee much reafon 
to apprehend much injury to our reputation, if, pre- 
vious to the performing a dangerous operation, the 
uncertainty of the event be but properly reprefented 
to the friends of the patient, or if, before our do- 
ing it, we fend for fome furgeon of eftablifhed re- 
putation, to juftify our opinion, and to be prefent, 
and perhaps afiift, whilft we do it, which is of all 
others the moft effectual method of preventing any 
injury to our character; and in places where the 
gentlemen of the profeffion behave liberally to each 
other, there can be no difficulty in procuring fuch 
affiftance. 
Thus, I have ventured to place one of the moft 
important fubje&s in midwifery in a new light, and 
have endeavoured to eftablifh a hitherto uncertain 
practice upon principles that are more fixed and 
conftant, by ascertaining when we may with pro- 
priety leave nature to do her own work, and when 
it will be requifite to proceed to immediate delivery, 
by turning the foetus: I have alfo endeavoured to 
fix the precifc time when it may, with moft fafety. 3° 
ESSAY ON THE 
be done, and, in order to promote the pradice of 
turning, when fuch becomes neceflary for the wo- 
man’s fafety, have attempted to obviate the objec- 
tions which have been made to this operation, from 
a fuppofition of its being either difficult, dangerous, 
or ufelefs And, from what has been faid, it ap- 
pears, that the Placenta is fixed to the Os Uteri 
much more frequently than has hitherto been fup- 
pofed ; that when it is fo fituated, nothing but turn- 
ing the child will put a flop to the flooding; that 
when it is not fo fituated, nature will, for the mofl 
part, expel it fafely herfelf; that an early knowledge 
of this circumftance is of the utmoft importance; 
that it may be obtained with eafe and fafety; and 
that, therefore, it fhould, in every cafe, be enquir- 
ed into before much blood has been loft; that the 
information, procured by making fuch an enquiry, 
fhould govern our management of the cafe; if we 
find the Placenta at the mouth of the womb, that 
we fhould proceed to delivery; that, if it be not 
fo fituated, if the difcharge be not very profufe, 
and a very large quantity of blood have not been 
already loft, we fhould endeavour to reftrain it by 
the means commonly directed for that purpofe, and 
wait for nature’s alfiftance in the expulfion of the 
child: and it is thence evident, that this practice 
will have an advantage over the uncertain one hi- 
therto adopted, becaufe our determination about 
what we do, will ever be more fafe and fatisfaclory, 
for if, on the one hand, we wait, we (hall have the 
fatisfadion of knowing that, in all probability, na- 
ture will be able to expel the foetus; and if, on the 
other hand, we immediately turn the child, we fhall, 
alfo, have the fatisfadion of knowing that nothing 
but turning can relieve the woman, and that, there- 
fore, we do not give her unneceflary pain: and 
finally, that our doinsr it before the patient has fu- UTERINE HAEMORRHAGE. 
31 
Rained too great a lofs of blood, will make the 
chance of fuccefs more probable, and thereby be 
the means of preventing, in fome meafure, the fa- 
tality which has hitherto fo frequently attended 
thefe cafes, and which has, perhaps, been more 
owing to a rational method of treatment not being 
known, than is commonly imagined. CASES. 
THE fubje&s of the following cafes were moft of 
them poor women, under the care of midwives 
when I was fent for to them, and had been floods 
ing a confiderable time before I faw them. As 
they may, on that account, be juftly confidered 
as labouring under every difadvantage, none, I 
think, could better exemplify what I have ven- 
tured to advance in the foregoing elfay. 
CASE I. 
DECEMBER 29, 1769, I was fent for, in the 
afternoon, to the wife of Balls. She 
was at the latter end of the eighth month of preg- 
nancy, and had been feized the preceding evening, 
with a difcharge of blood from the Uterus; it be- 
gan without pain, and in fmall quantity, but in- 
created by degrees, and was conliderable when I 
faw her; fhe had now, however, fmall pains, by 
which the Os Uteri was already fomewhat dilated: 
I admitted as much cold air as I could into the 
room, fupplied her frequently with cool and nou- 
rilhing drinks, and as the pains ftill continued, 
waited till the membranes were fo far diftended and 34 
CASES OF THE 
pufhed down, that I could fcratch them with my 
nail, by which means I broke them, and let the 
water efcape; the difcharge immediately leflened, 
the pains increased, and, in a little while, I felt one 
foot of the foetus prefenting; I brought it down, 
and with great eale drew forth a fmall dead child. 
The Placenta came away in about a quarter of an 
hour, the flooding became lefs and lefs, and the 
poor woman, though much reduced by the lofs fhe 
had fuftained, recovered in the ufual time. 
FEBRUARY 6, 1770, ** Stannard. She 
was a fmall delicate woman, of a fickly relaxed ha- 
bit, and had born feveral children. About the 
end of the eighth month, a flooding came on, with- 
out any previous pain, or fymptoms of labor. I 
faw her in the evening, after the difcharge had been 
feveral hours, though as yet it had not been very 
profufe; flie was, however, very faint and languid: 
by keeping her upon the bed with but few deaths 
upon it, and admitting cool air into the room, it 
evidently leflened: I found the Os Tincse relaxed, 
and a little open ; after examining feveral times, 
(and, probably by the flight irritation, occafioned 
by the frequent touch) it opened fomewhat more, 
and the membranes protruded fo far, as to be felt 
by my finger; I immediately broke them, the dif- 
charge abated ftill more, and fome flight pains fuc- 
ceeding, fhe was, in about half an hour after the 
breakmg of them, delivered, with remarkable eafe, 
of a fmall living child; the Placenta was removed 
without trouble, the difcharge was moderate, flop- 
ped at its proper time, and the woman perfectly re- 
covered. 
CASE 11. UTERINE HAEMORRHAGE. 
35 
CASE 111. 
IN the morning of March 12, 1772, Cou~ 
fins, a fickly relaxed woman, who had born many 
children, was feized with a flooding in the latter 
end of the laft month of her pregnancy. I was 
fent for upon the firft attack of the complaint, and 
living near the patient, was with her before much 
lofs had been fuftained by it, though the Haemor- 
rhage was then confiderable. She was without pain, 
and I found, upon examination, that the Uterus 
was very little open; the room being very fmall, 
and the air in it too warm and impure, I immedi- 
ately opened the door and windows, drew back the 
curtains of the bed, took off fome of the deaths, 
and did every thing to render he'r cool, and to ad- 
mit frefli air into the room, by which means the 
difeharge conflderably leflened; I gave her an ano- 
dyne, directed the cooleft drinks, and left her, de- 
firing to be called upon return of either pain or 
flooding. 
In the evening I was fent for again, when I found 
the latter had returned, and in an increafed quantity, 
infomuch that the woman was extremely faint and 
languid; the Uterus was, however, now rather 
more open, and fome flight pains were coming on, 
and upon examining whilft (he had one, I was juft 
able to perceive the membranes prefling againft the 
mouth of the Uterus; I introduced the fharpeft end 
of a probe along my finger, and broke them, the 
flooding became lefs immediately, and fome pains 
following foon after, flie was fafely, and with An- 
gular cafe, delivered by them of a living child: the 
Funis being fmall and tender, broke upon the Arft 
gentle effort to draw the Placenta by it, but by wa’n> 
ing about half an hour, it defeended far enough 36 
CASES OF THE 
into the Vagina, for the fingers to get hold of it. 
and bring it away. The woman was very much 
weakened by the lofs of blood fhe had fuftained, 
but in a few weeks fhe perfectly recovered. 
CASE IV. 
IN the evening of Augufl: 12, 1772, I was lent 
for to the wife of Leman, a pauper, belong- 
ing to the town; fhe had a midwife with her, who 
informed me her patient had been flooding in fome 
degree during the day, and that it had, in the laffc 
hour, very much increafed. I examined, found 
the difeharge confiderable, the Uterus was fcarce 
at all open, and Ihe was without pain ; flie was, 
moreover, extremely faint, and feemed to have fuf- 
fered much more than any of the former patients: 
admitting cool air into the room, &c. as in the 
other cafes, for awhile abated the difeharge, but as 
it returned very foon, and the woman feemed in the 
mod immediate danger, I was very defirous of at- 
tempting to relieve her by turning the child, but 
judging it right to have the opinion of another fur- 
geon, I fent for one who has had confiderable prac- 
tice in this city. He feemed to think my patient too 
far gone to receive relief from any attempt what- 
ever to flop the flooding, and as he added, that it 
was his opinion, fhe would fink during the opera- 
tion, as one or two had before done on whom he 
had made the like attempt, he advifed me not to 
turn the child. His advice prevented my doing it 
immediately, though before his arrival it was my 
defign to attempt it, if he juftified it: I was deter- 
mined, however, not to leave the bed-fide, that if 
there came on the lead degree of pain, fo as to al- 
low me to feel the membranes, I might, as I had 
before done, pierce them with a probe, or if the uterine haemorrhage. 
37 
flooding increafed, and I found it practicable to in- 
troduce my hand, I Rill refolved to attempt the re- 
moval of the child. 
By carefully attending to keep the room very 
cool, by preventing my patient from being the leait 
Rirred, and being myfelf her nurfe, in giving her 
every few minutes fmall quantities of the cooleß 
drinks, I prevented the difcharge from increafmg, 
and at the fame time fupplied, as far as I could, the 
waße of what Ihe did lofe, by the drinks Ihe took, 
being as nutritious as I could venture to give them, 
without their being irritating: after attending her 
in this manner about two hours, frequently examin- 
ing and gently Rimulating the Os Internum, there 
came on at length a flight pain, and foon after, I 
could juR feel the membranes with the end of my 
finger; I immediately introduced a probe, in the 
manner I had before done, and broke them; it had 
the lame good effect as before, for the difcharge 
immediately flopped, and pain coming on, the Ute- 
rus opened, the head of the child was pufhed down, 
and, notwithßanding the very alarming Rate flie 
had, but juR before, been in, Ihe was Toon eafily, 
and fafely delivered, by the natural pains, of a 
dead child. 
CASE V. 
NOVEMBER 5, 1772, about ten o’clock in the 
evening, I was fent for to Middleton, a poor 
woman, who had been flooding a little the greateft 
part of the day; the difeharge was about this time 
rather increafed, which induced the midwife,, who 
attended her, to deflre my alliflance; I found her 
without pain, and the Os Tineas not the leafl open- 
ed; but the difeharge was not fo great as in the laft 
cafe: I directed as in the former cafes, gave her an 3« 
CASESOFTHE 
anodyne, and left her with orders to be fent for 
again it the flooding increafed, or if pain came on. 
