NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice II \ s /^mn-x^CC. fS. \A/o-r:V?s, ^ «THE PRINCIPLES OF MIDWIFERY; INCLUDING THE DISEASES OF WOMEN AND CHILDREN. ——^m ----- BY JOHN BURNS, LECTURER ON MIDWIFERY, AND MEMBER OF THE FACULTY OF PHYSICfANS. AND SURGEONS, GLASGOW. THE THIRD AMERICAN, FROM THE SECOND LONDON EDITION, MUCH ENLARGED. WITH IMPROVEMENTS AND NOTES, BY THOMAS C. JAMES, M. D. PB.QEESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA. VOL. I. ■ -.,.. '. , . " ■!.... i PHILADELPHIA: PUBLISHED BY JOHNSON AND WARNER, BENJAMIN AND THOMAS KITE, EDWARD PARKER, KIMBER AND CONRAD, MATHEW CAREY, MOSES .THOMAS, ANTHONY BINLEY, AND REDWOOD FISHEIU Joseph Rakestvaw, Printer. 1813. DISTRICT OF PENNSYLVANIA, TO WIT: Be it remembered, That on the seventh day of September, in the thirty-oigtfUi Year of the Independence of the United States of America, A. D. 1813, Benjamin and Thomas Kite, Johnson and Warner, Edward Parker, Kimber and Conrad, Mathew Carey, Moses Thoma», Anthony Finley, and Redwood Fisher, of the said District, have deposited in this office the Title of a Book, the right whereof they claim as Propritors, in the words following, to wit: " The Principles of Midwifery ; including the diseases of If omen and Children. By "John Burns, Lecturer on Midwifery, and Member of't/ic faculty of Physicians anil * Surgeons, Glasgow. The third American, from the second London Edition, much " enlarged. With Improvements and Notes, by Thomas C. James, M. D. Professor " of Midwifery in tlie University of Pennsylvania.'''' In Conformity to the Act of the Congress of the United States, intituled," An Aof for the Encouragement of Learning, by securing the Copies of Maps, Charts and Books, to the Authors and Proprietors of such Copies during the Times therein men- tioned."—And also to the Act, entitled, * An Act supplementary to an Act, entitled fc An .Vet for the Encouragement of Learning, by securing the Copies of Maps, Charts and Books, to the Authors and Proprietors of such Copies during the Times therein mentioned," and extending the Benefits thereof to the Arts of designing, engraving, and etcking historical and other Prints." D. CALDWELL, Clerk of the District of Pennsylvania.- N V c^ PREFACE OF THE AUTHOR. «^r- IN preparing this work, I have endeavoured to pro- ceed as much as possible upon the method of induction. I have collected with care the different cases which have been made public, as well as my own private ob- servations. To these I have added the opinions and advices given by others, in so far as they seemed to be founded on facts, and supported by experience. From the whole I have deduced, in the different parts of my subject, both the symptoms and the practice. The anatomical descriptions, I have given from dis- sections and preparations before me whilst writing. I intended to have added to the text copious referen- ces to the opinions and cases contained in systems, or scattered through other publications. This would have rendered the present book, in some manner, an index to those already published, and been of considerable service to practitioners, who wished to consult them upon any particular point. But in spite of all my en- deavours, this work has extended to a length, which rendered it necessary to strike out many references, and shorten the account of cases, to prevent it from swelling to a size which would have rendered it less generally useful. Whilst I thus state the plan on which I have pro- ceeded, I acknowledge myself deeply sensible, that its execution does not bear any proportion to the importance of the subject. Should this work fall only into the hands of those, competent to judge on their profession, it IV would, if faulty or deficient, do little harm: But should it ever be circulated more extensively, it must, like other systems and elements, have an influence on the opinions and future practice of the student of midwife- ry: and will prove useful or injurious to society, ac- cording to the correctness of the principles it contains. When I consider how important the diseases of women and children are, and how much depends on the pru- dent management of parturition, I feel the high re- sponsibility which falls on those who presume to give lessons in midwifery; I do, however, sincerely trust, that the precepts I have inculcated will, in general, be found agreeable to the experience and practice of our best teachers ; and, on a review of the whole, I cannot say that I have either wasted the reader's time in idle theory, or misled his opinion by mere speculation. In preparing a second edition for the press, I have carefully revised the whole work, and have made many additions, which I hope will prove useful. Notwithstanding considerable attention, some typo- graphical errors exist in the work, but I hope the con- text will render them sufficiently evident. In the addi- tions, in one or two places, the punctuation is incor- rect ; but the reader can easily discern the mistakes, and therefore I do not put them into a list of errata. Glasgow. ") July, 1811. j PREFACE OF THE EDITOR. IT is not the intention of the present editor to incur the fault so sharply reprehended by Johnson, and " re- tard the instruction" contained in the ensuing volume, by an unnecessary and prolix preface. He will only briefly mention, that our author, " equally experienc- ed as a teacher and practitioner," has, from the acknow- ledgement of the most competent judges,* "by a judi- cious arrangement, by a faithful exposition of facts and observations, and by a methodical induction of the prin- ciples and practice of the art, accomplished in this work all that could be expected, in the present state of the science, to give a new interest to the subject. " The prominent advantage, that confers upon it a decided preference to all others, as a System or Class- book, is, that every subject, directly or indirectly con- nected with the practice of the accoucheur, is here brought into one connected view. " But what we are most disposed to recommend in this volume, is the pathological department, and the descriptions and treatment of the diseases of puerperal women, and of children. A more copious, scientific, and judicious account of these diseases, is perhaps no where to be met with." Thus far the editors of the Edinburgh Medical and Surgical Journal. • Edin. Med. and Surg. Journal, for 1810. VI One great advantage of this work to the student soli- citous of full and accurate information on the subjects of which it treats, is to be experienced in the very valu- able notes and references of the author, to almost all that has been communicated by practitioners of deserv- ed celebrity, on parallel subjects or cases. In this point of view, it may be considered as the Common- place Book of an immense fund of the most useful practical knowledge, indispensable as a guide to the in- experience of the student, and earlier practitioner, and of no ordinary utility and aid, to the maturer acquire- ments of advanced and established professional skill. This edition has been considerably enlarged and im- proved by the author. The sections on abortion and uterine hemorrhage, will be found to have been very considerably extended, and rendered of far greater value;—indeed, they may now be considered, as con- taining the essence of his separate Treatises on those very interesting subjects, which have for some time enjoyed the approbation of the public. The new articles, totally omitted in the former edi- tion, but by the author introduced into this, are those on pneumonia, on ephemeral fever, on weed or in- testinal fever, and on diarrhoea, as existing in the pu- erperal state, and on chorea, on bronchitis, and on peritonitis, as the diseases of the infantile age. These it is presumed, will not fail to give additional interest to the work. The editor has taken the liberty of introducing into the text, a section on the difference between the male and female pelvis; which as he conceived, the author ought not to have omitted; and Dr. Clarke's account of the cauliflower excrescence of the os uteri. Whether this is only a variety of the spongoid tumour, he will Ml leave to the reader to decide. It appears to assume some difference in its form and train of symptoms. Th» history is from the pen of an accurate observer of na- ture, and a judicious and experienced practitioner. As Baudelocque has explained the mechanism of parturition, more fully and minutely than almost any other writer, and as his work on midwifery has obtain- ed considerable reputation with the medical public of the United States, it has been judged proper, occasion- ally, to give a general view of his divisions of labour, together with the several species of presentations, which it may be useful to keep in recollection in actual practice. Some tables, relative to this part of our sub- ject, from the last edition of his valuable work, that have not, as far as we know, been hitherto translated, will also be given in the appendix. These, it is hoped, will not be entirely devoid of interest, either to the stu- dent or practitioner. The chief mass of the notes in Dr. Chapman's edi- tion of our author's production, have been, by permis- sion retained in this; these are marked with the Tetter C. The notes added by the present editor have alpha- betical references, and are thus sufficiently distinguish- ed from those of the author, and of the intelligent editor of whose information we have availed ourselves, and to whom we have just alluded. These will be found to be altogether of a practical nature, and are intended solely to explaip, or illustrate the text; as it has been found rarely necessary to differ in sentiment from one,'whose opinions seem generally to be founded on the solid basis of practical truth. Any additions made to the text, or Author's notes, are included between brackets. To those who may feel disappointment at the absence of flowing periods and polished diction in the deduc- viii tions of physical knowledge, we must offer, although trite, the apologetical line so often prefixed to the pages of didactic treatises: " Ornari res ipsa negat, contenta doceri." Philadelphia, September, 1813. CONTENTS. BOOK I. Of the Structure, Functions, and Diseases of the Pelvis and uterine System, in the unimpreguated state, and during gestation. CHAPTER I. Of the bones of the Pelvis*. Section 1. General view - Page 1 Section 2. Ossa innominata f£ Section 3. Sacrum aaid coccyx 5 CHAPTER II. 6f the Articulation of the Bones of the Pelvis, and their occa- sional separation. Section 1. Of the symphysis pubis - 7 Section 2. Sacro-iliac junction - 8 Section 3. Vertebral junction, and obliquity of the pelvis - -9 Section 4. Separation of the bones - - 9 Section 5. [Difference of the female from the male Pelvis].....ti CHAPTER III. Of the soft parts which line the Pelvis. Section 1. Muscles - - . ±$ Section 2. Arteries - - - - 16 Section 3. Nerves - - - -17 Section 4. Lymphatics - -• - 19 X CHAPTER IV. Of the Dimensions of the Pelvis. Section 1. Brim and outlet - PaSe 19 Section 2. Cavity - - 20 Section 3. Pelvis above the brim - - 22 Section i. Axis of the brim and outlet - 23 CHAPTER V. the head of the Child, and its progress through the Pelvis in Labour. Section 1. Bones of the head - - 23 Section 2. Size of the head - -24 Section 3. Passage of the head - - 25 CHAPTER VI. Of Diminished Capacity and deformity of the Pelvis. Section 1. Deformity from rickets - - 28 Section 2. Deformity from malacosteon - 29 Section 3. Deformity from exostosis and tumors 31 Section 4. Means of ascertaining the dimensions and size of the head when broken down ♦ 32 CHAPTER VH. Of Augmented Capacity of the Pelvis 33 CHAPTER VIII. Of the external Organs of Generation. Section 1. General view - - 34 Section 2. Labia and nymphse - 34 Section 3. Clitoris - - - - 35 Section 4. Urethra - - - 35 Section 5. Orifice of vagina and hymen - 37 CHAPTER IX. Of the Internal Organs of Generation* Section 1. Vagina - - - 38 Section 2. Uterus and its appendages - 40 XI CHAPTER X. Of the Diseases ofjhe Organs of Generation. Section 1. Abscess in the labium - Page t3 Section 2. Ulceration of the labia - - 44 Section 3. Excrescences on the labia - 47 Section 4. Scirrhous tumors - -18 Section 5. Polypous tumors - - 48 Section 6. (Edema - - - - 49 Section 7. Hernia, laceration, &c. - 49 Section 8. Diseases of the nymphse - - 50 Section 9. Diseases of the clitoris - - 51 Section 10. Diseases of the hymen - - 52 Section 11. Laceration of the perinaeum - 53 Section 12. Imperfection of the vagina - 54 Section 13. Inflammation and gangrene of the vagina - - 55 Section 14. Induration, ulceration, and polypi - 56 Section 15. Inversion - - ;■ 56 Section 16. Watery tumor 57 Section 17. Hernia - „ - 57 Section 18. Encysted! tumor and varices - 58 Section 19. Erysipelatous inflammation - 58 Section 20. Fluor alb us - - - 59 Section 21. Affections of the bladder - 63 Section 22. Excrescences in the urethra - 67 Section 23. Deficiency and mal-formation of uterus 68 Section 24. Hysteritis - - - 69 Section 25. Ulceration of the uterutf 70 Section 26. Scirro-caneer - 72 Section 27. Tubercles «? - - 75 Section 28. Spongoid tumpr - - - 76 Section 29. [Cauliflower excrescence from the os uteri] 78 Section 30. Calculi - - 80 Section 31. Polypi • - . - - 80 Section 32. Malignant polypi - - 85 Section 33. Moles 86 Section 34. Hydatids - - 87 Xll Section 5b. Aqueous secretion Page 89 Section 36. Worms - 90 Section 37. Tympanites '- 90 Section 38. Prolapsus uteri 90 Section 39. Hernia - 96 Section 40. Dropsy of the ovarium 97 Section 41. Other diseases of the ovarium 102 Section 42. Deficiency 103 Section 43. Diseases of the tubes and ligaments - 103 CHAPTER XI. Of Menstruation - - 103 CHAPTER XII. Of Diseased States of tlie Menstrual Action. Section 1. Amenorrhea - - 108 Section 2. Formation of an organized substance 115 Section 3. Dysmenorrhea - - 116 Section 4, Menorrhagia - - 117 CHAPTER XIII. Of the Cessation of the Menses - 12% CHAPTER XIV. Of Conception, and the term of Gestation - 122 CHAPTER XV. Of the Gravid Uterus. Section 1. Size and position - - 126 Section 2, Developement of the uterus, and state of its cervix - - ,. _ 127 Section 3, Muscular fibres - 129 Section 4. Ligaments - - - 129 Section 5. Vessels - - - - 130 Xlll Section 6/Of the foetus - - Page 131 Section 7. Its peculiarities - - 136 Section 8. Umbilical cord - - - 140 Section 9. Placenta - I*3 Section 10. Membranes and liquor amnii - 145 Section 11. Decidua - - - 146 CHAPTER XVI. Of Sterility - - 149 CHAPTER XVII. Of Extra-uterine Pregnancy. Section 1. Symptoms, progress, and species 150 Section 2. Treatment - - - 153 CHAPTER XVIII. Of the signs of Pregnancy - 155 CHAPTER XIX. Of the Diseases of Pregnant Women. Section 1. General effects - - 158 Section 2. Febrile state - 160 Section 3. Vomiting - - - 162 Section 4. Heartburn - - 164 Section 5. Fastidious taste - - 164 Section 6. Spasm of stomach and duodenum - 165 Section 7. Costiveness ... 165 Section 8. Diarrhoea - 167 Section 9. Piles - - 168 Section 10. Affections of the bladder - 169 Section 11. Jaundice - - 170 Section 12. Coloured spots - - 171 Section 13. Palpitation - - - 171 Section 14. Syncope - 172 Section 15. Dyspnoea and cough » - 173 Section 16. Hsemoptysis and haematemesis - 173 Section i7. Headach and convulsions - 174 Section 18. Toothach - - - 175 XIV Section 19. Salivation - - * ra& Section 20. Mastodyma - 176 Section 21. (Edema - 177 Section 22. Ascites - Section 23. Redundance of liquor amnii Section 24. Watery discharge 182 Section 25. Varicose veins - A 119 Section 26. Muscular pain - Section 27. Spasm of ureter - - - 183 Section 28. Cramp - - " 184 Section 29. Distention of the abdomen - 184 Section 30. Hernia - - 184 Section 31. Despondency - - " 185 Section 32. Retroversion of uterus - - 186 Section 33. Antiversion - - - 192 Section 34. Rupture of uterus - ^ " 192 Section 35. Abortion, and treatment of pregnant women ----- *»*» Section 36. Uterine hemorrhage - - 233 Section 37. False pains - - - - 276 BOOK II. Of Parturition. CHAPTER I. Of the Classification of Labours 280 CHAPTER II. Of Natural Labour. Section 1. Stages of labour - - - 285 Section 2. Duration of the process - - 289 Section 3. Of examination - - 291 Section 4. Causes of labour ... 300 Section 5. Management of labour - •» 302 XV CHAPTER III. Of Premature Labour - Page 313 CHAPTER IV. Of Preternatural Labour. Order 1. Presentation of the breech - - 317 gOrder 2. Of the inferior extremities - - 321 Order 3. Of the superior extremities - - 323 Order 4. Of the trunk - - - - 331 Order 5. Of the face, &c. - - 331 Order 6. Of the umbilical cord - - 335 'Order 7. Plurality of children, and monsters - 337 [Table of Cases requiring Turning, &c] - 34^ No^s - - - - i 343 THE PRINCIPLES or MIDWIFERY. BOOK I. OF THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE PEL- VIS AND UTERINE SYSTEM, IN THE UNIMPREGNATED STATE, AND DURING GESTATION. CHAP. I. Of the Bones of the Pelvis. $1. GENERAL VIEW. 1 HE practical precepts, and rules in Midwifery, are easily understood, and readily acquired. They arise evident- ly from the structure and actions of the parts concerned in parturition; and whoever is well acquainted with this struc- ture and these actions, may, from such knowledge, deduce all the valuable and important directions which constitute the Practice of Midwifery. One of the first, and not the least important, of those parts eoncerned in parturition, is the pelvis, which must be exam- ined, not only on account of its connection with the uterus and vagina, but also of its own immediate relation to the delivery of the child, and the obstacles which, in many in- stances, it opposes to its passage. A The pelvis consists, in the full grown female, of three large bones, two of which arc very irregular, having no near resemblance to any other object; on which account they have been called the ossa innominata. These form the sides and front of the bason or pelvis. The back part consists of a tri- angular bone, called the os sacrum', to the inferior extremity or apex of which, is attached, by a moveable articulation, a small bone, which, from its supposed resemblance to the beak of a cuckoo, has been named the os coccygis. The os innoininatum, at first, consists of three separate pieces: the upper portion is called the ilium, or haunch bone; the under portion the ischium, or seat bone; and the ante- rior division, which is the smallest of the three, is called the os pubis, or share bone. These all join together in the ace- tabulum, or socket, formed for receiving the os femoris, and are connected by a very firm gristle or cartilage. This, be- fore the age of puberty, is converted into bone, so that the three different pieces are consolidated into one, though the names given to the bones originally are still applied to the different parts of the united os innominatum. The sacrum also, which seems to consist only of one curv- ed triangular bone, is really made up of several pieces, which, in the child, are nearly as distinct as the vertebra, to which, indeed, they bear such a resemblance, that they have been considered as a continuation of them; but from their imperfect structure, and subsequent union, they have been called the false vertebra. The bones of the pelvis are firmly joined together, by means of ligaments and intermediate cartilages, and form a very irregular canal, the different parts of which must be briefly mentioned. §2. OSS A INNOMINATA. When we look at the pelvis, we observe, that the ossa in- nominata naturally divide themselves into two parts, the uppermost of which is thin and expanded, irregularly con- vex on its dorsum or outer surface, hollow on the inside which is called the costa, and bounded by a broad margin* 3 extending in a semicircular direction from before backwards, which is called the crest of the ilium. The under part of the os innominatum is very irregular, and forms, with the sa- crum, the cavity of the pelvis. The upper expanded part has little influence on labour, and serves, principally, for affording attachment to muscles. In the under part, we have several points to attend to. 1st. The upper and under parts form an angle with each other, marked by a smooth line, which is a continuation of the margin of the pubis, or anterior part of the bone. It ex- tends from the symphysis pubis, all the way to the junction of the os innominatum with the sacrum, and is called the linca iliopectinea. It is quite smooth and obtuse at the sides, where the two portions form an angle; but at the anterior part, where the upper portion is wanting, it is sharp, and sometimes is elevated into a thin spine like the blade of a knife. 2d. The upper portion is discontinued exactly about the middle of this line, or just over the acetabulum; and at the termination, there is from this portion an obtuse projection overhanging the acetabulum, which is called the inferior spinous process of the ilium, to distinguish it from a similar projection about half an inch higher, called the superior spine. 3d. The under part of the bone is of the greatest import- ance, and in it we recognise the following circumstances. Its middle is large, and forms on the outside a deep cup or acetabulum, for the reception of the head of the thigh bone. On the inside, and just behind this cup, it forms a smooth polished plate of bone within the cavity of the pelvis, which is placed obliquely with regard to the pubis, and has a gen- tle slope forward. The vertex of the child's head, in labour, moves downwards, and somewhat forwards, on this, as on an inclined plane; it may be called the plane of the ischi- um, although a part of it be formed by the ilium. 4th. Standing off from the back part of this, about two inches beneath the linea iliopectinea, is a short projection, called the spine of the ischium, which seems to encroach a lit- 4 tie on the cavity of the pelvis, and is placed, with regard to the pubis, still more obliquely than the plane of the ischium. It must, consequently, tend to direct the vertex, as it de- scends, still more towards the pubis. 5th. Beneath this, the ischium becomes narrower, but not thinner; on the contrary, it is rather tlucker, and termi- nates in a rough bump, called the tuberosity of the ischium. 6th. Next, we look at the anterior part of the bone, and find, that just before the plane of the ischium, there is a large hole in the os innominatum. This is somewhat oval in its shape; and at the upper part within the pelvis, there is a depression in the bone, which, if followed by the finger or a probe, leads to the face of the pelvis. The hole is called the foramen thyroideum. 7th. Before this hole the two ossa innominata join, but form with each other, on the inside, a very obtuse angle, or a kind of smooth rounded surface, on which the bladder partly rests. The junction is called the symphysis of the pubis. 8th. The two bones, where they form the symphysis, are joined with each other for about an inch and a half; then they divaricate, forming an angle, the limbs of whicb extend all the way to the tuberosity of the ischium. This separation or divarication is called the arch of the pubis, which is prin- cipally constructed of the anterior boundary of the foramen thyroideum, consisting of a column or piece of bone, about half an inch broad, and one fourth of an inch thick, formed by the union of the ramus of the pubis, and that of the ischium. 9th. At the upper part of the symphysis, or a very little from it, the os innominatum has a short obtuse projection, called the crest of the pubis, into which Poupart's ligament is inserted; and from this there runs down obliquely, a ridge on the outside of the bone, which reaches all the way to the acetabulum, and overhangs the foramen thyroideum. 10th. When we return to the back part of the os innomi- natum, we find, that just after it has formed the plane of the ischium, it extends backwards to join the sacrum; but in do- ing so, it forms a very considerable notch or curve, the con- 5> cavity of which looks downwards. When the sacrum is joined to the bone, this notch is much more distinct. It is called the sacrosciatic notch or arch: for one side is formed by the is- chium, and is about two inches long; the other is formed chiefly by the sacrum, and is about half an inch longer. In the recent subject, strong ligaments are extended at the under part, from the one bone to the other; so that this notch is converted into a regular oval hole. 11th. Lastly, this notch being formed, the bone expands backwards, forming a very irregular surface for the articu- lation with the sacrum; and the bones being joined, we find that the os innominatum forms a strong, thick, projecting ridge, extending farther back than the spinous processes of the sacrum. This ridge is about two inches and three quar- ters long, and is a continuation of the crest of the ilium, but is turned downwards; whereas were the crest continued in its former course, it would meet with the one from the oppo- site side, behind the top of the sacrum, forming thus a neat semicircle; but this ridge, if prolonged on both sides, would form an acute angle, the point of junction being opposite the bottom of the sacrum. From this ridge strong ligaments pass to the sacrum, to join the two bones. § 3. SACRUM AND COCCYX. The sacrum forms the back part of the pelvis. It is a tri- angular bone, and gently curved; so that, whilst a line drawn from the one extremity to the other, measures, if it subtend the arch, about four inches; it will, if carried along the surface of the bone, measure full half an inch more. The distance betwixt the first or straight line, and the mid- dle of the sacrum is about one inch. The breadth of the base of the sacrum, considered as an angular body, is full four inches: the centre of this base is shaped like the surface of the body of one of the lumbar vertebra, with the last of which it joins, forming, however, an angle with it, called the great angle, or promontory of the sacrum. From this the bone is gently curved outward on each side, toward the sa- ti cro-iliac junction, contributing to the formation of the brim of the pelvis. The upper half of the side of the bone is broad and irre- gular for articulation with the os innominatum. The ante- rior surface of the bone is smooth and concave; but often we observe transyerse ridges, marking the original separation of the bones of the sacrum. Four pair of holes are found dis- posed in two longitudinal rows on the face of the sacrum, communicating with the canal which receives the continua- tion of the spinal marrow; through these the sacral nerves issue. These holes slope a little outward, and betwixt the two rows is the attachment of the rectum. The posterior surface of the bone is very irregular; and, we observe, 1st, The canal extending down the bone, for receiving the con- tinuation of the spinal marrow. 2d. At the upper part of this are two strong oblique processes, which join with those of the last lumbar vertebra. 3d. On a central line down the back of the canal, there is an irregular ridge analogous to the spines of the vertebrae. 