I was fent for again about fix in the morning, the 
had flept in the night, and the difcharge had been 
but little, but it was now very confiderable: nature, 
however, feemed difpofed to alfift her, for there 
foon came on a few pains which opened the Uterus, 
and diftended the membranes fo far as to enable me 
to break them; it had again the good effect of fup- 
prefling the flooding, and facilitating the labor, 
which terminated fafely in kfs than half an hour;— 
the child was dead. 
CASE VI. 
DECEMBER i, 1772, about midnight I was 
fent for to Welden, another pauper. She had 
a midwife with her, who informed me, the woman 
had been flooding a conftderable time, and had loft 
a large quantity of blood, which feemed to be true, 
from the ftate the poor creature was in; for her 
faintnefs was extreme, and fhe had every fymptom 
of the moft immediate danger. 
Upon examination, I found the Os Uteri more 
dilated than in any of the former cafes, and the 
Tlacenta evidently prefenting: as no poflible relief 
could, in this cafe, be expected from waiting, I at 
once refolved to give her the chance of an immediate 
delivery; which I effected by introducing my hand 
into the Uterus, turning and bringing away the 
Foetus; and this I did with much greater eafe than 
I could have imagined, as the refiftance from the 
Uterus was very trifling; I endeavoured to pafs my 
•hand through the fubftance of the Placenta, but 
not being able to do it, I feparated it on one fide, 
till there was room for my hand to pafs. UTERINE HAEMORRHAGE. 
39 
The woman remained very faint and weak a long 
time after delivery, but being carefully nurfed, Ihe 
recovered by degrees, and was able to go out be- 
fore the end of the month. This was likewife a 
dead child. 
CASE VII. 
DECEMBER 29, 1772, about fix o'clock in the 
morning, I was called to Freeman, a poor wo- 
man, who was under the care of a midwife; (he 
had been flooding many hours, and had loft an im- 
moderate quantity of blood, was greatly funk, and 
appeared to be almoft dying; on examination, I 
found the mouth of the Uterus as open as in the laft 
cafe, and the Placenta fituated in like manner, which 
determined me to purfue the fame method I had fo 
fuccefsfully ufed in that. 
The Pelvis was narrow and diftorted, but I in- 
troduced my hand into the Uterus, and turned the 
child with all defirable eafe; the feet, body, and 
arms of the Foetus I brought down in the ufual 
manner, and with no more than ufual difficulty; 
but when I came to the head, it remained fo fall: 
betwixt the bones of the Pelvis, that, though I got 
one of my fingers into the mouth, (the face being 
towards the Sacrum,) and pulled the body, at the 
fame time, with confiderable force, I could not 
move it in the lead degree, infomuch that the Ver- 
tebras of the neck began to give way; which made 
me defift from pulling fo forcibly, and induced me 
to fend for the affiftance of another furgeon. 
He made feveral fimilar but unfuccefsful attempts; 
we, therefore, concluded, that nothing but leiien- 
ing the fize or the head, by evacuating the brain, 
would allow it to pafs; but to effect this was no eafy 
matter; he thought it poffible to pafs the fcifiars 4° 
CASESOFTHE 
through the Os Palati into the head, and attempted 
it; when the fciflars had pierced the bones, I en- 
deavoured to enlarge the opening, but could not do 
it; in tracing with my finger, round the head, as 
far as I was able, I thought there was a poifibility 
of pufhing in fome curved inftrument behind the 
ear, at the lower end of the temporal bone; but 
the fciflars being ftrait, I could not ufe them; howT- 
ever, from the loofenefs of the fcalp, (for it ought 
to be obferved, that the child was dead, and almoft 
putrid, which was certainly the reafon why the Ver- 
tebra of the neck feparated fo eafily, when I at- 
tempted to pull the head,) I thought I could pufh in 
the curved end ot a blunt hook, which, with a good 
deal of difficulty, I effeded, and by degrees infinu- 
ated it under the temporal bone; the opening I 
eafily enlarged by my finger, and with one blade of 
the forceps, fo that at length fome of the brain came 
away, the head was thereby comprefled into a fmall- 
er compafs, and fhe was delivered; but the extreme 
fatigue Ihe had undergone by this unlucky difficulty, 
joined to the immoderate lofs of blood flie had pre- 
vioufly fuftained, was more than fhe was able to 
fupport, and ffie died the following morning. 
Since the above cafe happened, I have procured 
a pair of fciflars of Cargill, in Lombard-ftreet, curv- 
ed at the points, (fomewhat like Tonfil fciflars) 
which may eafily be ufed where it is found neceffary 
to open the head, after delivering the reft of the 
child. 
CASE VIII. 
JANUARY 4, 1773. By grave, a pauper, 
fell in labor, and a flooding came on, after having 
had fome pain; I was fent for about an hour after 
the difcharge began, and found it very conliderabie; UTERINE HAEMORRHAGE. 
41 
but there had been pain fufficient to dilate the Ute- 
rus, and to enable me to break the membranes, when 
I found a hand and foot prefenting; I immediately 
brought down both feet, and delivered her, fafely, 
of a living child. 
CASE IX. 
FEBRUARY 3, 1773, Clarke. She had 
flooded feveral times, and in confiderable quantities, 
in the lad month of her pregnancy; but it was every 
time fuppreflcd by the means I have before related, 
and ihe went to her full time. 
Her labour was a natural one, and at that time 
there was very little difcharge, though it had been 
confiderable a few days before. She was delivered 
by the natural pains, of a large, living child; but 
immediately upon the expulfion of it, there came 
on a moil protufe fluor; I inftantly introduced my 
hand into the Uterus, and was fortunate enough to 
remove the Placenta, with but little lofs of time; 
the womb immediately contracted, and the difcharge 
abated. 
CASE X. 
FEBRUARY 12, 1773, I was fent for to 
Mar/hall, a poor woman in the workhoufe, who 
was in her lad month of pregnancy, and had been 
flooding about two hours; die had, in that time, 
loft a very great quantity of blood, and was fo much 
funk by it, that die died foon after I came into the 
room. 
I had an opportunity of opening the body, the 
following morning: the membranes adhered uni- 
verfally to the Uterus, by the Spongy Chorion; I 
carefully meafured the water contained in the bag. 42 
CASES OF THE 
and there were three pints of it: the child laid, with 
the head obliquely to the right fide of the Fundus 
Uteri, and the face towards the Spine; the hands 
were turned upon the face, holding each one of the 
feet, fo that the Podex would have prefented; the 
Placenta was fituated upon the Os Uteri, and a 
partial feparation of it, not bigger than a crown 
piece, was the caufe of this fatal Haemorrhage. 
Before flie died, I examined with my finger, found 
the Uterus very little open, and did not feel the 
Placenta. 
REMARK. 
This cafe proves, that the Os Uteri fornctimes 
does not at all dilate to the fize that has been ufual- 
ly thought neceffary for fafe delivery, and that it is 
not, therefore, always right to defer turning the 
child, in expectation of it: had I been with the 
woman fooner, I certainly fhould have attempted it, 
and as from the firft, there had been a confiderable 
difeharge, in all probability the Uterus was fo re- 
laxed, that it might have been eafily and fafely ef- 
fected. 
CASE XL 
MAY 15, 1773, I was fent for, in the evening, 
to Maliward, who had fpoken to me to at- 
tend her; fhe had gone her full time, and fome 
fymptorns of labor came on, accompanied with a 
flight difcharge of blood; I gave her an anodyne, 
directed her to be kept cool, &c. and left her, with 
orders to be fent for again if the complaint increas- 
ed. 
About four o’clock in the morning I was called 
to her again, and found the difcharge was increaf- UTERINE HEMORRHAGE. 
43 
cd, but Ihe had had but little pain; however, after 
frequently examining, in about half an hour, the 
membranes began to fwell, and I was able to break 
them; the flooding abated, more pains came on, 
and the child defcended into the Vagina, with the 
breech presenting; but, as the woman was well 
formed, it pafled eafily, and Ihe was foon, fafely, 
and almod entirely by the natural pains, delivered 
of a dead child. 
CASE XII. 
JUNE 25, 1773, I was called to Sherwood, 
a pauper, under the care of a midwife. She had 
been flooding feveral hours, had 101 l a large quan- 
tity of blood, and was extremely faint. I treated 
her as I had done molt ef the former ones, gently 
irritated the Os Uteri, and, as foon as I was able, 
broke the membranes, and Ihe was, in like man- 
ner, fafely delivered, by the natural pains, of a 
dead' child. 
CASE XIII. 
JUNE 27, 1773, Vlay ford. She was at- 
tended by a midwife, at the time I was fent for, 
and had been flooding very much feveral hours; 
the difcharge was dill profufe, the Os Uteri quite 
fhut, and from the faintnefs Ihe was in, Ihe was al- 
together without pain, though the complaint came 
on with labor pains: Ihe had the mod threatening 
appearance, and I very much feared I could be of 
no fervice to her, and intimated it to the midwife 
and the aflidants, but added, that if there were 
any poflible chance, it mud be from immediately 
delivering her. 44 
CASES OF THE 
As they were defirous of another furgeon’s opi- 
nion, I fent for a gentleman, who confirmed what 
I had faid refpe&ing the danger the woman was in, 
and agreed with me, that the only chance fhe could 
have mud be from a fpeedy delivery; the practica- 
bility of which, however he rather doubted, as the 
Os Tincae was fo little open: 1 apprehended great 
difficulty in doing it, and feared likewife, that it I 
fucceeded in bringing away the child, the woman 
would hardly furvive the lofs (he had fuftained; but 
having fuccecded before, much beyond my expec- 
tation, I thought it right to attempt it; I introduced 
my hand into the Vagina, for this purpofe, and firll 
one, then more fingers, into the Uterus, when, 
(and not before,) I found the Placenta fixed to the 
Os Uteri; I endeavoured to pafs my finger through 
the fubftance of it, but was not able, though I tried 
fome time; I, therefore, feparated it on one fide, 
and got my hand compleatly into the Uterus; the 
head of the child prefented, but I foon got hold of 
the feet, brought them down, and delivered with 
the fame eafe as in the lafh cafe of turning: the wo- 
man remained very languid a long while, and feem- 
ed hardly alive for many hours; but by fupplying 
her frequently with cool and nutritious drinks, and 
carefully managing her in other refpeCls, fhe re- 
covered entirely. 
REMARK. 
This Cafe appears much to have refembled that 
of Marjhall, who died undelivered; as the difeharge 
wras very profufe, and the Uterus very little open, 
the difference in the event being produced merely 
by my being fortunately called fooner to this woman. 
The eafe with which the turning was effected, and 
the fuccefs which attended it, confirm the remark UTERINE HEMORRHAGE. 
45 
made to that cafe, that it 5s fometimes juftifiable to 
deliver where the Os Uteri is not dilated to the fize 
of a {hilling, or a half crown. 
CASE XIV, 
JANUARY i, 1774, I was fent for, about noon, 
to King, a poor woman, who was at the full 
term of her fourth pregnancy: without any previ- 
ous accident, or complaint, fhe was feized with a 
trifling pain, like the beginning of labor pains, 
which was accompanied with a little appearance of 
blood; when I firft faw her, fhe was not at ail faint, 
had loft a very fmall quantity of blood, and was 
fitting by the fire fide; the Os Tincae was a little 
relaxed, but not open, and fhe had no pain. I de- 
fired her to be laid upon the bed, to be kept very 
cool and quiet, and ordered the midwife to fend for 
me again, if flie found the flooding increafe. 
From this treatment it abated, and the woman 
got fome reft in the afternoon; but in the evening 
her pain returned, and with it fo profufe an He- 
morrhage, that before I could get to .herj fhe had 
loft an aftonilhing quantity of blood, and had the 
moft threatening appearance; Ihe, before, had a 
good pulfe, and a florid, healthy countenance, but 
now her pulfe were fcarce perceptible, her counte- 
nance was pale, her lips livid. See. from the extreme 
faintnefs fhe was now in, the difeharge and pain 
were abated, but as the Uterus was very little open., 
as fhe had no pain, and was fo much funk, there 
feemed to be no reafon to expect affiftance from na- 
ture, and no chance but from an immediate deli- 
very. 
I fent for another furgeon, to juflify what I did; 
he agreed with me, that it was the only chance of 
relieving her, though a very poor one; however. 46 
CASESOFTHE 
as he approved of it, and the friends oh the patient 
confented to it, I proceeded to turn the child. I 
found, as foon as I had introduced one finger into 
the Os Tineas, that the Placenta was fituated as it* 
the lad cafe, and I was now able to infmuate my 
finger and hand through the fubftance of it, which, 
as 1 before obferved, is an advantage; the child 
was in a natural pofture, but I palled the head, got 
hold of the leet, and by them brought it away with 
all defirable facility: the woman immediately, and 
for fome time after delivery, appeared rather better, 
as Hie took nutriment, and was rather revived; but 
nature was unable to recover from the great lofs fhe 
had fuflained, and ihe died about fix hours after. 
CASE XV. 
JANUARY 2,r, 1774, Bond. This was a 
patient of the fame gentleman who was with me in 
the lad cafe- He lent for me in the evening, and 
the woman was then, in the fame dreadful ftate that 
my lad patient was in, when I fent for him. 
He informed me, that he had feen her the pre- 
ceding evening, that fhe was then, to all appear- 
ance, in perfect health, but that fhe had been alarm- 
ed by a.fmall difcharge of blood from the Uterus; 
he bled her, gave her an anodyne, ordered her to 
be kept cool and quiet, and law her the following 
morning: {he had had a good night, and the appear- 
ance of blood was not more considerable, but in the 
evening it had fuddenly increafed to a mod violent 
degree, infomuch as to have reduced her, in a Short 
{'pace of time, to the deplorable date we found her 
in. 
. She feemed to be dying, but as we thought it 
juftifiabte to give her the only podible chance, by 
Cuming the child, by Ids leave, I introduced my UTERINE HAEMORRHAGE. 
47 
hand, the Uterus was flint, though loofe and relax- 
ed, and as foon as I got one of my fingers into it, 
I found the Placenta fixed to the mouth of it: in this 
cafe I could not pafs through the fubftance of it, 
but feparated it on one fide, got my hand within 
the membranes, turned, and brought away the 
child, with the fame remarkable eafe as in the other 
cafe; but this was attended with no better fuccefs 
than the former cafe, for fhe died in half an hour 
after delivery. 
II E M A R K, 
The unhappy events of the two lad related cafes, 
feem, at firft, to contradict a remark made but a 
few pages before; as it may, perhaps, be thought, 
that it would have been later to have deferred the 
dehvery longer, becauie the Os Uteri was fo little 
open in either of them. 
But fo far from the turning having been prema- 
turely done, I am convinced its want of fuccefs 
was owing folely to its having been too long delayed ; 
for when I proceeded to deliver, the women had 
every fymptom of approaching death, and though 
my principal motive in turning was to give them a 
chance of recovery, as no other means could pof- 
libly do it, yet 1 was, likewife, further induced to 
attempt it, that I might be fatisfied of the fstuadon 
of the Placenta, which, about this time, began to 
excite my attention; and I well remember urging 
this to the gentleman who was with me, as an ad- 
ditional reafon why 1 wilhed to do it, as from their 
being fo much reduced by the great lofs of blood, 
he, at firft, rather difeouraged it. 
The lingular eafe with which it was effected in 
both cafes, is, likewife, in my opinion, a pohtiva 
proof that no mifehief was brought on by turning; 48 
CASES QF THE 
for, with rcfpeft to that operation, it has been be- 
fore obferved, that difficulty in doing it is the true 
mark of danger, and eal'e is therefore that of fafety. 
If I had not delivered, very probably I fhould not 
have had an opportunity of opening the bodies af- 
ter death, and as, confequently, I fhould have known 
nothing of the Placenta, I could not poflibly, with 
lo much certainty, have made the diftindlion 1 have 
hnce done, between floodings which are accidental, 
and thofe which are unavoidable. 
It may not be improper further to remark here, 
that in the management of the cafes which have hi- 
therto been related, I was influenced by no other 
circurnftances than thofe which are ufually attended 
to in floodings, namely, the quantity of blood 
which had been loft, and the feeming ftrength of 
the patient; for, though the Placenta being found 
at the mouth of the Uterus, was, in the cafes of 
Weldcn and Freeman, an additional inducement to 
my turning, yet the idea of the frequent occurrence 
of fuch a circumftance, did not ftrike me till thofe 
of P/ayford, Marjhall, J\ing9 and Bond had fallen 
under my notice ; nor, indeed, was I fenfible of 
the importance of an early enquiry, whether the 
Placenta was, or was not, fo fituated, till the two 
laft cafes happened, in both which it appeared lb 
evident, that, had its fttuation been fooner known, 
the children might have been brought away before 
fo great a quantity of blood had been loft, and, 
very probably, the lives both of the mothers and 
the children have been faved. 
CASE XVI. 
JANUARY 24, 1774, I was lent for on the even- 
ing of this day, by the fame gentleman with whom 
I had been in the laft cafe, to —— Flood, who was UTERINE HEMORRHAGE. 
49 
at the latter end of the ninth month of pregnancy, 
and had, juft before he faw her, been feized with 
a Uterine Haemorrhage, but much blood had not 
been yet loft; 1 advifed a careful and immediate ex- 
amination of the Uterus, to know whether the Pla- 
centa was fituated at the mouth of it, and that the 
management of the cafe ihould be influenced by 
the information thence gained; this examination 
was accordingly made, and we were convinced that 
the Placenta was not there; we, therefore, direded 
an anodyne, ordered her to be kept ftill and cool, 
and left her. 
From this treatment, the difeharge for fome hours 
abated, but it returned in the morning, accompani- 
ed, however, with flight pains, which were increafed 
by gently irritating the Os Uteri with the finger, 
till the membranes fwelled, and gave us an oppor- 
tunity of piercing them; more pains fucceeded, and 
the patient was at length fafeiy delivered by their 
foie affiftance. 
CASE XVII. 
APRIL 7, 1774, I was called in the morning to 
Hozulett, a poor woman, who was feized with 
a flooding at the end of her ninth month;, at the 
time I faw her, fhe had a midwife with her; I ex- 
amined her in the fame manner I had done the laft 
patient, and being fully fatisfied that the Placenta 
was not in the way, I gave the fame directions as 
were obferved in the laft cafe; the difeharge, in like 
manner, abated, and towards the evening, fhe was 
fafely delivered by the natural pains, having no 
other afliftant than the midwife, who was with her 
at firft. 5° 
CASES OF THE 
CASE XVIII. 
MAY 18, 1774, a very delicate relaxed lady, 
in the beginning of the ninth month of her firit 
pregnancy, foon after getting her break faff, had 
fuddenly a flight difeharge of blood from the Ute- 
rus, occafioned, as fne imagined, by a fmart fhock 
of fneezing; file was immediately carried to bed, 
and I was fent for. 
The difeharge continued, but was not increafed 
in quantity, and, in about half an hour, I had an 
opportunity of examining, and found the Os Uteri 
quite clofe and unyielding. As the Vagina was ve- 
ry flrict, and there had not been difeharge of any 
kind to relax it fufficiently for the admiflion of the 
hand, without confuierable pain, and greatly alarm- 
ing the patient, who had no apprehenfion of the 
danger of her fit nation, I ventured to defer the en- 
quiry, and made ufe at firfi only of the methods 
commonly ufed to reflrain it; but I thought it right 
to ftay with her: the Hsembrrhage was, thereby, 
kept from increafmg many hours; but before the 
next morning, it became more formidable, fo that 
I thought it imprudent to remain any longer igno- 
rant of the caule of it; I therefore examined in the 
way before directed, which was now done with to- 
lerable eafe; and finding that the Placenta was not 
at the month of the Uterus, I flill waited for the 
natural pains, and endeavoured to excite them by 
the genfie flimulus of the finger on the Os Tincae; 
in about two hours they came on, and puflied down 
the bag, which f foon opened; the difeharge abated, 
and the head defeending by repeated and gentle 
pains, flic was at length iafely (delivered of a dead 
child. UTERINE HAEMORRHAGE. 
CASE XIX. 
JULY 14, J774’ ab°ut eleven o'clock in the 
forenoon, I was fent for to Fear man, with 
whom a midwife had been feveral hours; (he was 
in her ninth month, had a frnall but increafmg dif- 
eharge from the Uterus, was faint, and without la- 
bor pain: I examined carefully, without lofing any 
time, and being convinced the Placenta was not at 
the Os Uteri, I gave her hopes of being releafed 
by the natural pains; to efledt which I rendered the 
air as cool as I could, leflened the number of bed- 
cloaths, and endeavoured to excite pain, by gentle 
irritation on the Os Tinea:; the difeharge became 
lefs, but no pain coming on, 1 left her, with direc- 
tions to be called again on return of flooding, or 
coming on of pain. 