4th. The rest of the surface is ve- ry irregular and rough; and we observe, corresponding to the holes for transmitting the sacral nerves on the exterior surface, the same number of foramina on this posterior sur- face, but, in the recent subject, they are covered with mem- brane, leaving only a small opening for the exit of nervous twigs. The coccyx is an appendage to the sacrum, and as it is in- clined forwards from that bone, the point of junction has been called the little angle of the sacrum. It is, at first, al- together cartilaginous, and cylindrical in its shape, but it gradually ossifies and becomes flatter, especially at the up- per part, which has been called its shoulder. In men it is generally anchylosed witli the sacrum, or at least moves with difficulty, but it almost always separates by macera- tion. In women it remains mobile, and, during labour, is pressed back so as to enlarge the outlet of the pelvis. By falls or blows it may be luxated; and if this be not discov- ered, and the bone replaced, suppuration takes place about the rectum, and the bone is discharged. 7 CHAP. II. Of the Articulation of the Bones of the Pelvis, and their occa- sional separation. § 1. OF THE SYMPHYSIS PUBIS. The bones of the pelvis are connected to each other, by intermediate cartilages, and by very strong ligaments. The ossa innominata are united to each other at the pubis, in a very strong and peculiar manner. It was supposed that they were joined together by one intermediate cartilage; but Dr. Hunter* was, from his observation, led to conclude, that each bone was first of all covered at its extremity with cartilage, and then betwixt the two was interposed a medium, like the intervertebral substance, which united them. This substance consists of fibres disposed in a transverse direction. M. Tenon | has lately published an account of this arti- culation ; and is of opinion, that sometimes the one mode and sometimes the other obtains. I am inclined to think, that Dr. Hunter's description is applicable to the most natural state of the part; but we often in females find that the inter- mediate fibrous substance, especially at the posterior part, is absorbed, and its place supplied with a more fluid sub- stance ; or, on the contrary, anchylosis may sometimes take place; a circumstance which Dr. Hunter says he never saw, but which I have met with. Besides this mode of connection, there is also in addition a very strong capsule to the articu- lation, the symphysis being covered on every side with liga- mentous fibres, which contribute greatly to the strength of the parts. ' Vide Med. Obs. and Inq. Vol. II. p. 333. t Vide Mem. de l'lnstitut des Sciences, Tome VI. p. 172. 8 § 2. SACRO-ILIAC JUNCTION. The ossa innominata are joined to the sacrum by means of a thin layer of cartilaginous substance, which covers each bone; that belonging to the sacrum is the thickest: both are rough, and betwixt them is found a soft yellowish substance in small quantity. The connection of the two bones, there- fore, so far as it depends on this medium, cannot be very strong; but it is exceedingly strengthened by ligamentous fibres, which serve as a capsule; and behind, several strong bands pass from the ridge of the ilium to the back of the sa- crum ; sometimes the bones are united by anchylosis. At the lower part, additional strength is obtained by two large and strong ligaments, which pass from the ischium to the sacrum; and therefore are called the sacrosciatic ligaments. The in- nermost of these arises from the spine of the ischium, is very strong, but at first not above a quarter of an inch broad; it gradually expands, however, becoming at its insertion about an inch and a quarter in breadth. It passes on to the sacrum, and is implanted into the lower part of the side of that bone, and the upper part of the coccyx. It converts the sacrosci- atic notch into a regular oval hole, the inferior end of which, owing to the neat expansion of the ligament, is as round and exact as the upper. As it makes a similar expansion down- wards, there is a kind of semilunar notch formed betwixt it and the coccyx. The outer ligament may be said to arise from the side of the sacrum, and, like the other, is broad at that part. It runs for some time in contact with the inner ligament, and parallel to it; but afterwards it separates, passing down to be inserted in the tuber ischii; and, when the ligaments separate, their surfaces are no longer parallel to each other. There is, in consequence of this separation, a gmall triangular opening formed betwixt the ligaments; or rather there is an aperture like a bow, the string being formed by the under ligament, and the arch partly by the spine of the ischium, and partly by the upper ligament. 9 § 3. VERTEBRAL JUNCTION AND OBLIQUITY OF THE PELVIS. The pelvis is joined to the trunk above, by means of the last lumbar vertebra; to the extremities below, by the in- sertion of the thigh bones into the acetabula; and it is so placed, that when the body is erect, the upper part of the sacrum and the acetabula are nearly in the same line. The brim of the pelvis, then, is neither horizontal nor perpen- dicular to the horizon, but oblique, being placed at an angle of 35 or 40 degrees. Were the ligaments of the pelvis loos- ened, there would, from this position, be a tendency in the sacrum to fall directly towards the pubis, the ossa innomi- nata receding on each side. But the structure of the part adds greatly to the power of the ligaments; for it is to be observed, that in standing, and in various exertions of the body, the limbs re-act on the pelvis; and the heads of the thigh bones pressing on the two acetabula, force the ossa in- nominata more closely on each other at the symphysis, and more firmly on the sacrum behind. It is not possible, indeed, to separate the bones of the pelvis, unless the connecting ligaments be diseased, or external violence be applied, so as to act partially or unequally on the pelvis. § 4. SEPARATION OF THE BONES. By external violence, the symphysis has been wrenched open, as was the case with Dr. Greene*; or the sacro-iliac junction may be separated, as in the case of the young pea- sant, related by M. Louis.f By some morbid affection of the symphysis, it may yield and become loosened during pregnancy, or may be separat- ed during labour. Some have been inclined to consider this as an uniform operation of nature, intended to facilitate the birth of the child. Others, who cannot go this length, have nevertheless conjectured, that the ligaments do become somewhat slacker; and have grounded this opinion on the * Phil. Trans. No. 484. T Vide Mem. de l'Acad. de Chir. Tome IV. p. 63s B 10 supposed fact of the pelvis of quadrupeds undergoing this relaxation. But the truth is, that this separation is not an advantage, but a serious evil; and in cases of deformed pel- vis, where we would naturally look for its operation, did it really exist, we do not observe it to take place. When a person stands, pressure is made upon the sym- physis, and therefore, if it be tender, pain will then be felt. When a person walks, pressure is made on the two aceta- bula alternately, and the ossa innominata arc acted on by the strong muscles which pass from them to the thighs, so that there is a tendency to make the one os pubis rise above the other; but this, in a sound state of the parts, is suffici- ently resisted by the ligaments. In a diseased state, how- ever, or in a case of separation of the bones, there is not the same obstacle to this motion; and hence, walking must give great pain, or be altogether impossible: even attempts to raise the one thigh above the other, in bed, must give more or less pain, according to the sensibility or laxity of the symphysis. Standing has also an effect on the symphysis, as I have mentioned; but sometimes the personcan, by fixing one os innominatum, with all the muscles connected with it, and throwing the chief weight of the body to that side, stand, for a short time, easier on one leg than on both. This is the case when one os innominatum has been more acted on than the other, at the saero-iliac junction. The person can stand easiest on the soundest side. From these observations, we may learn the mischievous consequences of a separation of the bones, and also the cir- cumstances which will lead us to suspect that it has happen- ed. If the bones be fully disjoined, then, by placing the fin- ger on the inside of the symphysis, and the thumb on the outside, we can readily perceive a jarring, or motion, on raising the thigh. It is well known to every practitioner, that owing to the distension of the muscles during pregnancy, very consider- able pain is sometimes felt at the insertion of the rectus muscle into the pubis; and it is also known, that sometimes, m consequence of pregnancy, the parts aboat the pelvis, and 11 especially the bladder and urethra, and even the whole vul- va, may become very irritable. This tender state may be communicated to the symphysis; or some irritation, less in. degree than that I have mentioned, may exist, which, in particular cases, seems to extend to the articulation, produc- ing either an increased effusion of interstitial fluid in the intermediate cartilage, and thus loosening the firm adhesion of the bones, or a tenderness and sensibility of the part, ren- dering motion painful. In either case, exertion may produce a separation: and certainly, in some instances, has done so. The separation is always attended with inconvenience, and often with danger, especially when it occurs during partu- rition ; for abscess may take place, and the patient sink un- der hectic fever; or inflammation may be communicated to the peritoneum, and the patient die in great pain. When the accident happens during gestation, it some- times takes place gradually, in consequence of an increasing relaxation of the articulation, from slow but continued irri- tation. In the other instances, it happens suddenly after some exertion. It may occur so early as the second, or so late as the ninth month, and is discovered by the symptoms" mentioned above; such as pain at the pubis, strangury, and the effects of motion. In some instances, considerable fever may take place, but, in general, the symptoms are not dan- gerous, and I do not know any case which has terminated fatally before delivery. A state of strict rest, the applica- tion of a broad firm bandage round the pelvis, to keep the bones steady, and the use of the lancet and antiphlogistic re- gimen, if there be fever or much pain, are the chief points of practice. Nor must it be forgotten, for a moment, that al- though, by these means, the symptoms are removed, the patient is liable, during the remaining term of gestation, or at the time of delivery, to a renewal of the relaxation or se- paration, from causes which, in other circumstances, would have had no effect. So far as I have been able to learn, a woman who has had this separation in one pregnancy, is not, in general, peculiarly liable to a return of it in a subsequent 13 pregnancy, though there m ay be particular exceptions to this observation.1 When it happens during parturition, it sometimes takes place in a pelvis apparently previously sound; but in most in- stances, we have, during some period of gestation, symptoms of disease about the symphysis; and so far from making la- bour easier, the woman often suffers more, when the sym- physis is previously relaxed. The primary and immediate effects are the same as when the accident happens during pregnancy; but the subsequent symptoms are frequently much more severe and dangerous, the tendency to inflammation be- ing strong. The pain may be either trifling or excruciating at the moment, according to the sensibility of the parts. But, even in the mildest case, great circumspection is required, violent inflammation having come on so late as a fortnight af- ter the accident. The means used in the former case are to be rigidly employed, and the woman should keep her thighs together, .and lie chiefly on her back. If the separa- tion have been slight, re-union may take place in a few weeks, sometimes in a month2; but if a great injury have been sustained, it may be many months, perhaps years be- fore recovery be completed; and in such cases, it is proba- ble, that at last, an anchylosis is sometimes formed. . Either owing to the violence of the accident, or the pecu- liar state of the parts, it sometimes happens, that inflamma- tion takes place to a very considerable degree in the symphy- sis ; but it is to be remarked, that the symptoms are by no means uniformly proportioned in their severity to the degree of the separation. Inflammation is known by the accession of fever, with acute pain about the lower part of the belly, greatly increased by motion, succeeding to the primary ef- fects ; or, sometimes, from the first, the pain is very great, and not unfrequently it is accompanied by sympathetic de- rangement of the stomach and bowels, such as vomiting, nau- sea, looseness, &c. Presently matter forms, and a well mark- ed hectic state takes place. The patient is to be treated, at first, by the usual remedies for abating inflammation, such 13 as general and local evacuation of blood, fomentations and laxatives. When matter is formed, we must carefully exam- ine where it is most exposed, and let it out by a small punc- ture.3 The inflammation may be communicated to the peritoneum, producing violent pain in the lower belly, tumefaction and fever, and almost uniformly proves fatal; though frequently the patient lives until abscess takes place in the cellular sub- stance within the pelvis. If any thing can save the patient, it must be the prompt use of blood-letting and blisters. In almost every case of separation of the pubis, consider- able pain is felt in the loins, even although the junction at the sacrum be entire, and the ossa pubis be very little asun- der. But when the separation is complete, and in any way extensive, then the articulation of the sacrum with the ossa innominata4, especially with one of them, is more injured5, and the person is lame in one or both sides, and has acute pain about the posterior ridge of the ilium,6 and in the course of the psoas and glutei muscles. The mischief may also com- mence in the saero-iliac articulation, and the symphysis may be little affected. The general principles of treatment are the same as in the former case. When suppuration takes place about the saero-iliac articulation, the danger is greatly increased. In all cases of separation, when the patient has recovered so far as to be able to move, the use of the cold bath accele- rates the cure; the general health is to be carefully attended to, and any urgent symptom supervening, is to be obviated by suitable remedies. § 5. DIFFERENCE OF THE FEMALE FROM THE MALE PELVIS. [A slight inspection is sufficient to show the difference in form and proportions, between the female and the male pel- vis. The crista, as well as the anterior and superior spinous processes of the ossa ilia, are farther separated in the female 14 pelvis, hence affording a greater concavity to the iliac fossae,, and greater capacity to the large or superior pelvis. The two straits which terminate the cavity of the pelvis, differ also considerably in the two sexes. The circumference, or brim of the superior strait is larger and more rounded in the female, the sacro vertebral projection is less prominent; the two tuberosities of the ischia are also less rough, less pro- jecting, and farther separated than in the male; and finally, the extremity of the os coccygis docs not approach so near to the arch of the pubis, which affords to the inferior strait, greater extent from its anterior to its posterior termination. With regard to the excavation of the pelvis, it is more concave in the posterior part in the female, because the sa- crum has greater height and curvature; the arch of the pu- bis is broader,(a) and its branches are also turned more outward and forward. The region of the pubis is less convex, and the cartilage, which forms the symphysis, is thicker and shorter, offering towrards the interior of the pelvis a promi- nence more remarkable than in the male. But in this very conformation, which nature appears to have intended to render labour more easy, there are certain circumstances exposing the female to peculiar inconveni- ences, which in men are more rarely observed; thus the su- perior spinous processes which anteriorly terminate the crista, or spine of the ilium, could not be separated to a greater distance, without increasing the length of Poupart's ligament, forming the crural arch; from thence it follows, that the intestine and cpiplorn, finding in this part less re- sistance and a larger aperture, must more frequently pass down and produce femoral hernia. Again, women having their hips farther separated, must necessarily step with less firmness than men: for in pro- gressing, when one leg is elevated, the centre of gravity of the body is less readily thrown upon the other, which rests (a) Soemmering observes, that the angle between the diverging branches of the pubis, is in the male an acnte one 5 but in the female forms an angle of from 80 to 90 degrees, and hence approaches nearer to the figure of an arch, from which it receives its name. 15 on the ground; from hence results a species of elandication or vacillating gait, in which the trunk and the inferior ex- tremities, instead of advancing directly or in a straight line, describe greater or smaller arches of circles.] (b) CHAP. III. Of the soft Parts which line the Pelvis. § 1. MUSCLES. Various strong, and large muscles, pass from the spine and pelvis to the thigh bones, and act as powerful bands, strengthening, in a very great degree, the articulations of the pelvis. These it is not requisite to describe, but it will be useful, briefly to notice the soft parts which line the pelvis, and which may be acted on by the child's head during la- bour. 1st. When we remove the peritoneum from the cavity of the pelvis, we first of all are led to observe, that all the un- der portion of the os innominatum, and part of the sacrum, is covered with a layer of muscular fibres, which arises >at the brim of the pelvis, and can be traced all the way down to the extremity of the rectum* This is the levator ani; it is a strong muscle, with many glossy tendinous fibres, especially at the fore part, where it lines the ossa pubis. Under the symphysis, it is pierced by the urethra and vagina; and during the pas- age of the child's head, those fibres which surround the vagina must be considerably distended; and this is more readily ef- fected, as the anus is brought forwards when the perinseum is distended. 2d. Under this, on each side, we have arising from the membrane that fills up the thyroid hole, and also from the margins of the hole and the inner surface of the ischium, the obturator internus, which forms at that part a soft cushion of (t>) Vide Capuron. cours theorique et practique, &c Soemmering Tabula Scoleti fetninim juncta descriptione.. 16 flesh, the fibres running backwards and downwards, and ter- minating in a tendon, which passes over the- sacro-sciatic notch, running on it as on a pulley, in order to reach the root of the great trochanter. 3d. We find the pyriformis arising from the under part of the hollow of the sacrum, and also passing out at the notch, to be inserted with the obturator; and in laborious parturition, the injury or pressure which these muscles sustain, is one cause of the uneasiness felt in moving the thighs. 4th. From the spine of the ischium, originates the coccy- * geus, which runs backward to be inserted into the side of the coccyx, in order to move and support it. This gradually becomes broader, as we recede from its origin, and is spread on the inside of the sacro-sciatic ligament. Thus the cavity of the pelvis is lined with muscular substance, whose fibres are disposed in a very regular order, and which are exhibi- ted, when the peritoneum and its cellular substance are re- moved. 5th. When we look at the upper part of the os innomina- tum, we find all the hollow of the ilium occupied with the iliacus internus, the tendon of which passes over the fore part of the pelvis, to reach the trochanter of the thigh. Part of this muscle is covered by the psoas which arises from the lumbar vertebra, and passes down by the side of the brim of the pelvis to go out with the former muscle: though just upon the brim, it does not encroach on it, so as percept- ibly to lessen the cavity. These muscles afford a soft support to the intestines and gravid uterus. § 2. arteries.(c) Running parallel with the inner margin of the psoas mus- cle, and upon the brim of the pelvis, along the posterior half of the linea iliopectinea, we have the iliac artery and vein; the artery lying, for the upper half of its course, above the vein, and for the under half on the outside of it; when fille'd, they, especially the vein, encroach a little on the brim. About (c) Consult engravings of the Arteries by C. Bell. Finley's Edition. 17 three inches from the symphysis, they quit the brim, running rather more outward, over the part which forms the roof of the acetabulum, and pass out with the psoas muscle. The great lash of arteries and veins connected with the pelvis, and in- ferior extremities, is placed on the saero-iliac junction. The iliac vessels are so situated, that they escape pressure du- ring labour, wiien the head enters the cavity of the pelvis; but the hypogastric vessels must be more or less compressed, according to the size or position of the head, but the circula- tion is never interrupted. § 3. NERVES. When we attend to the nerves, we find, 1st. Upon the ili- um, at least four branches of cutaneous nerves, traversing the iliac, and psoas muscles, in order to pass out belowT Poupart's ligament. The largest of these cutaneous nerves is the outermost, which has its exit towards the spine of the ilium. These nerves, which supply chiefly the skin of the thigh, cannot suffer during labour; but sometimes may from the position of the child, or the inclination of the uterus, sustain pressure, during gestation, and occasion numbness and anomalous sensations in the thigh. 2d. Between the two muscles, and in part covered by the outer margin of the psoas, is the anterior crural nerve, which is formed by the second, third, and fourth lumbar nerves. It is of considerable size, and has a greater share than the others, in producing the un- easy sensations I have mentioned. 3d. Running parallel with the brim of the pelvis, but three quarters of an inch below it, in the cavity of the pelvis, is the obturator nerve, coming from the third lumbar, and which may be traced all along the side of the ilium to the thyroid hole. In many cases, it cannot fail during labour, to be pressed on by the head. 4th. Beneath the vessels at the saero-iliac junction, we have the great nerves which form the sciatic nerve, which is made up of the fourth and fifth lumbar nerves, and the first sacral nerve, which is as large as either of the former: to these are added the second and third sacral, which are much smaller. The fourth lumbar nerve passes down on the saero-iliac junction, c 18 and is quite covered with the vessels. The fifth traverses that curved part of the sacrum, which lies betwixt its promon- tory and side; like the former, it is hid by the vessels. In going to form the sciatic nerve, the fourth lumbar nerve passes un- der the gluteal artery, or the common trunk of the gluteal and ischiatic arteries, and the fifth passes over it. The first sacral nerve passes along the upper margin of the pyriform muscle, to join with these at the sacro-sciatic notch. There a large plexus is formed, which, uniting into a single trunk, passes out, and is the greatest nerve in the body. The lum- bar nerves may be pressed on early in labour; but from the cushion of vessels and cellular substance which defends them, they suffer little. When the head has descended lower, and is beginning to turn, the first sacral nerve may be compress- ed. Pressure of the nerve produces pain, numbness, and cramp in the thigh and leg. Different nerves are acted on in different stages of labour. In the very beginning, the an- terior crural nerve may be irritated or gently compressed, pro- ducing pain in the fore part of the thigh; next the obturator, producing pain in the inside; and last of all, the back part suf- fers from the pressure on the ischiatic nerve. 5th. The second and third sacral nerves are small compared to the first. They are covered by the pyriformis muscle, but part of them pierce it, forming a plexus, which joins the sciatic nerve, and sends twigs to the bladder, rectum, &c. This plexus may be press- ed in the last stage of labour; and the irritation thus produ- ced may be one cause of the passage of the faeces, which gene- rally takes place involuntarily. 6th. The fourth sacral nerve is altogether devoted to the extremity of the rectum, and its vicinity. The great plexus, forming the sciatic nerve, as it lies in the sacro-sciatic notch, yields to any pressure it may receive, and cannot suffer in labour, at least, so as to cause inconve- nience ; but the nerves going to it may suffer, and the person not only have cramp and pain during labour, but palsy and lameness for a long time afterwards. Friction, and the warm bath at first, may relieve the pain; and then, the cold bath may, with much advantage, be employed for perfecting the cure. 19 § 4. LYMPHATICS. The lymphatics in the upper part of the pelvis follow the course of the iliac vessels, forming a large and very beauti- ful plexus, from Poupart's ligament to the lumbar vertebra. These are out of the way of pressure during labour. Nume- rous glands accompany them, which are sometimes enlarged by disease, but they do not interfere with parturition. The lymphatics of the cavity of the pelvis have glands in the course of the vagina and rectum; and these, if enlarged, may impede delivery. CHAP. IV. Of the Dimensions of the Pelvis. § 1. BRIM AND OUTLET. The pelvis has been divided into the great and the little, the first being formed by the expansion of the ilia, and the second, comprehending all that part which is called the ca- vity of the pelvis, and which lies below the linea ilio-inno- niinata. The cavity of the pelvis is the part of the chief importance in Midwifery, and consists of the brim, or en- trance, the cavity itself, and the outlet. The brim of the pelvis has no regular shape, but approaches nearer the oval than any other. The short diameter of this, extends from the symphysis of the pubis to the top of the sacrum. This has been called the conjugate, or antero-posterior diameter, and measures four inches. The lateral diameter measures five inches and a quarter; and the diagonal diameter, or a line drawn from the saero-iliac symphysis to the opposite aceta- bulum, measures five inches and an eighth; but as the psoas muscles, and iliac vessels, overhang the brim a very little at the side, the diagonal diameter, in the recent subject, appeals to be the longest. From the saero-iliac symphysis to the crest of the pubis, on the same side, is four inches and a half. From the top of the sacrum, to that part of the brim which is directly above the foramen thyroideum, is three inches . 