In a few hours after, I w’as fent for, on the form- 
er account; I then repeated my efforts to make the 
Uterus contraU, and at lafl; fo much pain came on 
as protruded the membranes, which, as before, I 
inftantly broke; more pains fucceeded, the Haemor- 
rhage flopped, and, to the furprize of the patient 
and her attendants, a few very trifling pains expel- 
led a living child. 
CASE XX. 
NOVEMBER 8, 1774, I was fent for to a poor 
woman at Ringland, about fix miles from this city: 
the meffenger’s account of her was, that fhe had 
been flooding, more or lefs, for feveral days; that 
the difeharge had that morning increafcd immode- 
rately; and, that the midwife who was with her, 
was greatly alarmed, and thought herfelf unable 
to relieve her. From this difeription of her, I told 52 
CASES OF THE 
him, there was very little probability of finding her 
alive; and my conjecture proved true, for fhe had 
been dead about an hour before we got there. 
The midwife who attended her, being an intelli- 
gent and communicative woman, I learned from 
her, that her patient, who was in her laft month of 
pregnancy, had been as well as ufual during the 
former months; but fix days before, without any 
previous complaint, a flight dlfcharge came on, ac- 
companied with fome pain, which, however, flop- 
ped of itfclf, and the pain went off; that it had re- 
turned feveral times, and at each time in an increas- 
ed quantity; that fhe had examined her at feveral 
different times, but found the mouth of the womb 
fhut; and with the laft attack, which was the morn- 
ing of that day, and was more violent than any of 
the preceding ones, fhe had very confiderable pains, 
and exprefled luch ftrong figns of bearing down, 
that fhe thought her near delivery; in that ftate fhe 
examined her, and then found the Os Uteri confi- 
derably open; fhe removed feveral coagula of blood, 
which were in the Vagina, and at the mouth of the 
womb, and expe&cd to feel the head of the child, 
but in its ftead fhe found (to ufe her own words) a 
Jlrange hnnp of ftringy fuhjlancc, unlike any thing 
fhe had ever before felt; the flooding ftill continui 
ed, the blood pouring forth with every pain, till 
the poor creature fell into a fainting, from whence 
fhe did not recover., 
I was defirous of opening the body, to be con- 
vinced of the fituation of the Placenta, but could 
not obtain the confent of the by-ftanders; there 
can, however, I think, be little reafon to doubt its 
being at the Os Uteri, as nothing elfe could anfwcr 
the midwife’s defcription of a lump of [tr 'mgy fub~ 
Jiance, or could hinder the defcent of the child, 
when nature was alibied by fuch ftrong pains, and UTERINE HEMORRHAGE. 
53 
when the mouth of the womb was fo much open. 
I afked her, if fhe had ever before found the Placenta 
in fuch a fituation; Ihe told me fhe had never, till 
now, been with a patient who flooded before delive- 
ry, though fhe had attended feveral hundred wo- 
men; but Ihe believed this could be nothing elfe. 
CASE XXL 
NOVEMBER 20, 1774, a midwife, with whom 
I have before frequently been, called upon me for 
my advice about a patient fhe was then going to, 
whofe name was Bailey, and with whom Ihe had 
been the day before, at which time there was a 
flight flooding, which had been then checked by 
keeping her ftill and cool, but fhe found it was at 
this time returned. 
As I could not conveniently go with her, I de- 
fired her to be very careful in examining the patient, 
and to be fatisfied, whether there v/as any thing un- 
ufual at the Os Uteri, in which cafe I defired her 
to fend for me; otherwife, fhe might fafely wait 
the coming on of pains, in the mean time keeping 
her cool, and in bed. 
She called on me the next day, to inform me fhe 
had purfued my advice, that the mouth of the womb 
was opening, but fhe found nothing there like what 
I had defcribed to her; fhe, therefore, agreeable 
to my directions, waited, and, notwithflanding the 
continuance of the difcharge, fhe was fafely and 
eafily delivered, by the natural pains, before the 
following morning. 54 
CASES OF THE 
CASE XXII. 
DECEMBER 16, 1774, Smith, a healthy6 
(bong young woman, in the laft month ot preg- 
nancy, fent for me in the evening, having had, for 
feveral hours, a difcharge of blood from the Ute- 
rus. I immediately introduced my hand into the 
Vagina, and with one finger in the Os Uteri, which 
was foft and yielding, I imagined 1 found the Pla- 
centa, but, upon further examination, was fatisfied 
that it was nothing more than a coagulum of blood, 
as I very evidently felt the membranes, with the 
head of the child behind them. The dilatation pro- 
duced by this examination, was fufficient to have 
rendered the introduction of the hand into the Ute- 
rus, to turn the foetus, if it had been neceflary, 
very practicable; but being confident of the great 
probability, not to fay certainty, there was of na- 
ture’s being able to expel the child in due time, I 
thought it right to endeavour to reftrain the prefent 
difcharge, and wait for pain. This was foon effect- 
ed, by the ufual means, and there feemed a proba- 
bility of her going to her full time, if kept ftill and 
cool, for it flopped entirely for two days. 
It returned, however, on the third day from the 
firfl attack, when it was probably occafioned by 
fome imprudent exercife in the woman, as fhe had 
not yet gone her full time; but being now accom- 
panied with pains, the Uterus opened, the child 
was pufhed down and expelled with remarkable eafe. 
The Haemorrhage, in this cafe, rather increafed af- 
ter the delivery of the child, and did not abate till 
the Placenta was removed, which did not defcend 
fo foon as it ufualty does. UTERINE HAEMORRHAGE. 
55 
CASE XXIII. 
DECEMBER 21, 1774* I vifited Mrs. L , 
flie was in her laft month of pregnancy, and had 
had a flight difcharge of blood from the Uterus the 
preceding day, but as it was flopped when I was 
with her, and (he had no pain, 1 had not an oppor- 
tunity of examining the ftate of the womb; I, there- 
fore, only recommended ftillnefs and reft, and de- 
fired to be again fent for, if it returned in the leaft 
degree. 
On the 25th, I was fent for early in the forenoon, 
the difcharge having returned, and being then con- 
flderable; I immediately examined, and, as in the 
laft cafe, imagined I felt one edge of the Placenta 
on the pofterior fide of the Os Tincse, but on tra- 
cing my finger compleatly round it, I diftinftly felt 
the membranes, and the child’s head behind them; 
I ventured, therefore, to wait, and gave my patient 
hopes of being fafely delivered, without any other 
than the ufual afliftance; from cooling the air, &c. 
it again abated, nor was there any return of it du- 
ring the remainder of the day, and the following 
night. About nine o’clock the next morning, the 
2,6 th, fhe was again alarmed by a return of it, and 
with increafed violence; upon examination, I again 
thought there was an edge of the Placenta in the 
mouth of the Uterus, but as it could be but a very 
fmall portion of it, and as there was fufficient paffage 
for the child, and, moreover, during the pains, 
which now came on, the difcharge did not increafe, 
but flopped; I thought it ftill fafe to wait, and en- 
deavoured immediately to break the membranes, 
which, with fome difficulty, I effe&ed; the difcharge 
became lefs, but the pains went off, and by keeping 
her very cool and free from motion, the Haemor- 56 
CASES OF THE 
rhage was inconfiderable all the day, and the fol- 
lowing night. 
On the 27th, about fix o’clock, it came on again, 
and in a larger ftream than ever, and as her pains 
were ffcill but trifling, and, from the frequent re- 
turn of the flooding, (he had loft a large quantity 
of blood, I began to apprehend danger, and almoft 
to think I had done wrong in fo long trufting to 
nature; 1 was therefore, for fome time, erabarraf- 
fed to determine what was now beft to do, but it 
being again checked by increaftng the cold air in 
the room, which had not been fufficiently attended 
to in my abfence, I was once more encouraged to 
wait, and fortunately from this time, there was no 
great return of it; in about two hours the pains in- 
creafed, the Uterus opened, and the head came 
forward, and though from its being large, and the 
Pelvis not a good one, the progrefs of the labor 
was much flower than I had ever before found it in 
fimilar circumftances, it terminated fafely by na- 
ture’s foie afliftance before one o’clock; the Hae- 
morrhage was inconfiderable after delivery, and 
my patient, though much reduced, and being in 
other refpecfs a fickly woman, recovered entirely. 
There was a peculiarity in the fon» and texture 
of the Placenta in this cafe that deferves notice, as, 
probably, the Haemorrhage was, in fome meafure, 
occafioned by it; inftead of the ufual circumfcribed 
and circular cake, thick in the middle, and becom- 
ing left and left towards the edges, it was an uneven 
maft, thinly, and, in fome places, almoft fuperrici- 
ally fpread over near one fide of the Uterus; the 
edges of it terminated in a broken manner, form- 
ing fomewhat like the lines of a very irregular illand 
on a map, and one edge, making almoft a detached 
lobe, hung down on one fide of the Os Tincse, and 
was, I was now convinced, what I had before felt. UTERINE HAEMORRHAGE. 
57 
and what had probably produced fome of the flood- 
ing, but the principal difcharge feemed, by the dif- 
coloration of the Placenta, to have arifen from a 
reparation of it higher up in the Uterus. 
CASE XXIV. 
JUNE 19, 1775, I was fent for to Hook, a 
poor woman, under the care of a midwife; fhe 
had been flooding feveral hours, and, in the laft 
half hour, the dilcbarge had confiderably increafed. 
I immediately examined with my hand in the Vagina 
(for with the finger only I could but juft touch the 
outfide of the Os Uteri,) and found, by introduc- 
ing one finger into the Uterus, that the Placenta 
was at the mouth of it: fhe had loft a confiderable 
quantity of blood, and was very faint, but did not 
appear to have fullered fo much as to have induced 
me, had the Placenta not been there, or had I made 
no enquiry to find it, to have turned the child; but 
being convinced of the danger of delay, I deter- 
mined to deliver, and previous to my doing it, fent 
for a furgeon who had been before with me in fome 
of the foregoing cafes. 
When he came, I told him the woman’s fixa- 
tion, and defired him to examine in the common 
way, with one finger only, which he did, but could 
find nothing unufual at the mouth of the womb; 
I then defired him to introduce his hand, as I had 
done; be did this, and immediately difeovered the 
Placenta; he, therefore, agreed with me in the 
propriety of immediate delivery. 