20 and a half. The line, if drawn to the acetabulum, in place of the foramen, is a quarter of an inch shorter; a line drawn across the fore part of the brim, from one acetabulum to ano- ther, is nearly four inches and a quarter. The outlet of the pelvis is not so regular as the brim, in its shape, even when the soft parts remain; but it is some- what oval. The long diameter extends from the symphysis pubis to the coccyx, and measures, when that bone is pushed back, as in labour, five inches, but an inch less when it is not. The transverse diameter, from the one tuberosity of the ischium to the other, measures four inches. The outlet of. the pelvis differs materially from the brim, in this respect, that its margins are not all on the same level; an oval wire will repre- sent the brim, but, if applied to the outlet, it must be curved. The outlet, from the symphysis pubis to the tuberosity of the ischium, is semi-oval; but behind, it becomes more irregular, and bends upwards and backwards. The arch of the pubis, or the fore part of the outlet, is four inches broad at its base; and a perpendicular line, dropped from its centre to the bone, is fully two inches long. The top of the arch will permit a circular body to come in contact with it, whose diameter is an inch and a quarter. The length of each limb of the arch is three inches and a quarter. § 2. CAVITY. The cavity of the pelvis is the next part to be attended to; and the most important observation to be made, is, that it is of unequal depth. At the back part, it measures from five to six inches, according as the coccyx is more or less extended; at the side, a line drawn from the brim, to the tuberosity of the ischium, measures three inches and three fourths. At the fore part, the depth of the symphysis pubis is an inch and a half. When the surface of the child's head, then, is parallel to the lower edge of the symphysis, the head is still far from having entered fully into the cavity of the pelvis; it cannot be considered in the cavity, until it be lodged fairly in the hollow of the sacrum. It may be proper to notice the dimensions of different parts ef the cavity itself. An oblique line, drawn from the sacro- SI iliac junction, on one side, down to the opposite tuberosity, measures six inches; and the long axis of the child's head, before it takes the turn forwards, corresponds to this line. From the ramus of the ischium, to the opposite saero-iliac junction, is five inches. From the top of the arch of the pubis, or orifice of the urethra, to the second bone of the sa- crum, is four inches and five eighths, to five inches. A line drawn from the top of the arch to the top of the sacrum, is about a quarter of an inch more than the antero-posterior diameter of the brim. From the top of the arch to the spine of the ischium, is three inches and a half. From the tuberosity of the ischium to the centre of the sacrum is four inches. From the back part of the tuberosity to the sacro- iliac junction on the same side, is three inches and a half. From the extremity of the tuberosity to the spine of the is- chium, is two inches. From the spine to the sacrum is two inches; and from the top of the arch of the pubis to the plane of the ischium, is two inches. The breadth of the plane itself is two inches; so that a line traversing these different parts, from the symphysis to the sacrum, would measure, including its slight irregularities, six inches. From the tuberosity to the inferior part of the thyroid hole, is an inch and a half. The long diameter of the sacro-sciatic notch, is two inches and three eighths; the short, one inch and three quarters.(d) In the living subject, we can readily recognize these dif- ferent parts of the pelvis; and by the relation which one bears to the rest, we can ascertain, by careful examination with the finger, not only the relative position of the head with regard to any one spot, and consequently, its precise situa- tion and progress in the pelvis, but also the shape and di- mensions of the pelvis itself.(c) (d) There may be some variation in dimensions, as stated by different writers; but it is probable, the above were given by our author, from actual measurement, of, what he considered, a standard pelvis. A similar observa- tion may be applied to the dimensions of the child's head, as stated in the succeeding chapter. (c) The very ingenious and indefatigable Bichat has observed, that sta- ture has no influence, or at least very little, on the dimensions of the pelvis; 22 § 3. PELVIS ABOVE THE BRIM. The shape, extent, and dimensions of the great pelvis, or that part which is above the brim, must be mentioned like- wise, especially as these arc of importance in estimating the deformity of a pelvis. From the symphysis pubis to the commencement of the iliac wing, at the inferior spinous pro- cess, is nearly four inches. From the inferior spinous pro- cess to the posterior ridge of the ilium, a line subtending the hollow of the costa, measures five inches. The distance from the superior spine is the same. From the top of the crest of the ilium to the brim of the pelvis, a direct line measures three inches and a half. The distance betwixt the two supe- rior anterior spinous processes of the ilium, is fully ten inches. A line drawn from the top of the crest of the ilium to the op- posite side, measures rather more than eleven inches, and touches, in its course the intervertebral substance betwixt the fourth and fifth lumbar vertebrae. A line drawn from the centre of the third lumbar vertebra, counting from the sa- crum to the upper spine of the ilium, measures six inches and three quarters. A line drawn from the same vertebra to the top of the symphysis, measures seven inches and three quarters, and, when the subject is erect, this line is exactly perpendicular. To conclude my observations on the dimensions of the pel- vis, I remark, that the shape is different in the child and the adult. The dimensions of the brim are reversed in these two states; the long diameter of the fcetal pelvis, extending from the pubis to the sacrum. By slow degrees, the shape changes; and nearly about the time of puberty, the conjugate and la- teral diameters are equal. When the female is fully perfect- ed, the brim becomes more oval, the long diameter extending and that the individual differences which may occur, are totally independent of stature. It is acknowledged, continues he, that delivery is as easy in small as in large women, although the first may bring forth very bulky chil- dren, and who, indeed, may be dispropojrtioned to the bulk of their mother's bodies, if a comparison of size should be instituted between the two. Anatomie Detviptme, vol. l.p. 181—2. 23 from one side to the other. If a girl should, very early, be- come a mother, the shape of the pelvis may occasion a pain- ful and tedious labour.(/) § 4. AXIS OF THE BRIM AND OUTLET. Finally, we are to remember that the brim, and the out- let of the pelvis, are not parallel to each other, but placed at a considerable angle. The axis of the brim will be repre- sented by a line drawn from near the umbilicus, downwards and backwards, to the coccyx; that of the outlet, by a line drawn from the orifice of the vagina to the first bone of the sacrum. The precise points, however, which these lines will touch, must vary'a little, according to the conformation and obliquity of the pelvis, and the prominence of the abdomen. Each different part of the cavity of the pelvis has its own proper axis, and the line of motion of the child's head must always correspond to the axis of that part of the pelvis in which it is placed. A pretty good idea of this subject, with regard to labour, may be obtained, by placing a small ca- theter, of the usual curvature, in the axis of the brim, and making its extremity pass out at the axis of the outlet. CHAP. V. i Of the Head of the Child, and its progress through the Pelvis in Labour. § 1. BONES OF THE HEAD. The head of the child is made up of many different bones, and those of the cranium are very loosely connected together with membrane. The os frontis, temporal, parietal, and occi- pital bones, compose the bulging part of the cranium, and their particular shape regulates the direction of the sutures. (/) This remarkable difference in the comparative dimensions of the fe- male pelvis before and after puberty, has.been pointed out by analogy, and observed among the females of quadrupeds whose pelvis does not com- plete its developement, nor acquire the form and proportions necessary for the expulsion of the foetus until the period of puberty. VidCapuron. 24 The occipital bone is connected to the parietal bones, by the lambdoidal suture, which is readily discovered through the integuments, by its angular direction. The parietal bones are joined to the frontal bone, by the coronal suture, which is distinguished by its running directly across the head, and they are connected to each other by the sagital suture, which runs in a direct line from the occipital, to the frontal bone; as the os frontis, in the foetus, consists of two pieces, it can sometimes be easily traced with the finger, even to the nose. The upper and anterior angles of the parietal bones, and the corresponding corners of the two pieces of the frontal bone, are rounded off, so as to leave a quadrangular vacancy, which is filled up with tough membrane. This is called the great or anterior fontanell, to distinguish it from another smaller vacancy at the posterior extremity of the sagital su- ture, which is called the small fontanell. The first is known by its four corners, and by its extending forward a little be- twixt the frontal bones, and whenever it is felt, in an exami- nation, we may expect a tedious labour; for the head does not lie in the most favourable position. The lesser fontanell cannot, during labour, be perfectly traced, as it is lost in the angular lines of the lambdoidal suture, which, however, ought to be readily discovered. The head is of an oblong shape, and its anterior extremity at the temples is narrower than the posterior, which bulges out at the sides by a rising of the parietal bones, called the parietal protuberances: from these the bones slope backwards, like an obtuse angle, to the up- per part of the occiput, which is a little flattened, and is cal- led the vertex. From these protuberances, the head also slopes downwards and forwards to the zygomatic process of the temporal bone, becoming, at the same time, gradually narrower. § 2. SIZE OF THE HEAD. The longest diameter of the head is from the vertex to the chin, and this is about five inches.(g) From the root of the (g) When the vertex is stretched out in laborious births, it is sometimes extended to six oj seven inches. 25 nose to the vertex, it measures four inches. From the one parietal protuberance to the other, a transverse line measures from three inches and a quarter, to three inches and a half. From the nape of the neck to the crown of the head, is three inches and a half. From the one temple to the other, is two inches and a half. From the occiput to the chin, along the base of the cranium, is four inches and a half. From one mastoid process to the other, along the base, is about two inches; from cheek to cheek is three inches. Although these may be the average dimensions of the head, yet, owin^ to the nature of the sutures, they may be diminished, and the shape of the head altered. The one bone may be pushed a little way under the other, and, by pressure, the length of the head may be considerably increased, whilst its breadth is diminished; but these two alterations by no means corres- pond, in a regular degree, to each other. The size of the male head is generally greater than that of the female. Dr. Joseph Clarke*, an excellent practitioner, upon whose accuracy I am disposed fully to rely, says, that it is a twenty-eighth or thirtieth part larger. It is a well established fact, that owing to the greater size of male children, women who have the pelvis in any measure con- tracted, have often a more tedious labour, when they bear sons than daughters; and many who have the pelvis well formed, suffer from the effects on the soft parts. Dr. Clarke supposes, that one half more males than females are born dead, owing to tedious labour, or increased pressure on the brain; and owing to these causes, a greater number of males than females die, soon after birth. In twin cases, again, as the children are smaller, he calculates, that only one-fifth more males than females are still-born. Dr. Bland f says, that of eighty-four still-born children, forty-nine were males, and thirty-five, females. § 3. PASSAGE OF THE HEAD. By comparing the size of the head with the capacity of the pelvis, it is evident that the one can easily pass through the • Phil. Trans. Vol. LXXV1. t PhiL Tran*. Vol. LXXI. D 20 other. But I apprehend that the comparison is not always correctly made, for the child does not pass with the long di- ameter of its cranium parallel to a line drawn in the direc- tion of the long diameter of the brim of the pelvis; but it de- scends obliquely, so that less room is required. The vertex naturally passes first, the chin being placed on the breast Of the child. Now, the length of a line drawn from the nape of the neck, to the crown of the head, is three inches and a half; a line intersecting this, drawn from the one parietal protuberance to the other, measures no more. We have, therefore, when the head passes in natural labour, a circular body going through the brim, whose diameter is not above three inches and a half; and therefore, no obstacle, or diffi- culty can arise from the size of the pelvis. There is so much space superabounding betwixt the pubis and sacrum, as to prevent all risk of injury from pressure on the bladder, ure- thra, or rectum; and as the long diameter of the head is de- scending obliquely, the sides of the brim of the pelvis are not pressed on. This is so certainly the case, that the head may, and actually often does pass, without any great addi- tional pain or difficulty, although the capacity of the pelvis be a little contracted. But when the shoulders, which mea- sure five inches across, come to pass, then the brim is com- pletely occupied. If, however, any contraction should take place in the lateral diameter, the child would still pass, the one shoulder descending obliquely before the other. It is of great consequence to understand the passage of the child's head in natural labour; for upon this depends our knowledge of the treatment of difficult labour. The head na- turally is placed with the vertex directed to one side, or a little towards the acetabulum; and the forehead, owing chief- ly to the action of the promontory of the sacrum, is turned in the same degree, towards the opposite saero-iliac junction. When labour begins, and the head comes to descend, the chin is laid on the sternum, and the vertex is directed down- wards, nearly in the axis of the brim of the pelvis. When, by the contraction of the uterus, the head is forced a little lower, its apex comes to touch the plane of the ischium. Up, 27 on this the side of the vertex slides downwards and forwards* as on an inclined plane, the head being turned gradually, so that, in a little time, the face is thrown into the hollow of the Sacrum*, and the vertex presents at the orifice of the vagina. This is not fully accomplished, till the cranium has got en- tirely into the cavity of the pelvis. As the bason is shallow at the pubis, the head is felt near the orifice of the vagina, and even touching the labia and perineum, before the turn is completed, and when the ear is still at the pubis. The whole of the cavity of the pelvis is so constructed, as to con- tribute to this turn, which is further assisted by the curve of the vagina, and the action of the lower part of the uterus, on the head of the child. The head, whilst its long diameter lies transversely, continues to descend in the axis of the brim of the pelvis; but when it is turned, it passes in the axis of the outlet. When the turn is making, the direction of the motion is in some intermediate point; and this fact should, in ope- rating with instuuments, be studied and remembered. When the pelvis is narrow above, and the sacrum projects forward, the vertex is long in reaching the inclined plane of the ischi- um; and when the head is lengthened out, so as to come in contact with it, we find, that although the projection of the sacrum directs the vertex sometimes prematurely a little forward, yet, the tendency to turn fully, is resisted by the situation of the bones above; a great part of the cranium, and all the face, being above the brim, and perhaps in part locked in the pelvis. By a continuation of the force, the shape of the head may be altered; even the vertex may be turned a little to one side, its apex not corresponding exactly to the extremity of the long diameter of the head; the integuments may be tumefied, and a bloody serum be effused between them, so as greatly to disfigure the presentation. As, there- fore, in tedious labour, occasioned by a deformed pelvis, the skull may be much lengthened and misshapen, we are not to judge of the situation of the head, by the position of the apex of the tumour which it forms; but we must feel for the * Dr."Qsborn attributes this turn to the action of the spines of the ischia, on the two parietal bones, but not on opposite spots. 28 ear, which bears a steady relation to that part of the head which Resents the obstacle. The hack and upper part of the head are compressible, but the base of the skull and the face are firm. A line drawn from the neck to the forehead, pass- ing over the ear, is to be considered as the boundary betwixt these parts of opposite character; and therefore we attend to the relative situation of the ear, as it ascertains both the position of the head, and its advancement through the brim. CHAP. vr. Of Diminished Capacity, and Deformity of the Pelvis. § 1. DEFORMITY FROM RICKETS. The pelvis may have its capacity reduced below the na- tural standard, in different ways. It may be altogether upon a small scale, owing to the expansion stopping prematurely, the different bones, however, being well formed, and correct in their relative proportions and distances. This may occa- sion painful labour, but rarely causes such difficulty as to re- quire the the use of instruments. Sometimes the bones are all of their proper size, but the sacrum is perfectly straight, by which, although both the brim and outlet arc sufficiently large, yet the cavity of the pelvis is lessened; or when all the other parts are natural the spines of the ischium may be ex- uberant, encroaching on the lower part of the pelvis. Another cause of diminished capacity, is the disease called rickets, in which the bones in infancy are defective in their strength, the proportion of earthy matter entering into their composition being too small. In this disease, the long bones bend, and their extremities swell out; the pelvis becomes de- formed, the back part approaching nearer to the front, and the relative distance of the parts being lost. The distortion may exist in various degrees. Sometimes the promontory of the sacrum only projects forward a very little more than usual, or is directed more to one side than the other1; and the curvature of the bone may be either increased or dimin- ished. If the sacrum project only a little, without any other 29 change, the capacity of the brim alone is diminished; but if the curvature be at the same time smaller than usual, the cavity of the pelvis is lessened: but unless the isehia ap- proach nearer together, or the lower part of the sacrum be bent forward, the outlet is unaffected; and in most cases of moderate deformity, the outlet is not materially changed. In greater degrees of the disease, the anterior part of the brim becomes more flattened, the linea iliopectinea forming a small segment of a pretty large circle. The sacrum forms part of a concentric circle behind; and thus the brim of the pelvis, instead of beini^ somewhat oval, is rendered semicir- cular or crescentic, and its short diameter is sometimes reduced under two inches. The promontory of the sacrum may either correspond to the symphysis pubis, or may be di- rected to2 one side, rendering the shape of the brim more irregular, and the dimensions smaller on one side than the other. In some instances, the shape of the brim is like an equilateral triangle; and although the diameter from the pu- bis to the sacrum be not diminished, yet the acetabula being near the sacrum, the passage of the head is obstructed. § 2. DEFORMITY FROM MALACOSTEON. The pelvis is likew ise, especially in manufacturing towns, sometimes distorted b y malacosteon, or softening of the bones of the adult. This is a disease which sometimes begins soon after delivery, and very frequently during pregnancy. It is, indeed, comparatively rare in those who do not bear children, and it is always increased in its progress by gestation. It must be carefully att ended to, for, to a negligent practitioner, it has at first very miuch the appearance of chronic rheuma- tism. It very generally begins with pains about the back, and region of the peLvis. These pains are almost constant, or have little remission. They are attended with increasing lameness, loss of flesh, weakness, and fever; but the distin- guishing mark is di minution of stature, the person gradually becoming decrepid. In malacosteon. the pelvis suffers, but the distortion is ge nerally different from that produced by rickets; for whilst the top of the sacrum sometimes sinks 30 lower in the pelvis, and always is pressed forward3, the acC- tabula are pushed backwards and inwards, towards the sa- crum and towards each other4; so that, were it compatible with life, for the disease to last so long, these parts would meet in a common point, and close up the pelvis, or at least convert its cavity to three slits. The ossa pubis form a very acute angle; so that the brim of the pelvis, instead of be- ing a little irregular as in slight cases of rickets, or semi- circular as in the greatest degree of that disease, consists, when malacosteon has continued long, of two oblong spaces on each side of the sacrum, terminating before, in a narrow slit, formed betwixt the ossa pubis5. In this narrow space, when the woman is advanced in her pregnancy, the urethra lies, and the bladder rests upon the pendulous belly; so that, if it be necessary to pass the catheter, we must sometimes use one made of elastic materials, or a male catheter, direct- ing the concavity of the instrument towards the pubis. If the instrument be large, and the ossa pubis very near each other, it may be jammed betwixt them, if it be incautiously intro- duced. In this disease, as well as in rickets, it is to be re-« membered, that the promontory of the sacrum may overhang the contracted brim, so as more effectually to prevent the head from entering it. Rickets being a disease, which is at its greatest height in infancy, we have not at present to consider the treatment. Malacosteon is, on the contrary, a disease of the adult; and it would be of great importance to child-bearing women, to know how to check its progress. But the means capable of doing this with any tolerable degree of certainty, have not yet been discovered. As gestation uniformly increases the disease, it is, proper that the woman should live absque marito. As there is evidently a deficiency of earth in the bones, it has been proposed to give the patient phosphate of lime, but little advantage has been derived from it; and in- deed, unless we can change the action of the vessels, it can do no good to prescribe any of the component parts of bone. We have, in the present state of our knowledge, no means of rendering the action more perfect, otherwise than by endear 31 vouring to improve the general health and vigour of the sys- tem, by the use of tonics, the cold bath, and attending to the state of the bowels. Anodyne frictions, and small blisters, sometimes relieve the pain*. § 3. DEFORMITY FROM EXOSTOSIS AND TUMOURS. The pelvis may be well formed externally, and yet its ca- pacity may be diminished within, by exostosis from some of the bones ;(A) or it may be affected in consequence of the fracture of the acetabulum, from which I have seen exten- sive and pointed ossification stretch for nearly two inches in- to the pelvis; or steatomatous or schirrous tumours may form in the pelvis, being attached to the bones or ligaments, of which I have known examples.6 An enlarged ovarium7, or vaginal hernia8, may also obstruct delivery, even so much as to require the crotchet; and therefore, although they be not indeed instances of deformed pelvis, yet as they diminish the capacity of the cavity, as certainly as any of the former causes which I have mentioned, it is proper to notice them at this timef. Enlarged glands in the course of the vagina, polypous excrescences about the os uteri or vagina, schirrus of the rectum, and firm encysted tumours in the pelvis, may • Upon the subject of deformity of the pelvis, and for tables of many par- ticular instances of distortion, I have great pleasure in referring the reader to the works of Dr. Hull, a practitioner of sound judgment, and extensive knowledge. (A) Deformity of the pelvis, from the above causes, may be considered as comparatively a rare disease in the United States. In the course, of my ob- stetrical practice, I can at present recollect but four or five cases, where embryulcia and the employment of the crochet became indispensably neces- sary; and what may be worthy of remark, these were in individuals natives of Europe, chiefly of Ireland. A deformed pelvis is scarcely known among the aborigines of our country. This subject shall again be taken up when embryulcia is treated of; an operation, which we fear, is frequently resorted to very unnecessarily at least, to make use of the mildest term. f In all cases of moveable tumours, as well as in stone in the bladder, it is evident, that they ought, in the very beginning of labour, to be pushed above the brim, and prevented from entering it before, or along with the head, 32 likewise afford an obstacle to the passage of the child. Some tumours, however, gradually yield to pressure, and disap- pear until the child be born; others burst, and have their contents effused in the cellular substance. A large stone in the bladder may also be so situated during labour, as to di- minish very much the cavity of the pelvis; and it may be even necessary to extract the stone before the child be de- livered. § 4. ME.VXS OF ASCERTAINING THE SIZE OF THE HEAD WHEN BROKEN DOWN. In order to ascertain the degree of deformity, and the ca- pacity of tljo pelvis, different instruments have been invent- ed. Some of these are intended to be introduced within the pelvis, and others to be applied on the outside, deducting a certain number of inches for the thickness of the pubis, sa- crum, and soft parts. But these methods are so very uncer- tain, that I do not know any person who makes use of them in practice. The hand is the best pelvimeter, and must in all cases, where an accurate knowledge is necessary, be intro- duced within the vagina. By moving it about, and observing the number of fingers which can be passed into different parts of the brim, or the distance to which two fingers re- quire to be separated in order to touch the opposite points of the brim, or the space over which one finger must move in order to pass from one part to another, we may obtain a suf- ficient knowledge, not only of the shape of the brim, cavity, and outlet of the pelvis, but also of the degree to which the soft parts within are swelled, as well as of the position and extent of any tumour which may be formed in the pelvis. We may be farther assisted by observing, that in great de- grees of deformity or contraction, the head does not enter the brim at all; in smaller degrees it engages slowly, and the bones of the cranium, form an angle more or less acute, ac- cording to the dimensions of the brim, into which it is squeezed. As-in many cases of deformed and contracted pelvis, it is necessary to break down the head in order to get it through 33 the cavity, it will be proper to subjoin the dimension of the foetal head when it is reduced to its smallest size. When the frontal, parietal, and squamous bones are removed, which is all that we can expect to be done in a case requiring the crotchet, we find that the width of the base of the cranium, over the sphenoid bone, is two inches and a half. The dis- tance from cheek to cheek is three inches. From the chin to the root of the nose is an inch and a half; and by separating the symphysis of the jaw, the two sides of the maxilla may recede, so as to make this distance even less. From the chin to the nape of the neck, when the chin is placed on the breast, is two inches and three quarters. When, on the con- trary, the chin is raised up, and the triangular part of the occiput laid back on the neck, the distance from the throat to the occiput is two inches. The smallest part of the head, then, which can be made to present, is the face; and when this is brought through the brim, the back part of the head and neck may, although they measure two inches, be reduc- ed by pressure so as to follow the face. The short diameter of the chest when pressed, is an inch and a half; that of the pelvis is the same. The diameter of the shoulder is one inch. CHAP. VII. Of Augmented Capacity of the Pelvis. A very large pelvis1, so far from being an advantage, is attended with many inconveniences, both during gestation and parturition. The uterus, in pregnancy, does not ascend at the usual time out of the pelvis, which produces several uneasy sensations; it is even apt, owing to its increased weight, to be prolapsed: or, if the bladder be distended, it may readily be retroverted. At the very end of gestation, the uterus may descend to the orifice of the vagina; and, during labour, forcing pains are apt to come on before the os uteri be properly dilated, by which both the child and the uterus may be propelled, even out of the vagina; and in ma- E 34 ny instances, although this should not happen, yet the pains are severe and tedious, especially if the practitioner be not aware of the nature of the case. CHAP. VIII. Of the External Organs of Generation. § 1. GENERAL VIEW. The symphysis of the pubis, and insertion of the recti muscles, are covered with a very considerable quantity of cellular substance, which is called the mons veneris. From this the two external labia pudendi descend, and meet toge- ther about an inch before the anus; the intervening space receiving the name of perinseum. On separating the great labia, we observe a small projecting body placed exactly on the lower part of the symphysis. This is the clitoris, and it is surrounded by a duplicature of skin called, its prepuce. From this duplicature, or rather from the point of the clito- ris, we find arising on each side, a small flap, which is con- tinued down on the inside of the labia, to the orifice of the vagina. These receive the name of nymphse, or labise mino- res or interiores. On separating them, we observe, about nearly an inch below the clitoris, the extremity of the ure- thra ; and, just under it, the orifice of the vagina, which is partly closed up, in the infant state, by a semilunar mem- brane called the hymen. These parts are all comprehended under the general name of vulva, or external organs of gene- ration. § 2. LABIA AND NYMPHE. The labia have nothing peculiar in their structure, for they are merely duplicatures of the skin, rendered promi- nent by a deposition of fatty matter. Externally they have just the appearance of the common integuments; and at the age of puberty, are, together with the mons veneris, gene- rally, covered with hairs. Internally they resemble the in- 35 side of the lips or eye-lids, and are furnished with numerous sebaceous glands. They are placed closer together below than above; and at their junction behind, a small bridle calr led the fourchette, extends across, which is generally torn whenever a child is born. The nymphse at first appear to be merely duplicaturcs of the inner surface of the labia, but they are, in fact, very different in their structure. They are distinct vascular sub- stances, inclosed in a duplicature of the skin. When injected by filling the pudic artery, each nympha is found to be made up of innumerable serpentine vessels, forming an oblong mass. This at the upper part joins the clitoris, to which, per- haps, it serves as an appendage; whilst the loose duplicature of skin in which it is lodged, by being unfolded, permits the labia to be more safely and easily distended, during the pas- sage of the child, § 3. CLITORIS. The clitoris is a small body resembling the male penis, but has no urethra. It consists of two corpora cavernosa, which arise from the rami of the ischia and pubis, and unite at the symphysis of the pubis. These are furnished with two muscles analogous to the erectores penis of the male. When the crura and nymphse are filled with wax, we find on each side, two vascular injected bodies, one of them in close con- tact with the bones, the other more internal with regard to the symphysis of the pubis. When the one is injected, the other is injected also, and both are connected together at the upper part. The clitoris, formed by the junction of its crura, is apparently about the eighth part of an inch long, a part of it not being seen, and it is supported by a pretty strong suspensory ligament which descends from the symphysis. When distended with blood, it becomes erected and consi- derably longer, and is endowed with great sensibility, § 4. URETHRA. On separating the nymphse, we find a smooth hollow or channel, extending down from the clitoris for nearly an inchj 36 and at the termination of this, and just above the vagina, is the orifice of the urethra, which, although not one of the or- gans of generation, deserves particular attention. The blad- der is lodged in the fore part of the pelvis, immediately be- hind the symphysis pubis; but when distended, it rises up, and its fundus has been known to extend even to the umbi- licus. The urethra is the excretory duct of the bladder; it is about an inch and a half long, and passes along the upper jiart of the vagina, through which it may be felt like a thick fleshy cord. The structure of the urethra is extremely sim- ple, for little can be discovered except the continuation of the internal coat of the bladder, covered with condensed cel- lular substance. On slitting up the canal, numerous mucous lacunse may be discovered in its course, and two of these at the orifice are peculiarly large. The urethra is very vascu- lar, and, when injected and dried, its orifice is perfectly red. In the unimpregnated state, it runs very much in the direc- tion of the outlet of the pelvis; so that a probe, introduced into the bladder, and pushed on in the course of the urethra, would, after passing for about three inches and a half, strike upon the fundus uteri, and, if carried on for an inch and a half farther, would touch the second bone of the sacrum. The uterus being much connected with the bladder at its lower part, it follows, that when it rises up in pregnancy, the blad- der will also be somewhat raised, and pressed rather more forwards; and the vagina being elongated, the urethra, which is attached to it, is also carried a little higher, and, in its course, is brought nearer the inside of the symphysis pubis. In those women who, from deformity of the pelvis, or other causes, have a very pendulous belly, the bladder, during pregnancy, is sometimes turned over the pubis, the urethra curved a little, and its opening somewhat retracted within the orifice of the vagina. When it is necessary to pass the catheter, it is of great consequence to be able to do it readi- ly, and this is by no means difficult to do. The woman ought to be placed on her back, with her thighs separated, and the knees drawn a little up: A bason is then to be placed betwixt the thighs, or a bladder may be tied firmly to the extremity 37 of the catheter, to receive the urine. The instrument is then to be conveyed under the thigh, and the labia separated with the finger. The clitoris is next to be touched, and the finger run gently down the fossa that leads to the orifice of the urethra, which is easily distinguished, by its resemblance to an irregular dimple, situated just above the entrance to the vagina. The point of the instrument is to be moved lightly down the fossa after the finger, and it will readily slip into the urethra. It is then to be carried on in the direction of the axis of the outlet of the pelvis, and the urine drawn off. This operation ought always to be performed in bed, and the patient is never to be exposed. In cases of fractures, bruises, &c. where the woman cannot turn from her side to her back, the catheter may be introduced from behind, witlwut mov- ing her. When the bladder is turned over the pubis, as hap- pens in cases of great deformity of the pelvis, it is some- times requisite to u$e either a flexible catheter, or a male catheter, with its concavity directed forward. When the uterus is retroverted, if we cannot use a female catheter, we may employ a male catheter, directing the concavity back- wards. When the head of the child in labour has entered the pelvis, the urethra is pushed close to the symphysis of the pubis; then the flexible or flat catheter must be intro- duced parallel to the symphysis, and the head of the child may be raised up a little with the finger. This, indeed, of itself, is sufficient to allow the urine to flow; and when the urine is retained after delivery, it is often sufficient to raise up the uterus a little with the finger. § 5. ORIFICE OF VAGINA AND HYMEN. The orifice of the vagina is situated nearly opposite to the anterior part of the tuberosity of the ischium, about an inch and a half below the symphysis of the pubis, and in the di- rection of the axis of the outlet of the pelvis. It is, in all ages, but more especially in infancy, considerably narrower than the canal itself, and is surrounded by a sphincter mus- cle, which arises from the sphincter ani, and is accompanied with a vascular plexus, called plexus retiformis. In children, 36 it is always shut up by a membrane called the hymen, which consists of four angular duplicatures of the membrane of the vagina; the union of which may be discovered by corres- ponding lines on the hymen. At the upper part there is a semilunar vacancy, intended for the transmission of the menses. Sometimes it is imperforated, or partially or totally absorbed. When the hymen is ruptured, it is supposed to shrivel into three or four small excrescences at the orifice of the urethra, called the carunculae myrtiformes.(i) Immediately below the orifice of the vagina, there is a short sinus within the labia, which extends farther back than the vagina. This has been called the fossa navicularis, and reaches to the fourchette. CHAP. IX. Of the Internal Organs of Generation. § 1. VAGINA. The internal organs of generation consist of the vagina, w ith the uterus and its appendages. The vagina is a canal, which extends from the vulva to the womb. It consists principally of a spongy cellular substance, endowed with some elasticity, and having an admixture of in- distinct muscular fibres. It is lined by a continuation of the cutis from the inner surface of the labia; and this lining, or internal coat, forms numerous wrinkles, or transverse rugse, on the anterior and posterior sides of the vagina. They are peculiar to the human female, and are most distinctly seen in the virgin state; but after the vagina has been distended, they are more unfolded, and sometimes the surface is almost smooth. In the whole course of this coat, may be observed the openings of numerous glandular follicles, which secrete a mu- («') Haller, in his Elementa Physiologic, asserts, that the hymen is pecu- liar to the female of the human species ; but Daverney, in a Memoir read before the Institute and the School of Medicine, at Paris, asserts, that it is common to others of the mammalia. 39 eous fluid. In the foetus this is white and milky; in the adult it is nearly colourless. The vagina is very vascular; and when the parts are well injected, dried, and put in oil of tur- pentine, the vessels are seen to be both large and numerous. Just below the symphysis pubis, we observe a great congeries of vessels surrounding the urethra and upper part of the va- gina. The vagina forms a curved canal, which runs very much in the course of the axis of the outlet and cavity of the pelvis. It is not round, but considerably flattened; it is wider above than below, being in young subjects much contracted about the orifice. At its upper part, it does not join the lips of the os uteri directly, but is attached a little above them, higher up behind than before, so that the posterior lip of the uterus is better felt than the* anterior. In the infant, the vagina is at- tached still higher up, so that the lips of the uterus project in it something like a penis. The inner coat of the vagina is reflected over the lips of the uterus, and passes into its cavity, forming the lining of the uterus. The junction of the uterus and vagina is so inti- mate, that we cannot make an accurate distinction betwixt them; but may say, that the one is a continuation of the other. The vagina adheres before very intimately to the urethra, behind, it comes gradually to approach to the rectum, and at its upper part it is pretty firmly connected to it. This union forms the recto-vaginal septum. These connections of the vagina are formed by cellular substance, there being only a very small part of its upper extremity covered with perito- neum. When the finger is introduced into the vagina in situ, the urethra is felt on its fore part, resembling a firm fleshy cylin- der. Behind, the rectum can be traced down to the point of the coccyx. At the side, the ramus of the ischium and of the pubis, together with the obturator internus muscle arc to be distinguished. In a well formed pelvis, the finger cannot easily reach beyond the lower part of the sacrum; during la- bour, however, the parts being more relaxed, the bone may be 40 felt more easily* but its promontory cannot be touched with the finger. § 2. UTERUS AND ITS APPENDAGES. The uterus is a flat body, somewhat triangular in its shape, being considerably broader at its upper than at its under part. It is scarcely three inches in length, about two inches broad above, and one below. It is divided by anatomists into the fundus or upper part, which is slightly convex, and lies above theinsertion of the fallopian tubes; the cervix or narrow part below; the body, which comprehends all the space betwixt the fundus and cervix; and last of all, the os uteri, which is the termination of the cervix, and consists of a small trans- verse chink, tlie two sides of which have .been called the lips of the uterus. The uterus contains a small cavity of a trian- gular shape, which opens into a narrow channel formed in the cervix, and is continued down to the os uteri. At the upper angles may be perceived the openings of the fallopian tubes. Both the cavity and the channel are lined with a continua- tion of the inner coat of the vagina, but it has a very different appearance from that which it exhibits in the vagina. The surface of the triangular cavity is smooth, and the skin which covers it is very soft and vascular. The surface of the cer- vical channel again is rugous, and the rugse are disposed in a beautiful foliated manner, so as to have some resemblance to a palm tree. This part is by no means so vascular as the cavity above; but it contains betwixt the rugse several lacunae, which secrete a mucous fluid. Where the cavity of the uterus terminates in the channel of the cervix, there is sometimes a slight contraction of the passage. The substance of the uterus is made up of numerous fibres, disposed very irregularly, and having a considerable quantity of interstitial fluid interposed, with many vessels ramifying amongst them. A dense succulent texture is thus formed, • which constitutes the substance of the uterus. On cuttinc open the womb, we observe that its sides are about a quarter of an inch thick, but are rather thinner at the fundus, than 41 elsewhere, though the difference is very trifling. Several ir-* regular apertures may be perceived on the cut surface: these are the venous sinuses. The fibres which we discover are muscular; but we cannot, in the unimpregnated state,observe them to follow any regular course. The arteries of the uterus are four in number, with corres- ponding veins. The two uppermost arteries arise either high up from the aorta, or from the emulgent arteries. They de- scend, one on each side, in a serpentine direction behind the peritoneum, and are distributed on the ovaria, tubes, and upper part of the uterus. These are called spermatic arteries..The two lowermost, which are called uterine, arise from the hypo- gastric arteries. They run, one on each side, toward the cer- vix uteri, and supply it and the upper part of the vagina. Thus the fundus uteri is supplied by the spermatic arteries, and the cervix, by the uterine arteries; and these, from opposite sides, send across branches which communicate one with the other. But besides this distribution, the uterine artery is con-, tinued up the side of the uterus, and meets with the spermatic; so that, at the two sides, we have arterial trunks, from which the body of the uterus is liberally supplied with blood. The veins correspond t(; the arteries. The nerves of the uterus, like the blood vessels, have also a double origin, and follow nearly the same course. Those which come from below are derived from the sacral nerves, especially from the fourth pair. Those from above come chiefly from the mesocolic plexus, and trunk of the intercostal. The renal plexus furnishes nerves to the ovarium. The lymphatics, in the unimpregnated state of the uterus, arc small, and not easily discovered. Those from the upper part of the womb, and from the ovaria, run along with the spermatic vessels, terminating in glands placed by the side of the lumbar vertebrse. Hence, in diseases of the ovaria, there may be both pain and swelling of the glands. But the greatest number of lymphatics run along with the uterine artery, several of them passing to the iliac and sacral glands, and some accompanying the round ligament. This may ex- plain why, in certain conditions of the uterus, the inguinal F 42 glands swell. Others run down through the glands of the vagina; and hence, in cancer of the womb, we often feel those glands hard and swelled, sometimes to such a degree, as almost to close up the vagina. The uterus is covered with the peritoneum, which passes off from its sides, to reach the lateral part of the pelvis, a little before the saero-iliac symphysis; and these duplicatures, which, when the uterus is pulled up, seem to divide the ca- vity of the pelvis into two chambers, are called very impro- perly the broad ligaments of the uterus. A\ hen the uterus is raised, and those lateral duplicatures of the peritoneum are stretched out, we observe, that at the upper part they form two transverse folds or pinions, one be- fore, and the other behind. In the first of these, the fallopian tubes are placed; in the second, the ovaria. Besides these duplicatures, we likewise remark o'.her two, which extend from the sides of the fundus uteri to the linea ilio-pectinea at the side of the pelvis, and then run on to the groin. These contain, on each side, a pretty thick cord, which arises from the fundus uteri, and passes out at the in- guinal canal, being then lost in the labia pudendi. These cords, which are called the round ligaments of the uterus, consist of numerous blood-vessels, some lymphatics, small nerves, and fibrous matter. The fallopian tubes, in quadrupeds, are merely continua- tions of the horns of the uterus; but in the human female, they are very different in their structure from the womb. They appear to consist in a great measure of spongy fibrous substance, which, as Haller observes, may be inflated like the clitoris. This is hollow, forming a canal of about three inches long, lined with a continuation of the internal coat of the uterus; and as they lie in the anterior pinion of the broad ligaments of the uterus, they are covered of necessity with a peritoneal coat. They originate from the upper cor- ners of the uterine cavity by very small orifices, but termi- nate at the other extremity in an expanded opening with ragged margins, which are called the fimbrise of the tube. 43 The internal surface of the canal is plaited, the plicae run- ning longitudinally. The ovaria1 lie in the posterior pinion of the broad liga- ment. They are two oval flattened bodies, of a whitish co- lour, and glandular consistence. They are cellular, but not very vascular, although vessels run to their coat. After pu- berty, they contain numerous minute vesicles, the largest of which are near the surface, and even form slight projections from it. These are the ova of the female, and are filled with a coagulable lymphatic matter. Their number is uncertain, but Haller says he never saw above fifteen in one woman. In old women they disappear, or shrivel. The ovarium is covered with the peritoneum; but when the ovum is impregnated and becomes prominent, the peri- toneum which covers it is absorbed, the ovum passes into the fallopian tube, and the little scar which remains on the sur- face of the ovarium, is called corpus luteum. In the fcetus, the ovaria and tubes are placed on the psose muscles; but in the adult, they lie loosely on the pelvis, and the uterus sinks within the cavity. The os uteri is directed forward, and the fundus backward, being in general found opposite to, or resting on the second bone of the sacrum. CHAP. X. Of the Diseases of the Organs of Generation. § 1. ABSCESS IN THE LABIUM. The labia are subject to several diseases: of- these, the first which I shall mention, is phlegmonoid inflammation. This may occur at any period of life, and under various cir- cumstances; but frequently it takes place in the pregnant state, especially about the sixth and seventh month of gesta- tion, and sometimes it appears suddenly, oftener than once in the same pregnancy; occasionally it makes its attacks in child-bed, in consequence of the violence which the parts may have sustained in labour. It is marked by the usual 44 symptoms of inflammation, namely, heat, pain, throbbing, and more or less swelling, not unfrequently attended witl* fever. The swelling is sometimes hard and moveable, like a gland, especially when the progress is slower than usual. In general, the course of the disease is rapid, the pain and in- flammation arc at first very acute, and the part swells speed- ily. In a few hours, especially if a poultice have been appli- ed, the abscess begins to point at the inside of the labium, and the nympha is either lost, or if it remain, appears push- ed out of its place. Sometimes it bursts within thirty-six hours from its appearance. By means of cold saturnine appli- cations, and gentle laxatives, the inflammation may some- times be resolved, but most frequently it ends in suppuration, which is to be promoted by fomentations and warm cata- plasms. If necessary, an opiate may be given to abate the pain, and a pillow must be placed between the knees, to keep the part from pressure. If possible, the abscess ought not to be punctured, but, if the pain and tension be unbearable, we must indulge the patient by making a small opening; a good deal of blood will in this case come with the matter. After the abscess bursts, the parts may be dressed with any mild ointment. Should the opening of the abscess be higher than its bottom, it will be necessary, if the discharge continue*, to lay it open, after which it will speedily heal. § 2. ULCERATION OF THE LABIA. The internal surface of the labia is often the scat of ulce ration and excoriation, which may generally be avoided by the daily use of the bidet. The most general form under which excoriation appears, is that of a raw surface, as if the cuticle had been peeled from a blistered part. Most frequently these sores are the consequence of acrimony, produced by inattention to cleanliness, especially in children1; and in their case the labia, if care be not taken, may cohere. The treatment consists in keeping the parts clean, bathing the sore with a weak solution of sulphate of zinc, and preventing * Vide Mr. Hey's Surgical Observations, chap, xvii, 45 cohesion. Should the parts not heal readily, they may he washed with brandy, or a very weak solution of nitrate of silver, or touched with caustic. When adhesion takes place, it may, if slight, be destroyed, by gently pulling the one la- bium from the other; if firmer, the parts must he separated with the knife. In either case, re-union must be prevented, by washing the surface frequently with solution of alum, and applying a small piece of lint spread with simple ointment. Simple itching of the parts may be removed by the tepid bath, a dose of castor oil, and fomenting the parts with milk and water. Sometimes we meet with deeper ulcerations, which it is of great importance to the domestic happiness of individuals to distinguish from chancre. Nothing seems easier in a book, than to make the diagnosis, but in practice it is often very difficult. A well marked chancre begins with circumscribed inflammation of the part; then a small vesicle forms, which bursts, or is removed by slough, and displays a hollow ulcer, as if the skin had been scooped away or nibbled by a small animal; its surface is not polished, but rough, and covered with pus, which is generally of a buff or dusky hue; the margins are red, and the general aspect of the sore is angry. But the most distinguishing character of the chancre, is con- sidered to be a thickening or hardness of the base and edges of the ulcer. The progress of the sore is generally slow, either towards recovery or augmentation. When