I introduced my hand into the Uterus, and found 
the child lying in the natural pofture, I palled the 
head, and with tolerable eafe got hold of the feet, 
brought them down, and extracted a dead chilli. 5« 
CASES OF THE 
The woman remained extremely languid for fame 
time after delivery, but, notwithstanding this, and 
that ffie laboured under every difadvantage produc- 
ed by extreme poverty, and a remarkable ignorance 
in her affiflants, having neither pure air, clean li- 
nen, and hardly common nutriment for feveral 
hours, yet fhe perfe&ly recovered. 
REMARK. 
As this woman had not gone her full time, being, 
according to her own account, in the middle of the 
eighth month, which feemed true from the fmallnefs 
of the child, I expected to have had fome difficulty 
in introducing the hand, the Uterus not being com- 
pleatly diftended, but, notwithftanding 'the mouth 
of it was but little open, it gave way with the fame 
eafe I have ever obferved in thefe caies, and the 
delivery was effe&ed with no more than ufual trou- 
ble. 
The neceffity of introducing the hand into the 
Vagina, and admitting one finger into the Uterus, 
in order to diftinguifh with certainty whether the 
Placenta be at the mouth of it or not, has been be- 
fore obferved, and feveral of the former cafes have 
proved the propriety of it: in Playford, King, and 
Bond, it was not found till the hand was admitted 
for the purpofe of turning, and in Marjhall, though 
the ufual examination was made before fhe died, it 
was not known till the Uterus was opened : in the 
prefent cafe, its not being difcoverable by two dif- 
ferent perfons who examined at firft in the ufual 
way, is a very remarkable proof of the neceffity 
there is for doing it; I, therefore, thought it right 
again to take notice of it in this place, as it may, 
perhaps, more flrongly imprefs the reader. UTERINE HEMORRHAGE. 
59 
CASE XXV. 
JULY i, 1775, Sherringham. In the courfe 
of the preceding week fhe had feveral times had a 
flight Haemorrhage from the Uterus, which return- 
ing more confiderably this morning, made her fend 
for her midwife: it continued during the day, ac- 
companied, however, with flight pains; but as they 
did not increafe, the flooding continued, and flie 
became faint, I was fent for about fix o’clock in the 
evening. 
I immediately examined, as in the laft cafe, and 
was fatisfied that the Placenta was not at the mouth 
of the womb, as I very diftinftly felt the head of 
the child prefenting: I, therefore, waited, and en- 
deavoured to excite pain, and, as fcon as I was 
able, broke the membranes; her pains became 
flronger, the Os Uteri dilated, and the flooding 
entirely ceafed, and I expected fhe would have been 
delivered with the eafe and quicknefs peculiar to 
thefe cafes, but in this I was difappointed, for it 
proved very laborious, and the head defcended into 
the hollow of the Sacrum fo flowly, that fhe was 
not delivered till one o’clock in the morning: ic 
was a large living child, the Placenta was carefully 
removed, the difcharge was trifling, and the woman 
perfectly recovered. 
CASE XXVI. 
Mrs. B—, the fubjecl of the following cafe, is 
patient to the fame gentleman who has favoured me 
with his afliftance in feveral of the former cafes j 
fhe is a woman of a very tender and delicate con- 
futation, has been mother to fcven children, and 
has had very bad health for feveral years paft. 6o 
CASES OF THE 
Augufl 20, 1775, being at her full reckoning, 
fhe had the preceding day, and all the night, fmall 
pains in her back, which fhe confidered as the fore- 
runners of labor; about nine o’clock in the morn- 
ing the pains fuddenly became flronger, and fhe 
felt a preffure upon the lower part of the Uterus, 
which was followed by a difcharge; it was in a con- 
fiderable quantity, and fhe imagined it to be water, 
till, upon examination, fhe found it blood: fhe im- 
mediately fent for her furgeon, who came to her 
about ten o’clock; the pains had then entirely left 
her, but the difcharge continued flowly trickling 
from the Uterus; as foon as he had an opportunity, 
he examined with the hand in the Vagina, and dif- 
tinftiy felt the Placenta at the mouth of the womb; 
he foon after fent for me, and I was with the patient 
about eleven o’clock. 
She was flill without pain, and the difcharge was 
lefs in quantity, and of a paler colour: I examined 
in the fame manner he had done, and found the 
Placenta in the before-mentioned fituation; the Os 
Uteri was dilated to about the fize of a fhilling, but 
upon my attempting to introduce three fingers into 
it, it contracted fo clofely round them, and was fo 
rigid, that I concluded the delivery would as yet be 
attended with too much difficulty to render it ad- 
vifeable, and as there had not yet been bleeding 
fufficient to injure her, and it was now almofl en- 
tirely flopped, we thought it right to wait till the 
parts were more relaxed by difcharge, or dilated by 
pain; but we flaid with the patient, faw every cloth 
which had been ufed, and examined the Uterus al- 
ternately once in an hour. 
About three o’clock in the afternoon there came 
on fuch pains as fhe before had in the night, but 
they were not fufficient to open the Uterus more, and 
therefore did not increafe the bleeding: about five tJTERINE HAEMORRHAGE. 
61 
o'clock the pain fuddenly became more violent, the 
Uterus was more widely dilated by it, which pro- 
ducing a further reparation of the Placenta, a frefh 
difcharge was occasioned, and it was now rapid and 
considerable; there was, therefore, every reafon to 
juftify immediate delivery, the Os Uteri was more 
dilated, it was more relaxed, and more yielding, 
and the Haemorrhage was fo confiderable, that a 
further delay might have been attended with the 
utmofl; danger; he, therefore, proceeded to turn, 
which he did flowly, but with great eafe, and ex- 
tracted a living child. 
There was no difcharge of confequence imme- 
diately after delivery, nor whilft we ftaid with her, 
which was more than half an hour, but upon my 
calling again in the evening I found the room too 
warm, the bleeding had increafed, and flie was 
much more faint than fhe had before been; but 
from cooling the air, and adding a little preffure to 
the Abdomen, it abated, fhe had a tolerable night, 
and was nearly as well the next morning as fhe 
ufualiy found herfelf after labor. 
REMARK. 
The happy event of the above-recited cafe, has 
afforded me peculiar fatisfaCtion, as the management 
of it, from the beginning of the complaint, was in 
exaCt conformity to the directions I have given, and 
it appears to be a full proof of the propriety of them; 
for fuppofing it had been treated in the way com- 
monly adopted, the fituation of the Placenta would 
not have been known fo early; and fuppofing that 
circumftance not to have been thought of, as after 
the firft difeharge there was no pain, and the bleed- 
ing was inconsiderable, no one, I am perfuaded, 
would have fcrupled leaving the patient in the fore- 62 
CASESOFTHE 
noon. The furgeon, in fuch cafe, probably would 
not have been fent for again till the evening, when 
the pain and Haemorrhage returned lo fuddenly and 
profulely, and as fome time mult neceffarily have 
been loft before he could have been with her, it is 
not unlikely but at his arrival he might have found 
her in the fame fituation, that, under fimilar cir- 
cumftances, the women mentioned in cafes No. 14 
and 15, were found in, and might, therefore, have 
been unable to fave her. 
It may not be improper, likewife, to obferve, that 
the precife time for turning the child feems very hap- 
pily to have been hit upon; for had we proceeded to 
deliver before the Uterus was fufficiently relaxed, 
there certainly would have been great difficulty in 
effecting it, and the woman might, very probably, 
have fuffered materially from the violence that rauft 
in that cafe have been ufed; and, on the other hand, 
if we had waited for a further dilatation of the 
womb, as that could not have taken place without 
an increafc of the difcharge, (he, very likely, would 
have been unable to fuftain the lofs of blood, more 
efpecially as the extreme weaknefs of her conftitu- 
tion, and the bad health fhe had for fome time paft 
been in, rendered her a very improper fubjetft for 
either extreme. 
CASE XXVII. 
SEPTEMBER 16, 1775, about five o’clock in 
the afternoon, I vifited Olley, a poor woman, 
who was near her full reckoning; fhe had a dif- 
charge of blood from the Uterus, which firft came 
on about a month before, but it had never been 
profufe, as it abated by reft, and an horizontal 
poftnre, and returned only upon any confiderable 
exertion, in walking, (looping, it was this day. UTERINE HAEMORRHAGE. 
63 
however, a good deal alarming, being much in- 
creased in quantity, and unaccompanied with pain. 
I introduced my hand into the Vagina, and from 
a careful examination of the womb, was Satisfied 
that the Placenta was not at the mouth of it: in 
making this enquiry, I was able to break the mem- 
branes, a considerable deal of water efcaped, and 
the Haemorrhage inftantly ceafed; and, though 
fufficient pains did not immediately come on, fhe 
was, about feven hours after, fafely delivered, by 
their foie afliftance, of a large living child. 
CASE XXVIII. 
SEPTEMBER 18, 1775, I was called about mid- 
night to the wife of Baxter, another poor Wo- 
man, under the care of a midwife; I was informed, 
that in the courfe of the preceding three weeks fhe 
had frequently been alarmed with a difcharge of 
blood from the womb, and that for about two hours 
before my arrival, fhe had been flooding molt pro- 
fufely; though fhe was very near her full time, 
there were not any fymptoms of labor, nor had fhe 
yet had the molt trifling pain: fhe was extremely 
faint, her pulfe was hardly perceptible, and fhe ap- 
peared fo much reduced as to be in the mofl immi- 
nent danger. 
I introduced my hand into the Vagina, and found 
it full of coagulated blood, and with my finger 
carefully examined the mouth of the Uterus, which, 
though very little open, was, from the long conti- 
nuance of the Haemorrhage, loofe and dilatable: 
being convinced that the Placenta was not in the 
way, I endeavoured to break the membranes, but 
I could not do it fo foon as in the laft cafe; after 
i’everal repeated attempts, however, I at length fuc- 
cecdfd, and a very large quantity of water poured 64 
CASES OF THE 
forth, by which means the Haemorrhage was imme- 
diately fupprefled. 
I continued a little ftimulus to the Os Uteri, and 
it evidently brought on pain, which gradually in* 
creating, the part became more open, and, in two 
hours from my firft feeing the patient, without there 
being any return of bleeding, not even fo much as 
to occafion the leaft llain in examining, Ihe was 
fafely delivered by the natural pains, and the child, 
notwithftanding the great lofs which had been fuf- 
tained, was born alive and vigorous. The Placenta 
came away without trouble, and no material dif- 
charge accompanied it; the remained very faint for 
fome time after delivery, and was very feeble for 
feveral days; but nothing afterwards occurred to 
prevent her recovering in the ufual time. 