remedies are used, the first effect produced is removing the thickening by degrees, and lessening the discharge, or changing its na- ture, so that the surface of the sore can be seen; it has then in general a dark fiery look, which continues until all the diseased substance be removed, and the action of the part be completely changed, Now, from this description, we should, it may be supposed, be at no loss in saying, whether a sore were venereal; but in practice, we find many deviations from this description. The thickening may be less in one case than another, and may not be easily discovered, yet the sore may be certainly venereal. Peculiarity of constitution, or of the part affected, can modify greatly the effects of the 46 virus. There may be extensive inflammation, or phagedaenic ulceration: and yet the action may be venereal. It is, how- ever, satisfactory to know in these cases, that in a little time, unless extensive sloughing have taken place, the ap- pearance of the sore becomes more decided, the proper cha- racter of chancre appears, and the usual remedy cures the patient. Phagedena is very troublesome, and sometimes a formi- dable disease, especially to infants. I shall here only notice that form which appears in adults, and which, as it is infec- tious, may be mistaken for syphilis. It commences with a livid redness of the part, succeeded speedily by vesication and ulceration, which extends laterally, and sometimes pe- netrates deep. The ulcer has an eating appearance, is pain- ful, discharges a great quantity of matter, and very often is attended with fever. A variety of this disease is attended with superficial sloughing, which may be frequently repeat- ed, and is generally preceded by a peculiar appearance of cleanness in the sore. This is not to be confounded with sloughing, produced by simple inflammation or irritation of the parts, which is similar in its nature and treatment to common gangrene. We must foment the sore with decoction of camomile flowers, mixed with a little tincture of opium, and then apply mild dressings. Rest is essential to the cure: and if a febrile state exist, it is to be obviated by laxatives, acids, mild diaphoretics, and decoction of bark. If there be no fever, mercury, or the nitrous acid, often effectually change the action of the parts. Sometimes irritable sores appear on different parts of the labia, or orifice of the vagina, in succession, healing slowly one after another. These have an inflamed appearance, the margins are sometimes tumid, and the surface is at first ir- regular and depressed, but afterwards it forms luxuriant granulations. There is another sore met with on the inside of the labium, and which generally spreads to the size of a sixpence. The surface is quite flat, and sunk a little below the level of the surrounding parts. The margins are thick- ened, and sometimes callous, the discharge thin, and the 47 ulcer not in general painful, the surface soft and spongy with- out a hard base. These sores generally agree best with sti- mulants, especially caustic and escharotics. AVhen they do not yield to this treatment, it will be proper to have recourse to a cautious course of mercury. Some of these, like the phagedena, are infectious. Some of these sores are occasionally productive of second- ary symptoms, such as ulcers in the throat. When these succeed a sore, which has run its course differently from chancre, and been healed without the use of mercury, it is allowable to suppose, that they also may be cured, merely by attending to the general health, and perhaps by local ap- plications. But if they continue without amendment, or threaten danger to any important part, we must not delay making trial of mercury. § 3. EXCRESCENCIES OF THE LABIA. Sometimes after a slight degree of inflammation, produc- ing heat and itching of the parts, numerous excrescences appear within the labia. These are either soft and fungous, or hard and warty. Both of these states may be induced by previous venereal inflammation; but they may also occur in- dependently of that disease. Even where there is an offen- sive discharge from the fungi or warts, we are not always to conclude that they are syphilitic, but must be guided in our judgment by concomitant circumstances. Warty excres- cences are most readily removed, by the application of savin powder by itself, or mixed with red precipitate; and during its operation, the parts may be washed with lime water. The powder must be applied close to the roots of the warts, for their substance is almost insensible. Fungous excrescences may sometimes be removed by ligature; but when the parts are sensible, they must be destroyed, by applying a strong solution of caustic with a pencil, or sprinkling them with es- charotic substances. If these cannot be borne, we must first abate the sensibility by tepid fomentations with decoction of poppies, or water with a little tincture of opium, or decoction of cicuta, or weak infdsion of brlladona. Should there be 48 ground for suspecting a syphilitic action, mercury must he given, at the same time that \vr make suitable local applica- tions: but in doubtful cases, I have seen this medicine given without any benefit. These excrescences, from their appear- ance, their great pain, and foetid discharge, may suggest an opinion of their being cancerous; but they begin in a differ- ent way, and generally yield, though sometimes slowly, to proper applications. § 4. SCIRRHOUS TUMOURS. Solid tumours may form in the labia, and arc distinguish- ed by their hardness, and by their moving under the skin, until adhesion from inflammation takes place. These tumours are sometimes scrophulous and have little pain, even \\lien they have gone on to suppuration. Oftencr, however, they arc cancerous; and these are distinguished from the former, by their greater hardness and inequality, and by their shoot- ing pain. If they are not removed, the cancerous abscess points to the inner surface of the labium, its top becomes dark coloured, sloughs off, a red fluid is discharged, and pre- sently a fungus appears. Soon after this, the glands at the top of the thigh, and sometimes those in the course of the vagina, swell. If all the diseased parts can be removed, an operation must be performed. If they cannot, we must palli- ate symptoms by proper dressing and opiates. § 5. POLYPOUS TUMOURS. Soft fleshy appendicular, or firm polypous tumours some- times spring from the labia. Both of these, especially the latter, may give trouble by their weight or size. They may also, by being fretted, come to ulcerate, and the ulceration is always of a disagreeable kind. They ought to be, there- fore, early removed by the knife or the ligature. If the base be broad, the double ligature must be employed; but should there be any hardness about the part where the ligature would be applied, it is best to dissect the whole growth out. 49 Encysted tumours may form in the labia. They are elas- tic, and contain a glairy fluid. A seton may be passed, or the cyst may be laid open.(fc) § 6. (EDEMA. OEdematous tumour of the labium is either a consequence of pregnancy, or a symptom of general dropsy. The tumour is variable in its size. When it depends on pregnancy, it is seldom necessary to do any thing; and even in time of la- bour, although the tumour be great, we need be under little apprehension, for it will yield to the pressure of the child's head. But if at any time, during gestation, the distension be so great as to give much pain, then one or two punctures may be made, in order to let out the fluid, but this is very rarely necessary. Gentle laxatives are generally useful. Blisters applied to the vicinity of the part have been pro-' posed, but they are painful and inconvenient. When the swelling depends on dropsy, diuretics are to be employed; but if the woman be pregnant, they must be used cautiously. § 7. HERNIA, LACERATION, &C. Pudendal hernia is formed in the middle of the labium. It may be traced into the cavity of the pelvis, on the inside of the ramus of the ischium, and can be felt as far as the vagina extends. It differs farther from inguinal hernia, which also lodges in the labium, in this, that there is no tumour discov- erable in the course of the round ligament from the groin. It sometimes goes up in a recumbent posture, or it may by pressure be returned. A pessary has little effect in keeping it up, unless it be made inconveniently large. It is not easy to adapt a truss to it, but some good is done with a firm T- bandage, or one similar to that used for prolapsus ani. If it cannot be reduced, we must support it by a proper bandage, which is not to be drawn tight. (i) Would it not be more eligible, when practicable, to extirpate the cyst completely by the knife, to prevent the risk of its sloughing away. G 50 Sometimes the labia are naturally very small, at other times uncommonly large; one side maybe larger than the other. Laceration of the labia is to be treated like other wounds. When the hemorrhage is great, the vagina must be plug- ged, and a firm compress applied externally, with a proper bandage. § 8. DISEASES OF THE NYMPH2B. The most frequent disease to which the nympha is sub- ject, is elongation. When the part protrudes beyond the la- bia, it becomes covered with a white and more insensible skin. But sometimes it is fretted, on which account, or from other causes, women submit to have the nympha cut away. This is done at once by a simple incision; but, as the part is exceedingly vascular, we must afterwards restrain the he- morrhage, either with a ligature or by pressure. By neglect, the patient may lose blood, even ad deliquium. In some coun- tries, this elongation of the nympha is very common.1 In others, the nymphse, together with the preputium clitoridis, are removed in infancy.2 The nymphse are subject to ulcera- tion, tumour, and other diseases, in common with the labia. Sometimes by falls, but oftener3 in labour, the vascular structure of the nympha is injured, and a great quantity of blood is poured out into the cellular substance of the labia. producing a black and very painful tumour.4 This may take place even before the child is expelled; and, in a case of this kind, the midwife, mistaking this swelling for the protruded membranes, actually perforated the labium, and caused a considerable discharge of blood.5 More frequently, however, the tumour appears immediately after delivery,6 and the at- tention is directed to it both by its magnitude and its sensi- bility, which is sometimes so great as to cause syncope. It is tense, throbbing, and may also be accompanied by severe pain in the legs, and violent bearing down efforts,7 as if ano- ther child were to be born, or, as if the womb were inverted. It has, however, been known to advance so slowly, as not to attract attention for two days. There are also instances 51 where the inflammation runs high, and the recto-vaginal sep- tum sloughing, faeces are discharged by the vagina.8 In the course of a short time the tumour bursts, and clotted and fluid blood is discharged. This process should be hasten- ed by fomentations and poultices, and the pain be abated by opiates; but if it be very great, relief may be obtained, by making a small puncture in the inside of the labium.9 Whe- ther the tumour burst, or be punctured, the previous inflam- mation may close the vessels so as to prevent hemorrhage; but if it do not, the vagina is to be gently filled with a soft cloth to prevent the fluid from extending along the sides of the pelvis. A compress is also to be firmly retained exter- nally, to check all hemorrhage from the aperture. If inflam- mation run high, it is to be abated by the usual means. § 9. DISEASES OF THE CLITORIS. The clitoris may become scirrhous, and even be affected with cancerous ulceration. In this disease, it is generally thickened, enlarged,10 and indurated, and the patient com- plains of considerable pain. Presently ulceration takes place, and fungus shoots out. In no case of this kind that I have met with, has an operation been submitted to; and, in- deed, unless the whole of the diseased part can be removed, we must be satisfied with palliating symptoms. In one case, however, related by Kramer,u where the clitoris was enlarg- ed, with cauliflower-like excrescences, and the right nym- pha indurated, the parts were successfully removed by the knife, after failing with the ligature, which produced insup- portable pain. The clitoris sometimes becomes preternaturally elongat- ed ; and if this take place in infancy, and be accompanied with imperfect or confused structure of the other parts, the person may pass for a hermaphrodite." This is said to be most frequent in warm climates; and in these, extirpation is sometimes performed. Haller assigns a cause for the en- largement. 52 § 10. DISEASES OF THE HYMEN. The most frequent disease of the hymen is imperforation ; in consequence of which the menses are retained,13 the ute- rus is distended, and the orifice of the vagina protruded, so as sometimes to resemble polypus, or a prolapsus uteri." Even the perinaeum may be stretched, as if the head of a child rested on it.15 Menstruation is generally painful, and * the uterus becoming enlarged, contraction at last takes place, and pains like those of labour come on, especially about the menstrual period;16 such a case may, therefore, by inattention, be mistaken for parturition.17 The sufferings of the patient are, in some instances, increased by the addition of suppression of urine,18 or pain in passing the faeces,19 or convulsions*. Imperforated hymen is by no means uncom- mon, and the treatment is very simple, for the part is easily divided.20 The retained fluid is thus evacuated, sometimes in very great quantity. It has very rarely the appearance of blood, being generally dark coloured, and pretty thick, or even like pitch. Febrile and inflammatory symptoms may follow the operation.21 The hymen is sometimes perforated as usual, but very strong, so as to impede the sexual intercourse; yet in those cases impregnation has taken place, and the hymen has been torn,22 or cut in the act of parturition. Conception may take place, although the hymen be imperforated.! When the hymen is torn in coitu, some blood is evacuated, which, in many countries, is considered as a mark of vir- ginity. But as even the presence or absence of a hymen cannot be looked upon as affording any certain proof relative to chastity, this test must be considered as altogether doubt- ful. When the hymen is ruptured, and there is an inflamma- tion about the external parts, some have, in cases of alleged rape, considered the crime as proven. But whoever atten- • Vide Case by Mr. Fynney, in Med. Comment. Vol. III. p. 194. f Vide Ambrose Pare", Hildanus, cent. III. ob. 60__Ruysch, ob. 22.— Mauriceau, ob. 439- 53 tively examines the subject must admit, that these are very fallacious marks; that they may exist without any violence having been employed; and that a woman may have, if pre- viously stupified, been violated without exhibiting any mark of injury. Practitioners therefore ought, in a legal question of this nature, to be cautious how they give any opinion, especially if they have not seen the person immediately after the crime has been committed.* § 11. LACERATION OF THE PERINEUM. The perinseum may be torn during the expulsion of the head or arms of the child. In many cases, the laceration does not extend farther back than to the anus, nor even so far. This is a very simple accident, and requires no other man- agement than rest, and attention to cleanliness. But as the recto-vaginal septum is carried forwards and downwards, when the perinaeum is put on the stretch previous to the ex- pulsion of the head, it sometimes happens, that the laceration extends along this septum, and a communication is formed betwixt the rectum and vagina. In some cases, the sphinc- ter ani remains entire, although the rectum be lacerated; in others it also is torn. This accident is attended with consi- derable pain and hemorrhage, and succeeded by an inability to retain the faeces, which pass rather by the vagina than the rectum. Prolapsus uteri is also, in some instances, a conse- quence of this laceration. This accident is sometimes pro- duced by attempts to distend the parts previous to delivery, or by the use of instruments; but it may also take place, even to a great degree, in a labour otherwise natural and easy, and in which no attempts have been made to accelerate delivery. The most effectual way to prevent laceration is by supporting the perinseum with the hand, when it is stretch- ed, and keeping the head from being suddenly forced out. When the parts have been actually torn, our first attention is to be directed to the repression of the hemorrhage, which . * Vide Baudelocque, l'Art, &c. sec. 342, et Fodere Med. Legale, Tome II. p. 3.—Mahon Med. Legale Tome. I. p. 119, and seq. 54 is sometimes considerable; and this is best affected by com- pression and rest, which favour the formation of -coagula. Next, we arc to consider how the divided parts may he unit- ed. Rest, and retaining the thighs as much together as pos- sible, together with frequent ablution, in order to remove the urine, which sometimes, for a few days flows involuntarily, or the lochia and stools, are requisites in every mode of treat- ment. As there is nothing in the structure of the parts to pre- vent their re-union, it has very feasibly been proposed to in- duce a state of costiveness, and prevent a stool for many days. But with only one or two exceptions, this method has failed; the subsequent expulsion of the indurated fseccs tear- ing open the parts, if adhesion had taken place. An opposite practice, that of keeping the bowels open, and the stools soft or thin, by gentle laxatives, has been much more successful, the parts in some instances healing in a few weeks. During this period, the stools are, at least for a time, passed some- times involuntarily; but in other instances, they can from the first be retained, if the patient keep in bed. Sutures have been also employed, and ought eertainly to be had recourse to, if re-union cannot otherwise be effected. If necessary, the edges of the divided parts must be made raw. It would appear that there is no occasion for putting a ligature in the recto-vaginal septum. It is sufficient to place two in the pe- rinseum. When the sphincter ani remains entire, but the sep- tum is torn, some have considered it necessary to divide that muscle; but others, with more reason, omit this practice. During the cure, some introduce a canula into the vagina, to support the parts, and others apply compresses dipped in balsams; but I believe it is better to apply merely a pledget, spread with simple ointment to the part. If the radical cure fail, the patient must use a compress, retained with a T-ban- dage23. § 12. IMPERFECTION OF THE VAGINA. The vagina may be unusually small. I have known it not above three inches long, and sometimes it is very narrow. If the size prevent coition, it may be enlarged with a tent 55 of prepared sponge*. Should pregnancy take place before it be fully dilated, we need be under no apprehension with re- gard to delivery; for during labour, or even long before it, relaxation24 takes place. Sometimes the vagina is wanting or impervious, or all the middle portion of the canal is filled up with solid matter. More frequently, however, there is only a firm septum stretched across, behind the situation of the hy- men, or higher up in the vagina; and this25 it may be neces- sary to divide. In some cases, there is a great confusion of parts, and, indeed, it is impossible to describe the varieties of conformation; for the vagina may follow a wrong course, or communicate with the urethra, or the rectum26 may ter- minate in the vagina, &c. Malformation does not always pre- vent pregnancy27. § 13. INFLAMMATION AND GANGRENE OF THE VAGINA. In consequence of very severe labour, inflammation, fol- lowed by gangrene, may take place in the vagina. If the sloughs be small, then partial contraction of the diameter of the canal may take place, and produce much inconvenience from retention of the menses28, or during a subsequent la- bour ; but in this last case, the parts gradually yield, and it is seldom necessary to perform any operation: the pain, how- ever, is sometimes excruciating till the part yieldsf. In some instances the sloughs are so extensive, that the whole vulva is destroyed, or part of the urethra and vagina comes away, or general adhesion takes place, leaving only a small opening, through which the urine and the menses flow. Should this, by any means be stopped up for a time, the dis- charges cannot take place; and sharp pains, or even convul- sions, may be the consequence. Sometimes calculous concre- tions form beyond the adhering part:):. Whenever we have reason to expect a tender state of the parts after delivery, we must be exceedingly attentive; and • Vide Van Swieten Comment in aph 1290. t Harvey, exercit. LXXIII. p. 492. jfVide Puzos Traiti, p. 140—Case by Mr. Purton, in Med. and Phys. Jour. Vol. VI. p. 2. 50 if the vagina, or any other organ, be inflamed or tender, we must bathe the parts frequently, and inject some tepid water gently, to promote cleanliness. Saturnine fomentations and injections are often of service, but they must not be thrown high. The urine must be regularly evacuated; and should a slough take place, we must, by proper dressings, or the use of a thick bougie, prevent coalescence of the vaginal canal29. § It. INDURATION, ULCERATION AND POLYPI. The vagina may be contracted by scirrhous glands in its course, or induration of its parietes, which become thick and ulcerated, and communicate with the bladder or rectum. This disease is generally preceded by, or accompanied with, scirrhous uterus, and requires the same treatment. Foreign bodies in the vagina may produce ulceration, and fungous excrescences. The source of irritation being remov- ed, the parts heal; but we must, by dressing and injections, prevent coalescence. Polypous tumours may spring from the vagina, and are to be distinguished from polypus of the uterus by examination. The diagnosis betwixt polypus and prolapsus, or inversio uteri, will be afterwards pointed out. The cure is effected by the application of the ligature more solito. § 15. INVERSION. The vagina may be inverted or prolapsed, without a pro- cidentia uteri. The nature of this disease is similar to pro- lapsus ani. We find a fleshy substance protruding at the back part of the vulva, having an opening in the centre, or toward one side. At first it is soft; but after sometime, if the part has been irritated, it may inflame, indurate, or ulcerate. It is cured by astringent injections, tonics, and, if these fail, by a pessary, or by pregnancy*; but it sometimes returns after delivery30. In prolapsus vaginse, the urethra must be turned out of its course, and even the bladder may be pro- truded31. If the catheter be required, it must be introduced with its point directed backwards and downwards. * Pechlin, lib. 1. obs. 20. 57 § 16. WATERY TUMOUR. Water sometimes passes down from the abdominal cavity, betwixt the vagina and rectum, protruding the posterior sur- face of the vagina in the form of a bag; and the accumula- tion of water in the cavity of the pelvis is sometimes so great, as to obstruct the flow of the urine, or produce strangury. When the person lies down, the swelling disappears. If large, a candle held on the opposite side, sometimes shews it to be transparent; and in every case, fluctuation may be felt. As this symptom is connected with ascites, the usual treat- ment of that disease must be pursued, and, if necessary, the water may be drawn off by tapping the abdomen, or ra- ther by piercing32 the tumour, which is to be rendered tense, by pressing it with the finger. § 17. HERNIA. Sometimes the intestine passes down betwixt the vagina and rectum, forming perineal hernia, or protrudes either at the lateral or posterior part of the orifice of the vagina, like the watery tumour; but is distinguished from it by its firmer and more doughy feel, and by the manner in which it can be returned. By handling it, a gurgling noise may be heard, and sometimes indurated faeces may be felt. As the os uteri is pushed forward, and the posterior part of the vagina occu- pied by the herniary tumour, this complaint may put on some appearance of retroverted uterus. A case of this kind is mentioned by Dr. John Sims, in Mr. Cooper's work on her- nia. This complaint is frequently attended with a bearing down pain; and on this account, as well as from its appear- ance, it has also been mistaken for prolapsus uteri. Some- times the tumour does not protrude externally; but symp- toms of strangulated hernia may appear, the cause of which cannot be known, unless the practitioner examine the vagi- na. In a case occurring to Dr. Maclaurin, and noticed by Dr. Denman, the patient died on the third day, and the disease was not discovered till the body was opened. Should H 58 a woman have vaginal hernia during pregnancy, we must be careful to return it before labour begin, for the intestine may become inflamed, and the f.eecs obstructed, by the head entering the pelvis: or the labour itself, if the head can- not be raised and the intestine returned, may be impeded so much, as to require the use of instruments. Vaginal hernia requires the use of a pessary. The rectum sometimes protrudes into the vagina. This is remedied by the sponge or globe pessary. § 18. ENCYSTED TUMOUR AND VARICES. Indolent abscess, or encysted tumours, may form betwixt the vagina and neighbouring parts. These are distinguished from hernia and watery tumours, by being incompressible, and not disappearing by change of posture. The history of the disease assists the diagnosis, and examination discovers the precise scat and connections of the tumour, though it can- not with certainty point out the nature of the contents. These tumours seldom afford obstinate resistance to delivery; by degrees they yield to the pressure of the head, but sometimes they return after delivery. The treatment is similar to that required in other cases of tedious labour, and the tumour should not be opened if we can deliver the woman otherwise. Even in the unimpregnated state, unless inconvenience be produced, we ought not to perform any operation; but if it cause irritation, or if the bulk of the tumour be so great as to impede the evacuation of the urine or faeces, an opening must be made. Varicose tumours of a knotted form, disappearing or be- coming slack by pressure, and aneurismal tumours^ distin- guishable by their pulsation, may form about the vagina, and ought not to be interfered with, except by supporting them with a sponge in the vagina. § 19. ERYSIPELATOUS INFLAMMATION. The orifice of the vagina, together with the labia, and in- deed the whole vulva, may be affected by erysipelatous inom- ination. This appears under two conditions: 1st, it may ori- 59 ginate in the vulva, and spread inwards, even to the uterus; or, 2dly, it may begin in the womb, and extend outwards. The parts are tumid, painful, and of a dark red colour. The second affection is most frequent after parturition; but the first may occur at any age, and under a variety of circum- stances. It may be confined to the external parts alone, or it may quickly spread within the pelvis, and destroy the patient; for tlris disease generally terminates in gan- grene. Vigarous* says, this state may be distinguished from abscess of thelabium, by both labia being equally affected. The general history of the case, and proper examination, will point out the difference. When the disease is confined to the external parts, we may hope for a cure, and even for the preservation of the parts, by giving early, bark and opium internally, and applying to the surface pledgits dipped in camphorated spirit of wine, or vinous tincture of opium, made with half a dram of opium to each ounce of wine. When these applications give continued pain, fomentations with milk and water, or with decoction of chamomile flowers may be substi- tuted. A highly sensible or inflamed state of the parts may occur in nymphomania, or libidinous madness, either as a primary or secondary affection; and should the patient die under the disease, the parts are generally found black. The tepid bath and fomentations give relief, but sometimes spiritous appli- cations are beneficial. If the patient be feverish, she ought to be blooded, and have cathartics administered, and be put on spare diet. Nauseating doses of tartar emetic, or full do- ses of the medicine, given so as to operate briskly, are of ser- vice, especially if followed by sleep. Strict and prudent at- tention must be paid to the mind. § 20. FLUOR ALB US. The vagina is always moistened with a fluid, secreted by the lacunae on its surface. When this is increased in quantity, and changed in colour, it is known under the improper name ' Maladies des Femmes, Tome II. p. 169. 