REMARK. 
As the flooding, in this cafe, was fo very profufe, 
as the patient had not the leaft pain, and was likewife 
extremely reduced, it is not unreafonable to fuppofe, 
that I fliould have been induced to have turned the 
child upon my firft feeing her, if I had not before 
experienced fuch extraordinary proofs of nature’s 
ability to expel the child, when the Placenta was 
not in the way to prevent the opening of the womb, 
and when ever fo little pain could be excited by 
ftimulating the Os Tincae: at the fame time it ap- 
pears very likely, that debilitated as fhe was, (he 
would have been unable to fupport any other than 
the gradual and gentle dilatation of the womb, 
which nature effeded, and that therefore, fuch a 
method of treatment would, probably, in this cafe, 
have been unfuccefsful. UTERINE HAEMORRHAGE. 
65 
CASE XXIX. 
DECEMBER 18, 1775, Mrs. F , (whofe 
conftitution had fuffered confiderably, from having 
had exceflive menftrual difcharges for feveral years) 
was, at this time, in the beginning of the ninth 
month of her firft pregnancy. 
Without any preceding illnefs or pain, fhe was 
feized with a very profufe Haemorrhage from the 
Uterus: I was with her foon after its coming on, 
and found the Os Tines very little open, but relax- 
ed fufficiently to admit the finger for examination: 
the Placenta not being fituated on the Os Uteri, I 
purfued the fame methods to fupprefs the floodings 
which have fo often been before related; it foon be- 
came lefs, and in about two hours from the firft at- 
tack of the complaint, labor pains came on, the 
Uterus dilated, and the podex of the child was 
pufhed down, which being fmall, and the parts of 
the woman much relaxed, was with great cafe 
brought forth. The child was living, and the mo- 
ther did well. 
CASE XXX. 
APRIL 26, 1776, A lady at fome diftance from 
Norwich, who has had feveral children, and was 
now in the beginning of the eighth month of preg- 
nancy, had, a few days before this date, a di-charge 
of blood from the Uterus; fhe was attended by a 
gentleman in the neighbourhood, who, upon its in- 
creafing this day, defired I might be fent for.—Ac 
my arrival the Haemorrhage was very inconfiderable, 
and finding the Rate of the Uterus had been exa- 
mined, and that the Placenta was not at the mouth 
of it, we recommended the ufual palliatives to be 66 
CASES OF THE 
ufed if it again returned, and defired die might be 
kept exceedingly ftill. The flooding did not return, 
till two days after, and it was then accompanied 
with pain, which proved fufHcient to expel a fmall 
living child. 
CASE XXXI. 
MAY i, 1776. Mrs. H——, lives about nine 
miles from this city, and was patient to a furgeon 
who lives in the fame place. Being at this time at 
her full reckoning, (he was taken with labor pains, 
which were attended with a difcharge of blood from 
the womb: as it increafed with the increafe of pain, 
he defired I might be fent for, to aflift in the ma- 
nagement of the cafe; but being at that time en- 
gaged with another patient, who would nol permit 
me to leave her, another gentleman was called up- 
on, who went inftead of me. Before his arrival, 
another furgeon who lives in the neighbourhood of 
the patient was alfo fent for, from whom 1 learned 
that an enquiry was made for the Placenta, which 
was found at the Os Uteri, and as the Haemorrhage 
had then been of many hours duration, and much 
blood had been loft, it was determined immediate- 
ly to extraft the child by turning it, which was ac- 
cordingly done, and it proved, happily, the means 
of faving the patient. 
CASE XXXII. 
MAY 21, 1776. Jeary, a poor woman 
belonging to the town, under the care of a mid- 
wife: Ihe was nearly at her full reckoning, and was 
Suddenly feized with a profufe difcharge of blood 
from the Uterus. I faw her about an hour after its 
coining on, and immediately made the neceflary UTERINE HAEMORRHAGE. 
6; 
enquiry whether the Placenta was lituated on the 
Os Tineas or not; it was not there, and the womb 
was open enough to allow of puncturing the mem- 
branes, which inftantly leflened the flooding, and 
loon after gentle pains came on, which expelled a 
dead child, with the cafe peculiar to this relaxed 
Rate of the Uterus. 
CASE XXXIII. 
MAY 26, 1776. Mrs. N—*— was in the begin- 
ning of the ninth month of pregnancy, and had 
been confined to her bed feveral days, before I faw 
her, with a feverifli complaint, and a flight Uterine 
Hasmorrhage, but without any fymptoms of labor. 
A confiderable increafe of the latter, was the 
occafion of my being fent for this morning; I found 
the difeharge in an alarming quantity, and my pa- 
tient much reduced by it: upon examining the 
Uterus, I found the Placenta was not in the way: 
I endeavoured to excite pain, by ftimulating the 
Os Uteri, which fucceeded fo far as to enable me 
to pierce the membranous bag: the flooding imme- 
diately abated, the parts opened, and to the furprize 
of the patient and her attendants, flie was very foon 
and very eafily delivered of a fmall dead child. 
CASE XXXIV. 
JULY 7, 1776. Chaplin; fhe was in the 
lafl month of pregnancy, and an Uterine Haemor- 
rhage, unattended with labor pains, came on the 
day before I faw her: it was this day much increafed, 
and was fo confiderable, that the woman was niuch 
weakened. The Placenta was, upon examination, 
found not to be at the Os Uteri, and irritating the 68 
CASES OF THE 
pans, Sic. as in the laft cafe, brought on pain, and 
haftened the delivery, which was Angularly eafy, 
And the child a living one. 
CASE XXXV. 
AUGys r 27, 1776. Crajke; (he had born 
many children, and had now gone her full time of 
this. For feveral days before the date hereof, fhe 
had flight labor pains, accompanied with an increaf- 
ing difcharge of blood from the womb: juft before 
I was feat for to her, it was very rapid and a large 
quantity was fuddenly loft ; finding her extremely 
faint, I immediately introduced my hand, and with 
a finger in the Uterus, I diftindlly felt the Placenta 
adhering to the mouth of it. My patient had fuffer- 
ed too much by the great lofs fhe had fuftained, to 
admit of delaying to turn the child, and the Os 
Tineas, though not much opened, was fo much re- 
laxed, as to convince me I might with fafety attempt 
it; I therefore immediately did it, and with the fame 
cafe I experienced in all the former fimilar cafes. 
The child was born dead, but the mother, though 
extremely faint and languid, perfedlly recovered. 
CASE XXXVI. 
OCTOBER 5, 1776. Mrs. W , lives about 
two miles from my houfe; fhe was at this time in the 
beginning of the laft month of her fourth pregnancy, 
and was luddenly feized with a flooding, unattended 
with labor pain. I was immediately fcnt for, and 
found her fainting. Upon enquiring with the hand, 
I found the Placenta was not in the way, and the 
difcharge became lefs by admitting cold air into the 
room 5 I waited with her fome time, till it very UTERINE HAEMORRHAGE. 
69 
trifling, and as there feemed no probability of labor 
approaching, I ventured to leave her, notwithftand- 
ing her diftance from me, gave the ufual directions 
to be obfervcd in my abience, and defired I plight 
be fent for immediately upon the return of the 
bleeding, or upon the coming on of pain. I was 
twice fent for on the former account, but the dif- 
charge was as eafily fupprefled as at firft, and I was 
jftill unable to punChire the membranes; but on the 
evening of the third day from the firft attack of the 
complaint, nature was more difpofed to relieve her, 
for fuch pain came on, as with the ftimulus of a 
frequent examination, gradually opened the paflage, 
and a fmall living child was expelled with tolerable 
eafc. After which there was no return of the Hae- 
morrhage, and no accident happened to retard the 
mother's recovery. 
CASE XXXVII. 
NOVEMBER 28, ify6. Mrs. is—has had 
many children, was always very full of complaints 
in the two laft months of pregnancy, and has ufually 
had bad labors. 
' During the laffc three or four weeks before the 
above date, being in the laft month of pregnancy, 
fhe, at times, found a difeharge of blood from the 
Uterus; but it never had been confiderablc enough 
to make her content to a confinement, nor to in- 
duce her to give me leave to examine the ftate of 
the womb. During the day of the 18th of Novem- 
ber, being, as fhe imagined, at her full reckoning, 
(he had flight pains, which fhe confidered as the 
fore-runners of true labor: in the night they became 
jftronger, and though there had been none of her 
ufual difeharge, for more than the laft twenty-four 
hours, it now fuddenly returned, and was in an 7o 
CASESOFTHE 
alarming quantity. I was immediately fent for, 
and, living in the neighbourhood of the patient, 
was very foon writh her; but the pains were now 
gone, the flooding was abating, and foon flopped 
entirely. I introduced my hand, and didinftly felt 
the Placenta 6n the Os Uteri, and from thence con- 
cluded, that it would be neceflary to turn the child; 
but the Uterus was neither open nor relaxed enough 
to admit of xits being immediately doner I waited 
therefore in expectation of the return of the pain 
and difeharge; and continued with her the remain- 
der of the night, and all the next day; but during 
the whole time there was not the lead return of 
cither; fine was very little faint, and got at times 
refreshing fleeps. After this long attendance, and 
the Symptoms of labor being thus entirely gone, I 
ventured to leave my patient, not, however, with- 
out much anxiety, left her labor fhould Suddenly 
come on, and be attended with Such a difeharge, 
as poflibly to demand manual affiflance before I 
could be with her: to obviate which, as much as 
poflible, I defired another Surgeon, who lived near, 
might attend with me, and who therefore might, 
probably, be able to aflifl her, if ariy thing fhould 
happen to prevent my coming to her upon the firft 
alarm. 
She remained in this difagreeble ftate of fufpenfe 
till the 28th, on the evening of which day the fymp- 
toms of labor again came on; I was fortunately 
with her before the Haemorrhage was confiderable, 
but it increafed, as the Uterus opened. I again in- 
troduced my hand, and now could feel one edge of 
the Placenta, as the center of it did not immediately 
lie over the Os internum. The womb being, by 
this time, dilpofed to give way, I eafily palled my 
hand on one fide of the Placenta into the Uterus, 
and as the Podex prefented, I had not the trouble UTERINE HAEMORRHAGE. 
71 
of going to the Fundus, but eafily brought down 
the feet, and extracted a large living child, without 
any accident happening to injure it, or endanger 
the life of the mother. 
REMARK. 
The diftance of time from my firfl finding that 
the Placenta was fituated on the Os Uteri, to the 
time when it was practicable to extract the child, 
having, in this cafe, been fo great, as to have ren- 
dered it next to impoflible for me to have followed 
llriftly a rule, which I have confidered in the Efiay, 
as elfentially necdfary for the woman’s fafety, anti 
which directs that the furgeon (hould, on no account, 
leave his patient under fuch circumftances; it may 
not be improper to point out fome directions, which 
may poflibly aflift us in determining how far we may 
venture to follow the pra&ice of this embarrafling 
cafe, in future ones, which may prove fimilar to it. 
But as the Haemorrhage, in thefe cafes, depends 
entirely upon the coming on and progrefs of labor, 
as the fymptoms which occur at the firft onfet of la- 
bor are frequently fo equivocal, and as there mull 
always be fuch an uncertainty of knowing, upon 
the going off of thefe fymptoms, when they will 
return, 1 fear it will be out of our power to give any 
which will be totally fatisfadfory: for, independent 
of the rule above alluded to, and which I would 
(till (trongly urge, even in fuch a cafe as this, where 
the furgeon’s other engagements will permit him to 
comply with it, I confefs I know of none which can 
be wholly free from hazard. All that occurs to me, 
in any degree, likely to anfwer this purpofe, and 
which is what principally influenced me in the laft 
recited cafe, is, to obferve, as accurately as may be, 
the caufcs which take oft the pains; diftinguifhing. 72 
CASES OF THE 
if we can, between thofe which fpring from nature, 
and which produce an entire cejfation of labor, and 
thofe which arife from accidental circumftances, and 
which may be confidered as occafioning only a luf- 
penfion of it. 
The alarm which a patient fometimes feels when 
the furgeon firft enters her room, the furprize of 
feeing unexpected ftrangers, of fuddenly hearing 
a\|y intelligence in which fhc is much interefled, or 
the occurrence of any circumffance which at all 
agitates the paffions, are well known frequently to 
take off the ftrongeft and moff promifmg pains; 
and in floodings it happens very often, as appears 
from many of the foregoing cafes, that the faint- 
nefs which is brought on by the lofs of blood, pro- 
duces likewife the fame effeCts. When the abfence 
of pain, then, arifes from any of thefe or fimilar 
caufes, it is very reafonable to expeCt when they are 
removed, or when they have loft their influence on 
the patient, that it will immediately return: and as 
few of thefe caufes can be very permanent, it muff 
be very probable that this return will be foon; and 
moreover that it will be without any of thofe fore- 
warning fymptoms which ufually precede the firft 
attack of labor. It is obvious, therefore, that when 
the flooding is checked by fuch a fufpenfwn of labor 
as that now defcribed, that at all jevents it would be 
improper to leave the patient. 
But it frequently happens, and that too before the 
moft natural and eafy labors, that pains very much 
refembling true labor, and which in fome degree 
dilate the Os Tineas, fhall come on, and alarm the 
patient and her attendants with the expectation of 
delivery being near, and yet foon after, and with- 
out any apparent caufe, fhall entirely go off, leave 
the patient as well as ufual, and not return till the 
time of delivery: which in fome cafes may be many UTERINE HAEMORRHAGE. 
73 
days, or even weeks after the firft alarm. If this 
fhould happen when the Placenta is fituated on the 
Os Uteri, the effe&s of it with regard to Haemor- 
rhage, would probably be thefe: that at the firft com- 
ing on of thefe fpurious pains there would be fome 
difeharge; that upon the pains going off, the flood- 
ing would ceafe; that if the woman were carefully 
kept ftill, it would not return till the time of real 
labor, which, as obferved before, might be very 
remote, and that then, as the parts would be in the 
fame ftate as if there had been none of thefe falfe 
pains, that it would be preceded by fuch fymptoms 
as would give fufficient time to have the furgeon 
ready to allift the patient, before any confiderable 
lofs had taken place. This feems to have been 
exactly the Rate of the cafe above related, and the 
good fuccefs which attended it argues, at leaft, a 
probability, that after fuch an entire ce(fation of la- 
bor has taken place as that now deferibed, no harm 
would arife from leaving the woman. 
After all, however, I would be underftood to de- 
duce no more from this view of the circumftances 
which may attend this peculiar cafe of flooding, 
than that, on the one hand, if there be only a fuf- 
penfion of labor, that it would be abfolutely wrong 
to leave the patient; and on the other hand, if we 
have waited long enough to be convinced that the 
labor is entirely gone off, that though it would Rill 
be moft fecure to flay with the patient, yet there 
is fome reafon to believe we may then leave her 
without hazard; which if we venture to do, I can- 
not help repeating the neceflity there is of being 
pretty fure the abfencc of pain is not produced by 
any of the accidental circumftances before enume- 
rated, and more efpecially that of faintnefs. /4 
CASES OF THE 
CASE XXXVIII. 
MARCH 24, 1777. Barking; fhe was at 
die latter end of the eighth month of her firft preg- 
nancy. About two o’clock in the morning fhe was 
awakened by a difcharge of blood from the Uterus, 
unaccompanied with pain, or any of the fymptoms 
of labor; it was at firft very considerable, but it was 
fo much abated in half an hour, that fhe thought 
it, then, unneceflary to fend for any afliftance: in 
a few hours, however, it returned with an increafe 
of violence, and I was fent for about fix o’clock. 
I found the difcharge (till continued, and the woman 
was very faint, I therefore immediately examined, 
and was fully convinced the Placenta was not at the 
Os Uteri; during the examining, there came on 
fome pain, and the membranes foon broke, the 
Uterus opened, and a final! dead child was expelled 
in about half an hour after my arrival, and without 
much pain to the mother, who fuffered no other 
inconvenience from the Haemorrhage, than a tem- 
porary weaknefs. 
CASE XXXIX. 
APRIL 10, 1777. I was this day fent for to 
Mrs. G ,at a village about eight miles from 
Norwich: being engaged at the time, a gentleman 
who is converfant with the mode of pra&ice recom- 
mended in the preceding Eflay, went inftead of me. 
He found her under the care of an intelligent and 
experienced furgeon in the neighbourhood, and was 
informed by him, that his patient was near the full 
time of her fecond pregnancy, and that fhe had 
been feized in the forenoon with flight pains accom- 
panied with a difcharge, which though it had not UTERINE HAEMORRHAGE. 
75 
yet been very confiderable, was increafmg. It was 
refolved to make the neceffary enquiry for the Pla- 
centa, and manage the cafe agreeable to the refult 
of it; this was immediately done with the hand in 
the Vagina, and the Placenta was diftinftly felt to 
be at the Os Uteri: but the Haemorrhage was now 
much lefs, the Uterus very little open, and there 
was a peculiar rigidity of the Os Tincae, which ap- 
peared very unfavorable to that artificial dilatation 
of it, which the cafe required; more efpecially, as 
it was obferved by the furgeon who attended firft, 
that her former labor had been very long and labo- 
rious, from this part having been Angularly hard and 
unyielding: it was, therefore, judged proper to de- 
fer the introduction of the hand for delivery, till 
an increafe of pain, or difcharge, had rendered the 
Uterus more dilatable. They both, accordingly, 
waited a confiderable time with her; but, by de- 
grees, the pains went off, and the difcharge flopped. 
It being now very uncertain when the true labor 
pains would come on, one of the gentlemen went 
away, and the other ftaid with her during the night, 
and as much afterwards as his other engagements 
would admit of. She remained free from pain or 
flooding till the 12th, and then the return was for- 
tunately not, at firll, fo quick, but there was time 
to fend for both the furgeons before the lofs of blood 
had been great; however, true labor feemed now 
to come on, and the Haemorrhage foon became 
confiderable, but the Os Uteri being much more 
dilatable than in the firfl examination, it was deter- 
mined to proceed to immediate delivery; the hand 
was, therefore, paffed into the Vagina, the fubflance 
of the Placenta was pierced through by the fingers, 
and the hand being admitted through the opening 
into the Uterus, the child was extrafted with eafe 
and fafety; the difcharge was very little increafed 7 6 
CASES OF THE 
during the operation, it was fuppreffed when the 
Uterus was compleatly emptied, and the woman 
had a happy recovery. 
REMARK. 
The circumflances attending this cafe being fimi- 
iar to thofc of No. 37, the remarks which arofe 
from that are exadlly applicable to it; and this fe- 
cond inftance of a patient’s being left in this fitua- 
tion, without receiving any injury, undoubtedly 
ftrengthens the reafoning which is there made ufe 
of.: but I fhould be forry if the fuccefs which attend- 
ed thefe two particular deviations from the general 
mode of practice which I have before recommend- 
ed, were ever an encouragement to run the rifque 
of leaving a patient in circumflances other than 
fuch as exaftly referable thefe, and even then, if 
the furgeon’s other engagements are not abfolutely 
incompatible with a long attendance. 
CASE XL. 
APRIL 15, 1777. Fouljham. I was called to 
this woman’s affiflance in the forenoon of this day; 
Ihe was near her full time, and under the care of a 
midwife. For feveral hours before I faw her, there 
had been an exceflive difcharge from the Uterus, 
none of the women, in any of the preceding cafes, 
having loft more blood, fo that fhe was extremely 
faint: but nature, by this time, 'made efforts to 
relieve her, for the Os Uteri opened, and the Pla- 
centa not being in the way, a fmail dead child was 
expelled with remarkable eafe, and very little affift- 
ance; after which the flooding flopped, and the 
woman did well. UTERINE HEMORRHAGE. 
77 
CASE XLI. 
JUNE 27, 1777* Mrs. C was in the middle 
of the eighth month of her firft; pregnancy: the 
day before this ihe received a fright, which was 
followed by a confiderable Uterine Haemorrhage, 
I was fent for, and immediately made the necdfary 
examination; the Placenta was not at the Os Uteri, 
and the difcharge was foon checked by the palliative 
means: Ihe remained free from the complaint till 
the following afternoon, when it again came on, 
but nature was then more difpofed to relieve her, 
for true labor pains came on, which opened the 
Uterus, and expelled the child and Placenta fo 
haftily, that though the former came footling, fhe 
was nearly delivered before any afliftance could be 
given her. 
CASE XLII. 