60 of gonorrhoea. When this is unaccompanied with inflammation, and independent of the application of venereal matter, it has been called the benign gonorrhoea, or is considered as a species of fluor alb us. Others confine the term fluor albus, or leucorrhtea. strictly to a discharge from the inner surface of the womb ; and in order to determine whether the secretion proceeds from the uterus or not, it has been proposed to stuff the vagina completely for some time, and then inspect the plug, to ascertain whether that part corresponding to the os uteri be moistened*. But this test is not satisfactory, and will seldom be submitted to. When the discharge proceeds from the womb, it some- times injures the function of that organ so much, or is de- pendant on a cause influencing the uterus so strongly, as to interfere with menstruation, either stopping it altogether, or rendering it too abundant or irregular in its appearance, and in such cases the woman seldom conceives. Very fre- quently, however, the menses do continue pretty regularly; and in those cases, the white discharge disappears dur- ing the flow of the menses, but is increased for little be- fore and after menstruation. When the menses are obstruct- ed, it is not uncommon for the fluor albus to become more abundant, and to be attended with more pain in the back about the menstrual period. If a woman, who has leucor- rhoea conceives, the discharge generally stops. In some cases, however, pregnancy produces a discharge of glary fluid, which it has been thought dangerous to check suddenly. Other women are subject to a similar discharge after any fatigue, but get easily rid of it by rest and attention to clean- liness. The fluor albus is almost always accompanied with a pain in the back and loins, and often with a feeling of weakness. Dyspeptic symptoms, and uneasy sensations, are very gene- rally produced; the countenance is less healthy than former- ly, the strength is reduced, and sometimes the patient is feverish and emaciated, or has oedematous swelling of the feet. The colour of the discharge is variable, being sometimes * Chambon Malad.des Filles, p. 104 61 white or yellow, without smell, and sometimes dark coloured and offensive. In the mildest form, the discharge is pale or glary, and unaccompanied by symptoms of much local irrita- tion. In a worse degree, the colour is green or yellow, and there is heat about the parts, with pain in the back and ute- rine region. Foetid discharge is usually connected with a diseased state of the uterus. Should the woman die during the continuance of fluor albus, the uterus is found to have its cavity covered with mucous matter. Fluor albus may be excited by the presence of a polypus in utero, or in consequence of disease of the womb; but in such cases it is symptomatic, and is not at present to be con- sidered. The idiopathic fluor albus may be produced by various causes, such as abortion, menorrhagia, frequent par- turition, excessive venery, cold or fatigue after a miscarri- age or a delivery at the full time, and whatever can weaken the action of the uterus. It was at one time supposed, that it might also be produced by a bad state of the fluids of the body, a bilious cacochymy, a leucophlegmatic habit, catar- rhal affections, passions of the mind, &c. Worms may pro- duce it. The vaginal discharge is attended with slighter effects, but the symptoms are similar in kind, with these differences, viz. that menstruation does not make it disappear, and it continues during pregnancy, nay, is even increased, or some- times brought on by it. Pessaries may have the same effect, and sometimes the prolapsus uteri, for which they are used, causes it. It is very difficult to distinguish betwixt venereal gonor- rhoea, and fluor albus. In the former case, there is at first, at lease, evident marks of inflammation, with a heat and smarting in making water, and the discharge has a purulent appearance. In the latter case, although all these symptoms may be present, yet there is much seldomer smarting or an inflamed state of the parts, and the discharge has more of a mucous appearance. Often, however, we must be deter- mined in our judgment by concomitant circumstances. To- 65 pical applications, such as injections of solution of acetate of lead, sulphate of zinc, infusion of oak bark with opium, *cc. readily cure the gon n riiaa. We do not possess any medicine capable of operating di- rectly on the uferus, and improving its action. We must therefore, employ s'ich means as tend to invigorate the whole frame, and thus indirectly improve the action of the organs of generation; at the same time that we obviate an effect of the discharge, namely, weakness, for this may be an effect as well as a cause. When the disease is symptomatic of po- lypus, cancer, &c. we must attend to its primary cause; but in simple leucorrhoea, we may directly attempt the removal of the discharge, unless it have been of very long standing: in which ease, we have been advised to insert an issue*; but this is perhaps seldom necessary, for the disease docs not yield suddenly. Emetics are of very considerable advan- tage, on account of their operation on the stomach and ali- mentary canal, and are accordingly advised by nost writeisf. Purges have also been used^:, in order to carry off noxious matter; but they are only to be given, so as to keep the bowels regular^, for brisk and repeated purging is hurtful**. Tonic medicines and those which improve the action of the chylopoetic viscera, such as lime water, myrrh, bark, steel, rhubarb, &c. are also of much utility, and along with them we may, with great advantage, employ the cold bath. The diet is to be light and nourishing, and the patient ought not to indulge in too much sleep. Along with these means we may, with decided advantage, when there is no organic dis- ease, make use of astringent injections, such as solution of alum, sulphate of zinc, &c. changing the ingredients, and • Vigarous Malad. des Femmes, Tome I. p. 257. f Smellie, Vol. I. p. 67.—Vigarous, Tome I. p. 261.—Mead, Med. Pre- cepts, chap. XIX. sect 3d—Denman, Vol. II. page 104.—See also Ettmul. ler, Riverius, &c. &c. J Chambon Malad. des Filles, p. 107.—Mead, Med. Precepts, chap, xix, section 3d. i Stoll Prslectiones, Tomus II. p. 385. •• Vigarous Malad. des Femmes, Tome I. p. 261- 63 varying the strength, till wre find some form which is of benefit. These are of great benefit in vaginal discharges, and in the mild form of uterine fluor albus. In every case, the parts ought to be kept clean, by regular ablution. Various medicines, such as cicuta, uva ursi, balm of gilead, diuretic salts, calomel, resins, cantharides,(i) electricity, arnica, &c. have been proposed; but they have very little good effect, and sometimes do harm. By suckling a child, the discharge has in some instances been removed. Plasters and liniments have been applied to the back, and sometimes re- lieve the aching pains. Opiates are occasionally required, on account of uneasy sensations. When the discharge seems to be connected with plethora, or attended with a feverish state, bleeding, laxatives, and spare diet are proper. § 21. AFFECTIONS OF THE BLADDER. The bladder is subject to several diseases. The first I shall mention is stone. This excites very considerable pain in the region of the bladder, considerably increased after making water. There is also irritation about the urethra, with a frequent desire to void the urine; but it does not always flow freely, sometimes stopping very unexpectedly. The urine deposits a sandy sediment, and is often mixed with mucus. These symptoms lead to a suspicion that there is a stone in the bladder, but we can be certain only by pass- (/) Mr. Roberton, a surgeon of Edinburgh, in a paper published in the London Medical and Physical Journal, vol. XV. and also in a distinct work on.the Effects of Cantharides, when taken internally, strongly recommends this powerful article of the materia medica, in obstinate cases of Leucor- rhoea; and recites a number of instances, in which it appears to have pro- duced the best effects. In his exhibition of this medicine, he generally began with about ^ij or^ijssof the tincture, in^vj of water; a table-spoonful of which was given thrice a day. He continued gradually increasing the dose, until his patient had taken giv of the tincture in 24 hours, 5jj of the tincture being added to §vj of water. It was generally given, until considerable pain, and a puriform discharge from the vagina was produced. I cannot say, that in the few trials I have made of it in this complaint, the beneficial ef- fects have been so conspicuous. 64 ing a sound. By means of soda.(ro) the warm bath, and opi- ates, much relief may be obtained, and very often the stone may be passed, for the urethra is short and lax. But when these means fail, an operation must be performed. This has been done during pregnancy*, but is only allowable in cases of great necessity. Sometimes the stone makes way, by ulceration, into the vaginaf. It has even been known to ulcer- ate through the abdominal integuments:):. In many cases the symptoms of stone are met with, al- though none can be found in the bladder. This is most fre- quently the case with young girls, previous to the establish- ment of the catamcnia, or with women of an irritable habit. There is no organic disease, nor have I ever known it, in such p-orie, end in a diseased structure of the bladder or (m) Our author has omitted to mention the efficacy of magnesia in calculous complaints, as recommended by Messrs. Brande and Hatchet: The result of the inquiries of these ingenious gentlemen, on this very inter- esting subject, has been communicated to the scientific world in a paper printed in the Philosophical Transactions for the year 1810, entitled " Ob- servations on the Effects of Magnesia, in preventing an increased formation of the Uric Acid, by William T. Brande." This gentleman (in a communica- tion to Sir John Sinclair) says, that the best method of giving the magnesia, is in plain water, or milk, to be taken in the morning early, and at mid-day. If the stomach is weak, and this produces flatulency or uneasy sensations, some common bitters, such as gentian, may be taken with it: if it purges, a little opium may be added. He supposes its beneficial operation depends, on preventing the formation of acid in the stomach. The dose of magnesia, he observes, must always depend upon the circum- stances of the case ;—generally, five grains twice or thrice a day to children ten years of age; fifteen or twenty grains to adults. Mr. Brande has always given the common magnesia, although he re- marks, that, the calcined may be occasionally used with advantage. For fuller information on this subject, the reader is referred to Brande's paper, above quoted, in the Phil. Trans, and to a letter from Sir John Sinclair, vide Eclectic. Repertory, vol. III. p. 120. Dr. Gilbert Biane, so well known in the medical world, has also written an interesting paper on the effects of large doses of mild vegetable alkali, or potassa. carbonata in gravel, and the beneficial effects of opium combined with it. * Deschamps Traite de P Oper. de la Taille, Tome IV. p. 9. f Hildanus, cent. I. obs. 68 and 69. t Vide Case by M. Caumond in Recueil Period. 65 kidneys; indeed, they rarely complain of uneasiness about the kidneys. I have tried many remedies, such as soda, uva ursi, narcotics, antispasmodics, tonics, and the warm and cold bath, but cannot promise certain relief from any one of these33. In process of time, the disease subsides and disap- pears. The use of a bougie may be of service. Induration, or scirrhus of the bladder, produces symptoms somewhat similar to calculus, but there is a greater quantity of morbid mucus mixed with the urine; and blood with puru- lent matter is discharged, when ulceration has taken place. No stone can be found, but the bladder is felt to be hard and thick. Sometimes it is much enlarged with such appear. ances, as give rise to an opinion, that the uterus is the part principally affected34. The scirrhus and ulceration may ex- tend to the uterus and vagina. In this disease we must avoid all stimulants, and put the patient on mild diet; avoid every thing which can increase the quantity of salts in the urine; keep the bowels open, with an emulsion containing oleum ricini; and allay irritation by means of the tepid bath and opiates. Mercury, cicuta, uva ursi, &c. with applications to the bladder itself, have seldom any good effect, and some- times do harm. Polypous tumours" may form within the bladder, producing the usual symptoms of irritation of that organ. In consequence of severe labour, or the pressure of instru- ments, the neck of the bladder may become gangrenous, and a perforation take place by sloughing. The woman com- plains of soreness about the parts, and does not void the urine freely. In five or six days the slough comes off, and then the urine dribbles away by the vagina. In all cases of severe labour, and indeed in every case when the urine does not pass freely and at proper intervals, and especially if there be tenderness of the parts, we must evacuate the water, in order to prevent distention and farther irritation of the blad- der; and the parts must, if there be a tendency to slough or to ulcerate, be kept very clean, and be regularly dressed, in order to prevent improper adhesions. If the bladder should give way, we must try, by keeping in attentively an elastic • i 66 catheter*, to make the urine flow by the urethra, and then perhaps the part may heal. If this have been neglected, it will be proper to make the edges of the opening raw by par- ing if it be large, or by caustic if it be small, and afterwards use the catheter. When an incurable opening is left, we must, by introducing a sponge, or some soft, but pretty large substance, like a pessary, into the vagina, close it up, at least so far as to make the woman more comfortable. In a curious case I met with, there was an attempt by nature, to plug up the opening35. Puzos justly remarks, that it is always the bladder, and not the urethra, that suffers. Sometimes, after a severe labour, the woman is troubled with incontinence of urine, although the bladder be entire. This state is often produced directly by pressure on the neck of the bladder; sometimes it is preceded by symptoms of inflammation about the pelvis, and, in such cases, the os uteri is often found afterwards to be turned a little out of its proper direction, and the patient complains much of irregular pains about the hypogastrium and back. When the woman is in bed, some of the urine collects in the vagina, and comes from it when she rises; after she is up, it comes from the ure- thra alone, which distinguishes this from the complaint last described. Time sometimes cures this disease. The cold bath is useful, unless it increases the pain; and, in that case, the warm bath should be employed. Benefit is derived from the use of a sponge pessary. It may be proper to use the bougie daily. And also try the effect of tincture of cantharides. The bladder may descend, in labour, before the uterus, producing much pain; or it may prolapse for some time pre- vious to labour, attended with pain resembling those of partu- rition, and sometimes with convulsive or spasmodic affec- tions37. When the prolapsus vesicae takes place as a temporary occurrence during labour, or antecedent to parturition, we must be careful not to mistake the bladder for the mem- branes, for thus irreparable mischief has been done to the • This succeeded in a very bad case related by Sedilliot, Recueil Period- Tome I. p. 187. 67 woman. The bladder when protruded, is felt to be connected with the pubis. It retires when the pain goes off. If the pa- tient be not in labour, the uneasiness is to be mitigated by keeping the bladder empty, and allaying irritation with opi- ates, and taking a little blood if feverish or restless. If labour be going on, the bladder must likewise be kept empty, and may, during a pain, be gently supported, by pressing on it with a piece of sponge in the vagina, by which the bladder is preserved from injury. In the unimpregnated state, it sometimes descends betwixt the vagina and pelvis, so as to form a tumour within the vagina, or at the vulva. In a case dissected by my brother, the bladder was found to form a hernia on both sides of the pelvis, hanging like a fork over the urethra. This is called a hernia* vesicalis, and is often attended with suppression of urine. If this be inattentively examined, it may be taken for prolapsus uteri; but it will be found to diminish, or even disappear, when the urine is voided, and by pressure, the urine may be forced through . the urethra. The hernia vesicalis is to be remedied by the use of a globe pessary or sponge. Sometimes it is combined with calculus in the bladder. In this case, it has been pro- posed to open the bladder, extract the stone, and keep up a free discharge of urine through the urethra, in order to al- low the communication with the vagina to heal. Deschamps advises, that the opening should be made near the pubis, and not at the posterior part of the tumour, lest that part of the bladder be cut, which, when the tumour is reduced, would communicate with the abdominal cavity. § 22. EXCRESCENCES IN THE URETHRA. Excrescences may, notwithstanding the opinion of Mor- gani, form in the course, or about the orifice of the urethra,3* and generally produce great pain, especially in making wa- ter ; on which account, the disease has sometimes been mis- taken for a calculous affection. The agony is sometimes so * Vide the Memoirs and Essays of Verdier and Sabbatier, and Hoin. Sandi- fort, Diss. Anat. Path. lib. I. cap. iii. and Cooper on Hernia, part II. p. 66. 68 great, as to excite convulsions, and it is not uncommon for the patient to have an increase of her sufferings about the menstrual period. When excrescences grow about the ori- fice of the urethra, they are readily discovered; but when they are high up, it is much more difficult to ascertain their existence. Dr. Baitlie* says, they cannot be known, but by the sensation given by the catheter passing over a soft body. They, liowever, in one case, were discovered, by turning the instrument to one side, so as to open the urethra a little3*. When their situation will permit, it is best to extirpate them with the knife or seissars; but sometimes they have yielded to the bougie, though they had returned after excisionf. The removal of large excrescences, has occasionally been attended with very severe symptoms40. The daily use of the bougie, for some time after extirpation, is of service41. Sometimes the urethra is partially, or totally inverted42. forming a tumour at the vulva, attended with difficulty and pain in voiding urine. A slight inversion may be relieved by a bougie; when there is a considerable prolapsus, the part must be cut off. The urethra is sometimes contracted by a varicose state of its vessels, or by a stricture; but these are not common occurrences. In continued irritation of the ure- thra, with difficulty of voiding water, the bougie is often of great service, even although there should be no contraction of the canal itself. Sometimes the urethra is preternatural]} dilated43, but this docs not necessarily cause incontinence of urine. § 23. DEFICIENCY ANU MAL-FORMATION OF THE UTERUS. The uterus may be larger than usual, or uncommonly small,44 or it may be altogether wanting45. Unless these cir- cumstances be combined with some deficiency, or unusual conformation of the external parts or vagina, the peculiar organization is not known till after death. It is, however, not uncommon for the external parts to be very small, when • Morbid Anatomy, p. 321. t Broomfield's Surgery, Vol. II. p. 296. 69 the uterus is of a diminutive size; and when it is altogether wanting, the vagina is either very short, or no traces of it can be found. In either of these cases, no attempts should be made to discover a uterus by incisions, unless, from symp- toms of accumulation of the menses, we are certain that a uterus really exists*. The uterus may be double46: in this case there is some- times a double vagina, but generally only one ovarium and tube to each uterus. This conformation does not prevent im- pregnation. The uterus is sometimes divided into two, by a septum stretching across at the upper part of the cervixf; or the os uteri is almost or altogether shut up47, by a continuation of the lining of the womb or vagina, or by adhesion, consequent to ulceration, or by original conformation; and in this last case, the substance of the os uteri is sometimes almost carti- laginous. The menses either come away more or less slow- ly, according to the size of the aperture, or are entirely re- tained when there is no perforation. As long as the menses are discharged, nothing ought to be done; but if they are completely retained, and violent and unavailing efforts made for their expulsion, an opening must, as a matter of necessi- ty, be made from the vagina. In such cases, the uterus has been tapped with success^; but it has also happened, that fa- tal inflammation has succeeded the operation. The vessels are sometimes enlarged; and I have secrt the spermatic veins extremely varicose, in an old woman who had been subject to piles; but I do not know that any parti- cular inconvenience results from the venous enlargement. § 2k HYSTERITIS. The uterus is subject to inflammation; but in the unimpreg- nated state, it is not common for the womb to be the original •Nabothus mentions a rash operator, who undertook, by incision, to find the uterus; but after cutting a little, he came to some vessels which obliged him to stop. t Baillie's Morbid Anatomy, chap. xix. t The menses being retained, and great pain excited, they were let out with a trochar by Schutzer. Vide Sandifort, p. 69. 70 seat of inflammation. After parturition, it is very frequently inflamed, and this will hereafter be considered. Inflammation is discovered by pain in the hypogastric region, accompanied with tension, and the part is tender to the touch; there is acute pain stretching to the back and groins; the bladder is rendered irritable; and acute fever accompanies these symp- toms. Blood letting, purges, fomentations, and blisters are to be used, as in other cases of peritoneal inflammation. Wounds of the uterus are dangerous, in proportion to the inflammation they excite. In the unimpregnated state, this accident is rare*. § 25. ULCERATION OF THE UTERUS. The uterus may, from irritation, become ulcerated like any other part; purulent matter is discharged, the woman feels pain in coitu, or when the uterus is pressed, and sometimes the finger can discover the ulcer. Simple ulceration is very rare, and, I apprehend, will always heal, by keeping the parts clean with mild injections. Ulceration from morbid poi- son is more frequent. Of this kind is the phagedena, a most obstinate and dreadful disease of the womb, which begins about its mouth, and goes on, gradually destroying its sub- stance, until almost the whole of it be removed; and some- times it spreads to the neighbouring parts. This disease is marked by pain in the region of the uterus, copious foetid dis- charge, small but frequent pulse, wasting of the flesh, and occasionally swelling of the inguinal glands. Examination, per vaginam. discovers the destruction which has taken place, and how far it has proceeded. It also ascertains, that the part which remains is not enlarged, and in this it differs from a cancerous uterus. The rapidity of the destruction is various in different cases. It is very difficult to cure this ulcer, or even to check its progress. Sometimes mercury has effected a cure, either by itself, or combined with cicuta; or hyocy- • In one instance the woman was murdered, by thrusting a piece of glass up the vagina; and Haller notices a fatal case, in which a piece of lead was thrust into the uterus. 