OCTOBER io, 1777. Wilkins, This woman 
had twins, and was attended by a midwife. After 
the delivery of the firft child, there came on an 
cxceflive flooding; I was immediately fent for, but 
not being at home, the fame gentleman, to whom 
I have fo often before been obliged for his afliftange, 
attended for me. It was evident the attachment of 
the Placenta to the Os Uteri could not, in this cafe, 
be the caufe of the Haemorrhage: it was, never- 
thelefs, in fo alarming a quantity, that he had, at 
firft, apprehenfions leaft it fliould be neceflary to 
turn the child; but by pun&uring the membranes, 
and gently ftimulating the Os internum, fome pains 
were foon excited, which immediately fupprefled 
the difeharge, and a living child was fpeedily and 
fafely expelled, the mother fullering no other in- 
convenience afterwards, but great weaknefs. 7» 
CASES OF THE 
CASE XLIIL 
OCTOBER 26, 1777. Stannard. This woman 
is the fame perfon whofe cafe fs related the fecond 
in this collection. She was at this time about thirty 
weeks gone with child, and for more than a month 
before had been troubled with an Uterine Haemor- 
rhage, which at firfl was occafioned, as the imagin- 
ed, by a fall. 
For feveral days before the above date it had in- 
creafed confiderably, and at the time when 1 faw 
her, it was immoderate; I immediately examined 
her, and with difficulty introduced a finger into the 
Os Uteri, againft which I found the Placenta; the 
had flight pains at intervals, which always produced 
a frefli flow. I was particularly perplexed from an 
apprehenfion, that it would be impracticable, from 
the fmall fize of the Uterus, to get the hand fuffi- 
ciently admitted into it, to effect the turning and 
extracting the child, which however appeared in- 
difpenfably neceflary for the woman’s fafety. I 
made feveral efforts to get two or three Rogers in- 
troduced, but without fuccefs; I therefore waited, 
but was more than ufually anxious for the event. 
The pains and difcharge flill continued, and my 
patient became mdre and more faint; I gave her 
gruel, &c. as often as fhe could take it, of which 
though flie drank in fmall quantities, fhe took a 
good deal in the whole: at length, about;an hour 
and a half after my arrival, while fhe was drinking 
fomething of this kind, there fuddenly came on a 
frtfh gufh, which inftantly made her Tick and vomit, 
which was followed by the moft alarming Syncope 
I ever faw, for the byftanders fuppofed her to be 
dead. It occurred to me, that it would be right 
to catch this moment of total relaxation, and at- UTERINE HAEMORRHAGE. 
79 
tempt the admiflion of the hand; I found the mouth 
of the Uterus quite loofe, and it dilated eafily as 
far as its fize would admit, fufficiently, however, to 
allow the hand to pafs far enough into it to find a 
foot, which I was fortunate enough to bring down 
into the Vagina immediately, by means of which, 
without a further introduction of the hand, I ex- 
tracted a fmall dead child: the Placenta came away 
in a few minutes afterwards, and the difcharge foon 
flopped; my patient was, therefore, fnatched from 
the moft imminent danger, and 1 was relieved from 
an anxiety greater chan any I have, for feveral years, 
experienced upon a fimilar occafion. 
REMARK. 
Though the attachment of the Placenta to the 
Qs Uteri, in this cafe, would at the expiration of 
the term of pregnancy have unavoidably produced 
a flooding, and though, as in all others of a fimilar 
fituation, it now prevented nature from relieving 
the patient, yet the caufe which made the Haemor- 
rhage come on at fo early a period, was certainly 
the accidental one of the fall. Thefe two caufes 
thus concurring in one cafe, prove the neccflity 
there always is for the unequivocal information 
which is alone to be derived from a manual exami- 
nation into the (late of the Uterus: For fuppofing, 
in fuch a cafe as this, it had been prefumed from 
the circumftance of the fall, and the time of the 
flooding firfl coming on, that the caufe of it had 
been merely accidental, and the patient on that ac- 
count had been left to the care of a midwife, (which 
had the Placenta not been in the way, it would have 
been juftifiable to have done,) it is very probable 
the happy opportunity of aflifting the woman would 
have been loft, and the cafe have terminated unfor- 
tunately. So 
CASES OF THE 
CASE XLIV. 
OCTOBER 20, 1777. —— James. I found 
this woman, being a pauper, under the care of a 
midwife, who informed me, that fhe was at the full 
time of her fixth child, and that after having had 
flight pains for fome hours, there came on a very 
confidcrable difcharge from the Uterus; it had been 
about an hour, when I faw her, but the membranes 
were broken, a good deal of water had efcaped, 
and the flooding was much abated; I introduced 
my hand into the Vagina, and found it full of coa- 
gulated blood; the mouth of the womb was much 
dilated, and very loofe, the Placenta was not in the 
way, and a hand of the child prefented: the dif- 
charge was now very trifling, but the preternatural 
pofition of the child requiring artificial delivery, I 
introduced my hand immediately into the Uterus, 
and very foon took hold of a foot, which I brought 
down with great cafe, and foon after, and without 
any difficulty, as the Pelvis was Angularly well form- 
ed, and the parts fo much relaxed by the difcharge, 
I extracted a large living child; the Placenta came 
away without any trouble, there was no return of 
the Haemorrhage, and my patient did well. 
REMARK. 
It is obvious, that in this cafe, the turning was 
had recourfe to on account of the bad prefentation 
of the child, and not on account of the flooding, 
which was owing to an accidcndal reparation of the 
Placenta; and that It cannot, therefore, be faid to 
contradift the general maxim, which I have adopted 
refpefling floodings which arife from an accidental 
caufe, namely, that nature is of herfelf able in inch UTERINE HAEMORRHAGE, 
81 
cafes to expel the child. The quick dilatation of 
the Uterus, and part of the child having been pufh- 
pd down, were in this cafe, fufficient proofs, that 
If that part had been the one ufually prefenting, 
nature would, as in the many others before related, 
with her own efforts, have been able to expel the 
child foon enough for the woman’s fafety. CONCLUSION. 
OF the foregoing cafes of flooding, fourteen 
were produced by a reparation of the Placen- 
ta, occafioned by its being fituated on the Os Uteri, 
and which was, therefore, in every one of them, 
unavoidable; and thirty were owing to a reparation 
of it, arifing from fome accidental caufe. 
Of the latter number it appears, that though 
•many were very alarming cafes, as the patients loft 
large quantities of blood, and were extremely faint, 
not one proved fatal, not one but terminated fafely, 
by waiting for the efforts of nature to expel the 
contents of the womb;* whilft, in all the former 
number, that no means whatever which nature could 
ufe, were able to fupprefs the difeharge, and that 
notwithftanding the complaint began in moft of them 
in a manner but little alarming, yet nothing but the 
removal of the Foetus by art could fave the patients 
lives: in nine out of the number, its being timely 
done, it had manifeftly that happy effeft; and in 
the others, where the turning was unfuccefsfully 
ufed, it feemed to be clearly owing to its having 
* In two or three of the cafes included in the latter num- 
ber, as well as in that of No. 44, which has already been re- 
marked, it happened, indeed, that the children'oame into the 
world footling, and confequentiy, that more manual afllflance 
was ufed than in natural prefentations; but as this circumftance 
was totally accidental, and independent of the flooding, as 
even in them, too, the dilatation of the womb was effefted 
folely by nature; and as it is likewife very probable, that, if 
no affiflance had been given (the children being fmall) that na- 
ture would at length have expelled them, I have confidered 
the fafe termination of the labors as effected by nature. CONCLUSION. 
83 
been too long delayed; for, in the cafes of King 
and Bond, where it was moll evidently fo, the 
flooding began by no means in a threatening man- 
ner, nor did either of thofe women appear at firft 
in lb much danger as moll of the thirty other pa- 
tients did, in whom the Haemorrhage was produced 
by the accidental feparation of the Placenta. 
From the ample tellimony of thefe cafes, it is 
evident, then, how very frequently the Placenta is 
fixed to the Os Uteri; and that notwithllanding fo 
little notice has been taken of it, by thofe who have 
written on the fubjeCl of Uterine Haemorrhages, 
how necelfary it is, in every cafe, to make an en- 
quiry for it: but the inferences, which arife from 
them, are fo obvious, and the method of pradicc 
which they point out, has been before fo fully con- 
fidered, that it need not now be repeated; efpecially 
as the happy events of all the cafes which were treat- 
ed agreeable to the method recommended in the 
Eflay, of themfelves, fo fully fpeak its fuperiority 
over that which governed the management of the 
firll related cafes. 
Before I entirely quit the fubjed, it may not, 
perhaps, be totally foreign to it, to confider what 
would probably have been my method of treating 
the cafes which fucceeded thofe of King and Bond, 
if I had not then eltabliflied fome criterion, by which 
I could judge determinately of the propriety of trail- 
ing to nature, or of applying to art. 
It is very natural to believe, that when my mind 
had been a good deal affeded by the difagreeable 
events of thofe two cafes, that I ihould not have 
hefitated to have had immediate recourfe to delivery 
by art, in every following cafe in which I found the 
difeharge at all confiderable; from a conclufion, 
(which under fuch circumltances, woilld not have 
been an unreafonable one,j that as there feejned to 84 
CONCLtJSIO N. 
be fome latent undifcoverable canfe, which fome- 
times unexpectedly produced the mofl fatal mifchief, 
when at the beginning of the complaint there was 
no appearance of danger, it w'as juftifiable to run 
the rifquc of: unneceflarily turning the child, in 
fome cafes, rather than be liable to omit doing it, 
in a Tingle inflance, where it might be abfolutely 
neceffary for the woman’s fafety: and, indeed, could 
it be admitted that the indifcriminate ufe of this 
operation was attended with rto danger, this would 
certainly be the only fecure method of treating 
floodings, were it not in our power to difeover thofe 
particular cafes in which the Placenta was fituated 
on the mouth of the womb. 
For thefe reafons, therefore, I doubt not but this 
would have been the method of practice which I 
ihould have adopted; and it is upoh the fame prin- 
ciples, I am perfuaded, that the invariable ufe of 
turning has been recommended by fome authors, 
and put in practice by fome furgeons. 
The objections to fuch a method of treatment, are, 
however, felf-evident, as it mud be particularly in- 
convenient and irkfome to the furgeon, always pain- 
ful, and fometlmes dangerous to the patient. 
This confuleration, then, {till further illuftrates 
the advantage of knowing the true caufes from 
whence thefe Hemorrhages proceed; and if, there- 
fore, by what has been faid, 1 have in the leaft de- 
gree added to the knowledge of them, and fliall be, 
on that account, but in a Tingle inflance, the means 
of faving the life of a fellow-creature, the little trou- 
ble I have had in throwing my thoughts together 
upon the fubjeCt, will not be lofl labor, nor thefe 
pages, few as they are, be written in vain. 
THE EN D.