71 amus, or other narcotics, have been given alone^ Nitrous acid occasionally gives relief, and when greatly diluted, forms a very proper injection. A very weak solution of ni- trate of silver, or oxymuriate of mercury, is also a good topical application. Should the pain be great, tepid decoction of pop- pies, or water with the addition of tincture of opium, will be of service as an injection. Fomentations to the lower belly, and friction with camphorated spirits on the back, also give relief; but very frequently opium, taken internally, affords the most certain mitigation of suffering. There is another kind of ulcer, which attacks the cervix and os uteri. It is hollow, glossy, and smooth, with hard margins; and the cervix, a little beyond it, is indurated* and somewhat enlarged, but the rest of the uterus is healthy. The discharge is serous, or sometimes purulent. The pain is pretty constant, but not acute; and the progress is generally slow, though it ultimately proves fatal, by hectic. In this, and all other diseases of the uterus, the morbid irritation generally excites leucorrhtea, in a greater or less degree; but examination ascertains the morbid condition of the part. Although this disease be very different in its nature from the former, yet the mode of treatment is very much the same. Material benefit may be derived from the warm salt-water bath, and the regular use of a solution of some saline purga- tive, or a laxative mineral water, such as that of Harrow- gate or of Cheltenham. This is Especially the case, when the ulcer is small, or when the part is only indurated, ulceT ration not having yet taken place. In this stage, the cervix is felt hard and sensible to the touch, and there is leucor-* rhoea, and pain in the uterine region. A gentle mercurial course is occasionally of service. Some may consider this disease as a species of cancer, but the ulcer is never fungous. Venereal ulceration may, although the external parts be sound, attack the uterus, producing a sense of heat with pain, which, in general, is not very great, and is not con- stant. There is sometimes, at first, very little discharge; but if the disease be allowed to continue, foetid purulent mat- 78 ter comes away. The ulcer is at first small, and there is no hardness about the os uteri, nor is it perceived to be dilated; but it is painful to the touch, and sometimes bleeds after coition. In process of time, the ulcer spreads, and may de- stroy a great part of the womb and bladder, and occasion fatal hectic. The history of the patient may assist the diag- nosis. The cure consists in a course of mercury*. § 26. SCIRRHO-CANCER. Scirrho-cancer may attack any part of the Uterus, but generally begins in the cervix. It may take place in the prime of life, but is most frequent about the time of the ces- sation of the menses. It begins with a feeling of heaviness or heat, and darting pains about the hypogastrium, aching in the back, dull pain about the upper and inner part of the thighs, with a sense of bearing down, together with dysuria, and glowing heat, or sometimes stinging pain betwixt the pubis and sacrum, with itchiness of the vulva. There is a leucorrhoeal discharge from the vagina, or uterus, or from both. The patient is troubled with flatulence, and sometimes with vomiting. The general health suffers, the countenance becomes sallow, the pulse quickens, the strength declines, and the body wastes. If the menses have not entirely ceased, they become irregular, or profuse. Presently a foetid, puru- lent, or bloody matter is discharged, which indicates that an abscess has burst, and the disease has proceeded to ulcera- tion. Repeated hemorrhages are now apt to take place, and hectic is established. The pain is constant, but subject to frequent aggravations, and the weakness rapidly increases. At length the pain, fever, want of rest, discharge, and loss of blood, completely exhaust the patient; and death termi- nates, at once, both her hopes and sufferings. At first, by examination per vaginam, the uterus is felt as if it were enlarged; the cervix is lengthened and thickened, and the os uteri open, and more sensible to the touch, a cir- cumstance which causes pain in coitu. A little blood is often • Vide Med. Comment. Vol. XIX. p. 257—Pearson on Cancer, p. 119. 73 observed on the finger after an examination. In some time after this, the os uteri is turgid, as if it contained a small abscess, and presently it is felt to be ulcerated and fungous; but sometimes the fungi are less perceptible, deep excava- tions being formed, the sides of which, however, after death, are found to be fungous. The uterus is sometimes very much enlarged before ulce- ration takes place; but, in other cases, the augmentation is much greater after ulceration, than before it; or the morbid affection may be very much confined to the cervix uteri48. In some cases, the womb acquires a size greater than the head of a child; in others, it is not above double its usual magnitude, or I have seen a scirrhous tumour form in the uterus, and enlarge alone, whilst the rest of the uterus was nearly natural. In this case, the tumour may perhaps be felt behind, or to one side, like an enlarged ovarium. In some, the disease proves fatal very early; in others, great devastation takes place, and the bladder49 or rectum* is opened. In most cases, the vagina becomes hard and thick- ened, or irregularly contracted with swelled glands, in its course. On examining the uterus after death, its substance is found to be thickened and indurated, and sometimes its cavity is enlarged. The substance is of a whitish or brown- ish colour, intersected with firm membranous divisions; and betwixt these are numerous cysts, the coats of which are thick and white. They contain a vascular substance, which, when wiped clean, is of a light olive colour. In proportion as the disease advances, some of the cysts enlarge, and thicken still more; and, when opened, are found to contain a bloody lymph, and to have the inner surface covered with a spongy vascular substance, similar to that which fills the small cysts, but rather more resembling fungus. Presently some of these cysts augment so much as to resemble abscesses, though they • M. Tenon found, in a case of cancerous uterus, all the posterior part of the womb ulcerated, the rectum diseased, and a communication formed be. twixt them. K 74 are not properly speaking abscesses, and soon afterwards they burst. It is extremely rare for a cyst to burst, or fungi to shoot out on the exterior surface of the uterus, which is covered with the peritoneum; but sometimes all the cavity of the womb is lined with irregular fungi, or very vascular sub- stance. Occasionally the tubes* and ovaria participate in the disease. The position of the uterus is often natural, but sometimes it is inclined to one or other side, or approaches to a state of retroversion. This is a very hopeless disease, but still much may he done to check its progress, or mitigate its symptoms. When uneasy sensations, about the cessation of the menses, indi- cate a tendency to uterine disease, we find advantage from the insertion of an issue in the^arm or leg, the use of laxative watersf, and spare diet50. If by examination we discover any alteration in the shape, size, or sensibility of the womb, the? most effectual treatment we can have recourse to, is the daily use of from two to three drachms of sulphas potassse cum sulphure; and if this lose its laxative effect, one or more aloetic pills may be added. The warm sea water bath every night is likewise of great service. When there is much sense of throbbing, heat, or pain about the pelvis, cupping glasses applied to the back or hypogastrium are occasionally of ser- vice, and the patient should keep in a horizontal posture as much as possible. When the disease has evidently taken place, we must still persevere in the same plan, and avoid such causes as excite action in general; keep the parts clean, by injecting tepid water, or decoction of camomile with hemlock or opium; allay pain by anodynes; and attend to the state of the bowels. Mercury, sarsaparilla, aconitum, cicuta, &c. have been given internally, but have seldom a good ef- fect. It has been proposed to produce, with an extracting • Vide Prochaska Annot. Acad. fasc. 2d. f Rcederer relates a case where scirrhous swelling was cured by keeping the bowels open, and giving every third evening, from ten to twenty grains of calomel—Haller Disp. Med. Tomus IV. p. 670. 73 instrument, a prolapsus uteri, and then cut off the protruded womb; but this operation is not likely to be resorted to. § 27. TUBERCLES. Tubercles are common in the uterus, insomuch that M« Bayle says, that in seven months he met with fourteen cases. They consist at first of fleshy matter, but in process of time become more like cartilage, or even bony, especially on their surface*. On examining the tumour, it is found to be inter- sected with membranous divisions; and a section exhibits a pretty compact granulated surface. A tubercle may take place in one spot, and all the rest of the uterus may be heal- thy, and nearly of the natural size. The magnitude of the tubercle is very variable, and it" may either project on the outer surface, or within the cavity of the womb; and in this last case, the adhesion to the surface of the cavity is gene- rally slightf after the tubercle has fully projected. In this it differs, even in its most detached state, from polypus, which is attached not by cellular substance, but by a pedicle. Some- times there are a great many tubercles, which are found in various stages of projection, and the uterus may become greatly enlarged, and very irregular externally^:. I have never seen the tubercle end in ulceration, nor the substance of the uterus, although thickened, have abscess formed in it. The effects of this disease are a pain in the back, and some- times in the hypogastrium, which is swelled if there be much enlargement of the womb, dyspeptic symptoms, leucorrhoea, and at length feverishness and gradual loss of strength. The progress is generally slow, and the pain and other symptoms less acute than in cancerous uterus. Sometimes one or more tubercles are thrown off, with pains like thoge of labour. • Sandifort Obs. Anat Path. lib. I. cap. viii.—Bayle in Jour- de Med. Tome V.—Murray de Osteosteatoma!©, p. 14, et seq. t Baillie's Morbid Anatomy, chap. xix. \ I have found the uterus as large as a child's head of a year old, with, many projections and tubercles.—Peyer has a similar case, Parerg. Anat. p. 131. 76 The antiphlogistic regimen should be pursued in modera- tion. The bowels especially should be kept open, and every source of irritation removed. The general treatment pro- posed in cancer, is in every respect proper, and is still more effectual than in that disease. Women may live a long time, even although these tumours acquire considerable magni- tude. Sometimes the whole uterus is a little enlarged, and changed into a white cartilaginous substance, With a hard irregular surface; or it may be enlarged and ossified51, and these ossifications may take place even during pregnancy*. Steatomatous or atheromatous tumours of various sizesf, or sarcomatous^: or scirrhus-like** bodies, may be attached to the uterus. All these diseases sometimes at first give little trouble. Even their advanced stage has no pathognomonic mark, by which they can be discovered, as they produce the usual effects of uterine irritation. I must also add, that they are very little under the power of medicine. The most we can do, is to palliate symptoms; by which, however, we greatly meliorate the condition of the patient. § 28. SPONGOID TUMOUR. A very dreadful disease, which I have called spongoid tu- mour, may form either within the pelvis, or about the hip joint, or tuberosity of the ischium, and spread inwards, pres- sing on the bladder and rectum. The uterus is more frequent- ly affected with spongoid tumour than is supposed; many cases of that disease passing for cancer. This is a firm, but soft and elastic tumour, the substance of which bears som» resemblance to brain, and contains cysts of different sizes, filled with red serum or blood, or bloody fungus according to circumstances. There is no certain way of distinguishing • Vide Observ. on Abortion, 2d edition, p. 37- f Vide Rhodius, cent. III. ob. 46.—Bcehmer Obs. Anat. fasc 2d.—Stolt Ratio Med. part II p. 379. | Vide Friedius, in Sandifort's Observ. lib. I. c. viii. and a case by Sandi- fort himself, where the tumour adhered by a cord, lib. IV. p. 115. •• Baader Obs. Med. ob. 29. p. 170. 77 or discovering this disease in its early stage, for it often gives very little trouble, and any symptoms which do occur, are common to other diseases of the womb. The tumour, how- ever, enlarges, and can at length be felt through the abdo- minal parietes. It is soft and elastic, and on the first appli- cation of the hand, feels very like a tense ventral hernia. There may be two or more tumours of unequal sizes in dif- ferent parts of the belly, which can be felt to have a connec- tion with each other, and may frequently be traced to the pubes. Per vaginam, the state varies in different cases; but by pressing on the external tumour at the same time, we dis- cover its connection with the womb below. We may find ulceration, or the os uteri soft, and tumified, and opened, or the posterior lip may be lost in a soft elastic tumour, and quite obliterated, whilst the anterior one, after a pretty care- ful examination, is felt high up, and apparently sound. Pressure seldom gives pain, till ulceration is about to take place, and no blood is usually observed on the finger after examination, unless a fungus has protruded. So far as I have seen, fluor albus is a rare attendant on this disease in the early stage, and little inconvenience is at that period produced, except what results from pressure on the bladder, causing strangury or suppression of urine, attended with fits of considerable pain, like those excited by a stone. The complexion is yellow, but the health is tolerably good, till ulceration or inflammation take place. This event may happen in different ways, it may be direct- ed to the vagina, and then we have foetid bloody discharge, or sometimes considerable hemorrhage, and ultimately the bladder or rectum are involved in the destruction: Or bloody fungus may protrude from the exterior surface of the uterus into the general cavity of the abdomen, and at length the bowels become inflamed and glued altogether: Or the tumour may adhere to the parietes of the abdomen, and the skin after becoming livid give way, and a fungus shoot out from the belly. As the disease advances towards ulceration, the health is more impaired, hectic fever takes place, and the patient is ultimately cut off. 78 The whole treatment, I am sorry to say, consists in pal- liating such sympathetic or local symptoms as may arise in the course of the disease. [§ 29. CAULIFLOWER EXCRESCENCE FROM THE OS UTERI. Dr. John Clarke of London, considers himself as the first writer who has taken notice of this disease. The cauliflower excrescence, according to him, arises al- ways from some part of the os uteri. As several of the early symptoms arc not very distressing to the patient, the tumour in the beginning is rarely the subject of medical attention. The first changes of structure have therefore not been ob- served. In general the tumour is not less than the size of a blackbird's es;^. At this period it makes an irregular pro- jection, and has a base as broad as any other part of it, attached to some part of the os uteri. The surface has a a granulated feel, considerable pressure on handling it, does not occasion any sense of pain. The remainder of the os uteri,Mill at this period, be found to have no sensible altera- tion of structure. By degrees more and more of the circle of the os uteri, and the external part of the cervix uteri, become affected with the same morbid alteration of structure, till at length the whole is involved in the disease. The growth is in some cases slow, but in others rapid, so that in the course of nine months, it will sometimes entirely fill up the cavity of the pelvis, and block up the entrance of the vagina. As the bulk of the tumour increases, the granulated struc- ture becomes more evident, and is found to resemble very much the structure of a cauliflower, when it begins to run to seed. In most cases it is of a brittle consistence, so that small parts of it will come away, if it be touched too rudely; and such pieces appear to be very white. Sometimes, though no violence has been used, small portions of a white sub- stance come away with the urine of the patient, and in the discharge from the vagina. When the tumour has arrived at a size greater than that of the os uteri, it spreads very much, and as the base is 79 the smallest part of the tumour, persons, not conversant with the disease, have often mistaken it for polypus. A little at- tention however, to the feel of the tumour, and the breadth of its base, will be sufficient to distinguish them. In the very early state of the cauliflower excrescence, a discharge from the vagina takes place like fluor albus; it very soon becomes thin and watery, and is sometimes tinged with blood. In most cases upon coming away, it is apparently as thin and transparent as pure water; but the linen on which it is received, when dry becomes stiff, as if it had been starched. The quantity of the discharge when the excres- cence is large, will sometimes be sufficient to wet thoroughly, ten or twelve napkins in a day. Now and then a discharge of pure blood occurs. When this ceases the discharge of thin tansparent fluid re-appears. An offensive odour generally accompanies the discharge, which is greatest when there has lately been an evacuation of pure blood, or of the cata- menia. Mucus has sometimes been found in the fluid dis- charged, but pus never. Patients labouring under this disorder, are variously af- fected with regard to pain. In the commencement none is felt; but during its progress pain is in some cases experi- enced. Generally in the advanced stage, the patient feels pain in the back, and in the direction of the round ligaments of the uterus. The pain is not described to be lancinating, as in cancer, and is without any sensible aggravation by paroxysms; but on the whole, it is most felt after the patient has been in a perpendicular attitude. , The disease attacks indiscriminately women of all ages. The patient is destroyed by the debility occasioned by the profuse discharge; and in the course of the disease, she al- ways becomes extremely emaciated from the above cause. It always terminates fatally. Respecting the treatment of this disease, nothing satisfactory can be offered. All stimu- lating substances either in diet or medicine, seem to aggra- vate it, by increasing the discharge; and no astringents in- ternally given appear to lessen it. The only means from which any benefit has been derived, is the injecting into the 80 vagina three times a day, a strong decoction of cortex gra- nati, or of cortex qucrcus, in which alum is dissolved in the proportion of eight or ten grains to every ounce of it. This has the double effect of lessening the quantity of the dis- charge, and rendering it less offensive. The use of anodynes must be resorted to for the mitigation of pain, and the occa- sional symptoms of suppression of urine, and costiveness, are to be relieved by the use of a catheter and mild laxa- tives.^)] § 30. CALCULI. Earthy concretions are sometimes formed in the cavity of the uterus, and produce the usual symptoms of uterine irri- tation ; and Vigarous considers them as very apt to excite hysterical affections. As in the bladder of urine, the constant presence of a calculus tends to thicken its coats; so the irri- tation of a stone in the uterus can excite a disease of the substance of the womb, and produce ulceration, which may extend to the rectum. The disease in question is very rare, and can only be discovered by feeling the concretion with the finger, or a probe introduced within the os uteri, which is sufficiently open to permit of this examination. Nature, it would appear, tends to expel the substance52; and we ought to co-operate, if necessary, with this tendency. We must also relieve suppression of urine*, or any other urgent symptom which may be present. § 31. POLYPI. Polypous tumours are not uncommon, and may take place at any age; they are not, however, often met with in very young women. They always affect the health, producing want of appetite, dyspeptic symptoms, uneasiness in the ute- rine region, a variable swelling in the abdomen, aching pain (n) Vide a paper on the Cauliflower excrescence from the os uteri, &c. by John Clarke, M. D. Transact, of a Society for the Improvement of Medical and Chirurgical knowledge, 1812. And new Medical and Physical Journal, July, 1812. * This proved fatal in a child of five years old. 81 in the back, bearing down pains, tenesmus, and a dragging sensation at the groins. When these symptoms have continued some time, the strength is impaired, and the pulse becomes more frequent. At first, there is generally a foetid discharge like leucorrhoea; but at length blood is discharged, owing to the rupture of some of the veins of the tumour, or sometimes from the uterine vessels themselves. These symptoms, how- ever, cannot point out, to a certainty, the existence of a po- lypus : we must have recourse to examination, by which we discover that the uterus is enlarged, its mouth open, and a firm, but generally moveable body within it. If the os uteri hath not yet opened, so as to admit the finger, the diagnosis must be incomplete. By degrees the polypus descends from the uterus, or pain- ful efforts are made more quickly to expel the tumour; the body of which passes into the vagina53, and sometimes occa- sions retention of urine54. The pedicle remains in utero, and the bad consequences formerly produced still continue, ex- cept in a few cases, where the tumour has dropped off*, and the patient got well. In such cases, it has been supposed that the os uteri acted as a ligature; and to the same cause is attributed the bursting of the veins, which produce, in many instances, copious hemorrhage. But although hemorrhage be most frequent after the polypus has descended, yet it may take place whilst it remains entirely in utero. It sometimes happens that the uterus becomes partially invertedf, before or after the polypus is expelled into the vagina; and this circumstance does not seem to depend alto- gether on the size of the polypus, or its weight. Polypus may also be accompanied with prolapsus uteri:}:. Polypi may be attached to any part of the womb, to its fundus, cervix, or mouth; and it has been observed, that there is less tendency to hemorrhage, when they are attach- • Mem. de l'Acad. de Chir. Tom. III. p. 552. t Vide case by Goulard, in Hist, de l'Acad. de Sciences, 1732, p. 42.—Dr. Denman, in his engravings, gives two plates of inversion, one from Dr. Hun- ter's Museum, the other from Mr. Hamilton. | Med. Comment. Vol. IV. p. 228. X 83 ed to the cervix, than either higher up, or to the os uteri it> self. If there be an union betwixt the os uteri and the tu* mour#, or if they be in intimate contact, polypus may pass for inversio uteri; but the history of the case, and attentive examination, will point out the difference, which will be no- tice 1 when I come to consider inversion and prolapsus of the uteris. Here I may only remark, that the womb is sensible, but the polypus is insensible to the touch, or to irritation; but it should be recollected, that if the polypus be moved,, sensation can be produced by the effect on the womb. Polypi are of different kinds. The most frequent kind is of a firm semicartilaginous structure, covered with a produc- tion of the inner membrane of the womb; and indeed it seems to proceed chiefly from a morbid change of that membrane, and a slow subsequent enlargement of the diseased portion; for the substance of the uterus itself is not necessarily affect- ed. The enlargement is generally greatest at the farthest extremity of the tumour, and least near the womb; so that there is a kind of pedicle formed, which sometimes contains pretty large blood vessels, and the tumour is pyriform. But if the membrane of the uterus be affected to a considerable extent, and especially if the substance of the uterus be dis- eased, then the base, or the attachment of the polypus, is broad. The vessels are considerable, especially the veins, which sometimes burst. In every instance, I believe, if the patient live long, the tumour is disposed to ulcerate. The ulcer is either superficial and watery, or it is hollowed out, glossy, and has hard margins, or it is fungous. The two last vari- eties are most frequent. Some polypi are soft and lymphatic, but these are rare in the uterus. Some are firm without, but contain gelatinous fluid, or substance like axunge within. Some are solid, others cellular, with considerable cavities. Polypi are hurtful at first, by the irritation they give the uterus, and by sympathetic derangement of the abdominal viscera. In a more advanced stage, they are attended with • Mem. of Med. Society in London, Vol. V. p. 12: 88 debilitating and fatal hemorrhage, and often with febrile symptoms, especially if the discharge be offensive, or the surface ulcerated. Notwithstanding the existence of polypus, however, it is possible for a woman to conceive*. Various means have been proposed for the removal of po- lypi, such as excision, caustic, or tearing them away; but all of these are dangerous and uncertain; and therefore the only method now practised, is to pass a ligature round the base or footstalk of the polypus, and tighten it so firmly as to kill the part. The ligature consists of a firm silk cord, or a well twisted hemp string, properly rubbed with wax, or covered with a varnish of elastic gum. This is better than a silver wire, which is apt to twist or form little spiral turns, which impede the operation, and may cut the tumour. It is difficult to pass the ligature properly, if the polypus be alto- gether in utero; and it ought not even to be attempted, if the os uteri be not fully dilated. On this account, if the symp- toms be not extremely urgent, it is proper to delay until the polypus havey wholly, or in part, descended into the vagina; and when this has taken place, no good, but much evil may result from procrastination. It has even been proposed to accelerate the descent of the polypus, and produce an inver- sion of the uterusf. A double canula has been long employed for the purpose of passing the ligature, one end of which was brought through each tube; and the middle portion, forming a loop, was car- ried over the tumour, either with the fingers, or the assis- tance of a silver probe with a small fork at the extremity. By practice and dexterity, this instrument will doubtless be adequate to the object in view; but without these requisites, the operator will be foiled, the ligature twisting or going past the tumour, every attempt giving much uneasiness to the patient, and not unfrequently, after many trials and much irritation, the patient is left exhausted with fatigue, * In M. Guiot's case, the polypus was expelled.—M. Levret adds other cases, Mem. de l'Acad. de Chir. Tom. III. p. 543. t M. Baudelocque observes, " Nous regardions ce renversement nec«ssaire pour obtenir la guerison de la malade " Recueil Period. Tome IV. p. 137- 84 vexation, and loss of blood. This is very apt to happen, if the polypus be so large as to fill the vagina. The process may be facilitated by employing a double canula, but the tubes made to separate and unite at pleasure*, by means of a connecting base, or third piece, which can be adapted to them like a sheath. The ligature is to be passed through the tubes, which are to be placed close together, and no loop is to be left at the middle. They are then to be carried up along the tumour, generally betwixt it and the pubis. Being slid up along the finger to the neck of the polypus, one of them is to be firmly retained in its situation by an assistant, and the other carried completely round the tumour, and brought again to meet its fellow. The two tubes are then to be united by means of the common base. The ligature is thus made to encircle the polypus, and, if necessary, it may after- wards be raised higher up with the finger alone, or with tha assistance of a forked probe. When the ligature is placed in its proper situation, it is to be gradually and cautiously tightened, lest any part of the uterus which may be inverted be included. If so, the patient complains of pain, and sometimes vomits; and if these symp- toms were neglected, and the ligature kept tight, pain and tension of the hypogastrium, fever and convulsions would take place, and in all probability the woman would die55. In some instances, however, the womb has been included with- out a fatal effect58. Even when the uterus is not included, fever may succeed the operation, and be accompanied with slight pain in the belly; but the symptoms are mild, and no pain is felt when the ligature is first applied. If the first tightening of the ligature, by way of trial, give no pain, it is to be drawn firmly, so as to compress the neck of the tumour sufficiently to stop the circulation. It is then • An instrument of this kind is proposed by M. Cullerier and is described by M Lefaucheux in his Dissert, sur lesTumeurs Circonscrites etindolentes du tissu cellulaire de- la matrice et du vagin.(o) (o) For a plate and description of this instrument, the reader is referred to Cooper's Surgery, Philadelphia edition. 85 to be secured at the extremity of the canula; and as the part will become less in some time, or may not have been very tightly acted on at first, the ligature is to be daily drawn tighter, and in a few days will make its way through. After the polypus is tied, it is felt to be more turgid, and harder; and if visible, it is found of a livid colour, and presently ex- hales a foetid smell. These are favourable signs. § 32. MALIGNANT POLYPI. There are other tumours still more dangerous*, as they end in incurable ulceration, and are so connected with the womb, that the whole of the diseased substance cannot be re- moved. These always adhere by a very broad base", and cannot be moved freely, or turned round like the mild poly- pus. They are sometimes pretty firm, but generally they are soft and fungous, or may resemble a mass of clotted blood. When dissected, they are found to be very spongy, with cells or cavities of various sizes; sometimes they are laminated. These, which have been called vivaces by M. Levret, are always the consequence of a diseased state of the womb; but they are not always, as that author supposes, vegetations from an ulcerated surface. They do, however, very frequently spring from that source, being generally of the spongoid nature. Occasionally they have been mistaken for a piece of a retained placenta, and portions of foetid fungi have been torn away, in attempts to extract the supposed placenta, or ovum. The hypogastric region is tumid, and painful to the touch, even more so than the tumour itself, which, felt per vaginam, is less sensible than the womb. Sometimes little pain is felt in this disease, except when the womb is pressed. The tu- mour often bleeds, discharges a sanious matter, and may shoot into the vagina; but in this it differs from polypus, that it comes into the vagina generally by growth, and not by expulsion from the womb, which does not decrease or become •Vide Mem. de l'Acad. de Chir. Tome III. p. 588.-Herbiniaux Observa- tions, Tome I. ob. 39.-Baillie's Morbid Anatomy, chap. xix.-Vigarous de Malad. des Femmes, Tome I. p. 425. 86 empty as the vagina fills. The treatment must be palliative, for extirpation does not succeed, the growth heing rapidly renewed. Opiates and cleanliness are most useful. § 33. MOLES. Moles* are fleshy or bloody substances contained within the cavity of the uterus. They acquire different degrees of magnitude, and arc found of various density and structure". They may form in women who have not borne childrenf, or they may succeed a natural delivery:}:, or follow an abortion, or take place in a diseased state of the uterus**. It is the opinion of many, that these substances arc never formed in the virgin state, and no case that I have yet met with con- tradicts the supposition. The symptoms produced by moles are at first very much the same with those of pregnancy, such as nausea, fastidious appetite, enlargement of the breasts, &c.; but the belly enlarges much faster, is softer, and more variable in size than in pregnancy, being some- times as large in the second month of the supposed, as it is in the fifth of the true pregnancy. Pressure occasionally gives pain. Petit observes, that the tumour seems to fall down when the woman stands erect, but this is not always the case. It must be confessed, that the symptoms are at first, in most cases, ambiguous, nor can we for some time arrive at certainty. In general, the mass is expelled within three months, or before the usual time of quickening in preg- nancy ; and more or less hemorrhage accompanies the process, which is very similar to that of abortion, and requires the same management!!. Sometimes the expulsion may be advan- tageously hastened, by extracting the tumour with the finger; • Sandifort Obs. Path. Anat lib. II. p. 78.—Schmid. de Concrement. Uteri, in Haller's Disp. Med. Tomus IV. p. 746. f La Motte, chap. vii. This chapter contains several useful cases, one of which proved fatal from hemorrhage. \ Hoffman. Opera, Tomus III. p. 182.—Stahl. Coleg. Casuale, cap. lxxvi. p. 797. •• With scirrhus of the uterus, Haller's Disp. Med. IV. p. 751 et 753. ft Puzos advises blood letting, Traite, p. 211.—Vigarous recommends eme- tics and purgatives, to favour the expulsion, Tome I. p. 115. 87 but we must he careful not to lacerate it, and leave part be- hind. If the mole be retained beyond the usual time of quick- ening, we find that the belly does not increase in the same proportion as formerly, and the womb does not acquire the magnitude it possesses in a pregnancy of so many months standing. There is also no motion perceived. Many of the symptoms of mole may proceed from polypus; but in that case, the breasts are flaccid, and the symptoms indicating preg- nancy are much more obscure. The os uteri is not necessarily closed in a case of polypus; whereas in that of a mole, if there have been no expulsive pains, it is generally shut. When a woman is subject to the repeated formation of moles, I know of no other preventive, than such means as improve and invigorate the constitution in general, and the uterus in consequence thereof. This is of no small impor- tance, as a weak state of the uterine system predisposes to more formidable diseases, and may be followed by scirrhus l>f the womb or of the breast. § 3i. HYDATIDS. Hydatids may also enlarge the womb, and these frequently are formed in consequence of the destruction of the ovum at an early period59, or of the retention of some part of the pla- centa, after delivery or abortion. We possess no certain diag- nostic; when they are formed in consequence of coagula, or part of the placenta remaining in utero, the symptoms must be such as proceed from the bulk of the womb, or from its irritation, as if by a polypus or mole. The remarks in the preceding section are therefore applicable here; but in a great majority of cases, hydatids are formed, consequent to the destruction of the ovum; and accordingly, the symptoms at first are exactly the same with those of pregnancy. Pre- sently these cease, and we have the time when the ovum is blighted, marked by the breasts becoming flaccid, and the sickness and the sympathetic effects of pregnancy going off. The conception remains, and the belly either continues near- ly of the same size, or, if it increase, it is very slowly. Men- etruatitn does not take place; but there may occasionally be 88 discharges of blood in different degrees. No motion is per- ceived by the woman, and the size of the belly and state of the womb do not correspond to the supposed period of preg- nancy. In some instances, the health does not suffer; in others, feverishncss and irritation are produced. After an un- certain lapse of time, pains come on and the mass is dis- charged, often with very considerable hemorrhage. The pro- cess may often be advantageously assisted by introducing the hand to remove the hydatids, or to excite the contraction of the womb; but this must be done cautiously, and only when hemorrhage or some other urgent symptoms occur. These must be treated on general principles. In some cases, milk is secreted after the hydatids are ex- pelled. In others, a smart fever, with pain in the hypogas- triuin, follows. It requires laxatives and fomentations. When hydatids form in a blighted ovum, their number varies great- ly in different cases. In some I have seen only a little bit containing vesicles, often only the under part which had been for some time detached in a threatened abortion. In others, almost the whole is changed, and the mass much en- larged. This, I presume, is connected with the womb, by the unchanged portions alone; and therefore, in examining the inner surface of such a uterus after the mass was expel- led, we should expect to find it more or less similar to the gravid state, according to the greater or less change in the ovum. The relative magnitude of the vessels in the two states has not been ascertained, few opportunities being af- forded of dissection in this disease.(p) (/>) Ruysch in the first volume of his valuable works, has given two very curious and accurate plates of these hydatids of the placenta or uterus. There is also a representation of these vesicles in Baillie's plates of Morbid Anatomy, executed with great truth and elegance. It is now generally con- sidered by naturalists, that the hydatids found in the human body, are a sort of imperfect animals; and as Dr. Baillie has observed, although there may be some difference between them in simplicity of organization, this need be no considerable objection to the opinion, as life may be conceived to be at- tached to the most simple form of organization. For further information on the subject of hydatids, particularly those of the uterus, the student is referred to a paper by the editor, inserted in the Eclectic Repertory. Vol. I. p. 499, and seq. 89 Sometimes there is only one large hydatid, or, at most, a very few in the womb, and the preceding remarks will also be applicable, in a great measure, to this case. In the ad- vanced stage, we find the belly swelled, as in pregnancy; but the breasts are flaccid, and no child can be discovered in utero, nor does the woman perceive any motion. There may be pain in the abdomen, and obscure fluctuation is discern- ible. The neck of the womb is small, and the case much re- sembles ovarian dropsy, except that the tumour occupies the region of the uterus. The duration of this complaint is uncer- tain ; but the water is at last discharged suddenly, and after making some exertion. The bag afterwards comes away, and the process is not attended with much pain*. It is most prudent to be patient; but if the symptoms be troublesome, the fluid can be drawn off by the os uteri. This disease, a solitary hydatid, is oftener combined with pregnancy, or with a mole, than met with alone. The first combination60 i» not uncommon, and I have seen the hydatid expelled some, weeks before labour. Hildanus gives an instance of the se- cond, where the ovum was converted into a mole intimately connected to the uterus, and complicated with a collection of fluid to the extent of six pounds. In this case, so much irri- tation was given, as to exhaust the strength, and produce local inflammation. § 35. AQUEOUS SECRETION. A different disease from that described in the last section, is an increased secretion from the uterus itself, accompanied generally with symptoms of uterine irritation; and if the woman menstruate, the menses are pale and watery. There may be a constant stillicidium of waterf, or from some ob- structing cause the fluid may be for a time retained,61 and repeatedly discharged in gushes; or it may be accumulated * Hildanus, I think, relates the history of a woman who was supposed to be pregnant, but, dutn noctu cum marito rem baberet, a sudden inundation swept away her hopes. f Hoffman mentions a woman who had a constant stillicidium, a pint be. ing discharged daily. It at last proved fatal. Opera, Tom. Ill- p. 160. M 90 in great quantity, and combined with a diseased state of the uterus.* Like other irritations of the uterus, this may be accompanied with a secretion of milky fluid in the breasts, or the secretion may be watery. I do not know any thing more likely to do good, than evacuating the serum by the os uteri, and injecting some astringent liquid daily, at the same time that we use means for improving the general health, or removing any particular symptom that may occur. § 36. WORMS. Worinsf have been found in the uterus, producing consi- derable irritation; and generally, in this case, there is a foetid discharge. We can know this disease only by seeing the worms come away. It is cured by injecting strong bitter infusions. § 37. TYMPANITES. Sometimes^ air is secreted by the uterine vessels, and comes away involuntarily, but not always quietly. Tonics, and astringent injections, occasionally do good; and as this disease rarely causes sterility, it is sometimes cured perma- nently by pregnancy. It is said, that the air is, in certain cases, retained, and the uterus distended with it, producing a tympantis of the uterus. § 38. PROLAPSUS UTERI. The prolapsus, or descent of the uterus, takes place in various degrees^. The slightest degree, or first stage, has. been called a relaxation; a greater degree, a prolapsus; and • Vesalius, Tom. I. p. 438, says, that he found an uterus containing 180 pints of fluid, and its sides in many places scirrhous. + Vigarous Malad. Tome I. p. 412—Mr. Cockson mentions a case, where maggots were discharged before the menstrual fluid. The woman was cur- ed, by injecting oil, and infusion of camomile flowers. Med. Comment. Vol. III. p. 86. | Vide Vigarous Maladies, Tome I. p. 401. f Vide Memoir by Sabatier, in the 3d Vol. of the Memoirs of the Aca- demy of Surgery. 91 the protrusion from the external parts, a procidentia. It is necessary to attend carefully to this disease, to ascertain its existence, as it may, if neglected, occasion bad health, and many uneasy sensations. The symptoms at first, if it do not succeed parturition, are ambiguous, as some of them may proceed from other causes. They are principally pain in the back and about the pubis, increased by walking, and gene- rally accompanied with a sensation of bearing down. In a more advanced state, the urine is obstructed, and the patient feels a tumour or fulness toward the orifice of the vagina. There are also, during the whole course of the complaint, but especially after it has continued for some time, added many symptoms, proceeding from derangement of the action of the stomach and bowels, together with a variety of those called nervous. On this account, an inattentive practitioner may obstinately consider the case as altogether hysterical, until emaciation and great debility are induced. But if the woman have been recently delivered, there is less likelihood of the practitioner being misled. She feels a weight and uneasiness about the pubis and hypogastric re- gion, with an irritation about the urethra and bladder; and sometimes a tenderness in the course of the urethra, or about the vulva. A dull dragging pain is felt at the groins, and when she stands or walks, she says she feels exactly as she did before the child was born, or as if there were something full and pressing. Pains are felt in the thighs, and the back is generally either hot, or aches. These symptoms go off in a great measure, when she lies down, though, in some cases, they are at first so troublesome, as to prevent rest. In some instances, no pain is felt in the back ^ but whenever the pa- tient stands, she complains of a painful bearing-down sensa- tion, or sometimes of pressure about the urethra, or orifice of the vagina. By examination, the uterus is felt to be lower down than usual, and the vagina either corrugated or inverted. In cer- tain circumstances, the vagina prolapses, forming a circular protrusion at the vulva, similar to prolapsus ani. In the greatest degree, or procidentia, the uterus is forced alto- 92 gether out, inverting completely the vagina, and forming a large tumor betwixt the thighs. The intestines descend82 lower into the pelvis, and even may form part of the tumor, being lodged in the inverted vagina, giving it an elastic feel. The uterus is partially retroverted, for the fundus projects immediately under the perinse'um, and the os uteri is direct- ed to the anterior part of the tumor. The orifice of the ure- thra is sometimes hid by the tumor, and the direction of the canal is changed; for the bladder, if it be not scirrhous, or distended with a calculus of large size, is carried down into the protruded parts j63 and a catheter passed into it, must be directed downwards and backwards. The procidentia is at- tended with the usual symptoms of prolapsus uteri, and also with difficulty in voiding the urine, tenesmus, and pain in the tumor. If it be long or frequently down, the skin of the vagina becomes hard, like the common integuments. Some- times the tumor inflames, indurates, and then ulceration or sloughing takes place. This procidentia may occur in conse- quence of neglecting the first stage, and the uterus is pro- pelled with bearing-down pains; or it may take plaee all at once, in consequence of exertion, or of getting up too soon after delivery. It may also occur during pregnancy, and even during parturition. Sometimes it is complicated with stone *n the bladder,64 or with polypus in the uterus*. Some have, from theory, denied the existence of prolap- sus,65 and others have disputed whether the ligaments were torn or relaxed. There can be little doubt, that when it occurs speedily after delivery, it is owning to the weight of the womb, and the relaxed state of the ligaments and vagina. From these causes, getting up too soon into an erect posture, 6r walking, may occasion prolapsus, particularly in those who are weak or phthisical. When it occurs gradually in the unimpregnated state, it is rather owing to a relaxation of the vagina, and parts in the pelvis, than elongation of the round ligaments. By experiments made on the dead subject,, • Vide the case of a girl aged twenty-one years, related by Mr. Fynney. The polypous excrescence was extirpated from the os uteri, and then a pes- svy was employed. Med. Comment Vol. IV. p. 228. 93 we find, that more resistance is afforded to the protrusion, by the connection of the uterus and vagina to the neighbour- ing parts, than by the agency of the ligaments; for although the ligaments be cut, we cannot, without much force, make the uterus protrude. Frequent parturition, fluor albus, and whatever tends to weaken or relax the parts, may occasion prolapsus. Sometimes a fall brings it on. No age is exempt from it.66 When symptoms indicating prolapsus uteri mani- fest themselves, wc ought to examine the state of the womb, the patient being in an erect posture. The symptoms some- times at first turn the attention rather to the bladder or pu- bis, than the womb; but a practitioner of experience will think it incumbent on him to ascertain the real situation of the viscus. If it be found considerably lower down than it ought to be, or the vagina lax and tumid from partial inver- sion, then we must have recourse to mechanical means for keeping it up. A piece of sponge introduced into the vagina, will have this effect, or we may use a pessary. The sponge ought to be oblong, and so large as to support the womb, but not to give uneasiness. It must be freed from earthy matter, and is to be softened and compressed, and then cautiously in- troduced, having previously had a firm tape passed through it, that it may be more conveniently withdrawn. Imprudent and rude attempts give pain, and may excite swelling and inflammation of the parts. The sponge gives immediate relief to the feeling produced by standing or walking, but it does not altogether remove them for some time. It is prudent to lie almost constantly for several days afterwards, on a sofa, and even for some weeks to be much in a horizontal posture. I need scarcely add, that the size and shape of the sponge may require alteration. - Pessaries are made of wood, and are of different shapes, some oval, some flat and circular, some like spindles, or the figure of eight, others globular. I believe, of all these, the globular pessary is the best, and it ought to be of such size as to require a little force to introduce it into the vagina; that is to say, it must be so large as not to fall through the orifice, 94 when the woman moves or walks.( 108 ation, seems to be to preserve the womb in a fit state for impregnation; at least, we know, that the presence of men- struation is generally necessary to, and indicates a capa- bility of, conception. As the female system is more irritable during menstrua- tion than at other times, and as changes effected in the sys- tem, or in particular organs, at that time, may come to interfere with the due performance of the uterine action, it is a general and proper custom with physicians, and a prac- tice consonant to the prejudice of women themselves, not to administer active medicines during the flow of the menses. It is also proper, that indigestible food, dancing in warm rooms, sudden exposure to cold, and mental agitation, espe- cially in hysterical habits, be avoided as much as possible. By neglecting these precautions, the action may either be suddenly stopped, or spasmodic and troublesome affections may be excited. CHAP. XII. Of Diseased States of the Menstrual Action. § 1. AMENORRHffiA. Amektorrhcea, or absence of the menses, has been divid- ed into the retention, or emansio mensium, and the suppres- sion of the menses. By the first term, we are to understand, that the menses have not yet appeared, the action being longer than usual of being established. By the second, is meant the interruption of the action which has already been established, and hitherto performed. The retention of the menses is very generally attended with chlorosis, or a feeling of weariness and debility, with haave, [Amstelxdami, A. D. 1744,] speaks of the menses as a secretion. His words are, " Sed facile ipsa fabrica partium demonstrat nterum naturale or- ganum esse bujus secretionis. Vol. VI. p. 72. Dr. Chapman says, that Dr. Craven supported this opinion, in a Thesis published at Edinburgh in the year 1778. 109 dislike to active employment; a pale or sallow complexion, cathectic appearance, cedematous swelling of the legs and feet; costiveness, complaints of the stomach, such ; flatu- lence, acidity, loathing of food, but craving for indigestible substances, as chalk, lime, or cinders; pains of the head, and different parts of the body; swelling of the belly, with hys- teric symptoms, such as palpitation, or dyspnoea; and if this state be not soon removed, it is apt to end either in consump- tion or dropsy. The menses, may, from, one person not arriving so early as another at puberty, be longer of appearing in some women than in others; and in such cases, no peculiar inconvenience attends the retardation. But when the retention proceeds from other causes, it is to be considered as a disease; and generally, is to be attributed to a want of vigour in the sys- tem ; by which, not only a new action is prevented from be- ing formed, but also those which were formerly performed become impaired. In some cases, indeed, the absence of the menses depends upon a malformation of the organs of gene- ration, a deficiency of the ovaria,* or an imperfect develope- ment of the uterus; but in far the greatest number of instances, the action is postponed, merely from general de- bility of the system; and accordingly, the most successful mode of treatment consists in improving the health, and in- creasing the strength of the patient. This is to be done by regular exercise, proportioned to the ability of the person; the use of the hot salt water bath every day, succeeded by frictions with dry flannel, or a soft brush; a nourishing and digestible diet, with a proper portion of wine; avoiding every thing which disagrees or ferments; the administration of tonic medicines, particularly preparations of iron, such as • There is much reason to believe, that an influence somehow derived from the ovaries, excites the uterus to the menstrual effort—Certain it is, that in several instances, a permanent suppression of the menses has followed the loss of these organs. May not amenorrhoea, oftener than we suspect, be oc- casioned by a diseased state of the ovaries? This, at least, was the opinion of the celebrated Cullen. Cases have also occurred, where, from original defi-: tiency of the ovaries, menstruation never took place- C 110 chalybeate waters, tincture of muriated iron,or thecarbonas ferri prccipitatum combined with myrrh. The use of the Bath waters, internally as well as externally, is of service in the chlorotic state, but hurtful if the patient be of a full habit. In that case, purgatives are of most benefit. Strict attention must indeed in every case be paid to the state of the bowels. This is necessary in plethoric habits, to lessen the fluids, and in the chlorotic condition to stimulate the sys- tem ; for in that case, the bowels are generally torpid, and communicate a similar debility to the rest of the system. The aloetic or compound rhubarb pill should be freely em- ployed. The cold bath in chlorosis is seldom proper, as it is apt to be followed by dullness, headach, and languor. It is only useful when succeeded by a sense of heat and comfort. The warm salt water bath is generally of greater service. Besides this general plan, it has also been proposed, to ex- cite more directly the uterine action, by marriage, and the use of emmenagogues; but with respect to the latter part of 'the proposal, I must observe, that some of these, if rashly employed, may, from their stimulating qualities, do harm; and they do not generally succeed without the use of such means as tend to invigorate and improve the system. Should the tonic plan, however, fail, then we may employ some of those medicines, which will be presently mentioned. If reten- tion should be combined with a plethoric state, the best plan is to use purgatives regularly, in a degree proportioned to their effect on the system, and make the patient take as much exercise as she can do without producing fatigue. Suppression of the menses is naturally produced by preg- nancy, and, very generally, by such diseases as tend greatly to weaken the patient. The first of these causes is soon re- cognised, by its peculiar effects. In the second, the effect is often mistaken for the cause; the bad health being attributed to the absence of the menses, and much harm frequently done by the administration of stimulating medicines. But in such cases it will be found, upon inquiry, that before the menses were suppressed, the patients had begun to complain. In them, the irregularity of the menses is symptomatic, and Ill generally indicates considerable debility; induced, perhaps, by great fatigue, bad diet, loss of blood, or long continued serous discharge, hectic fever, or dyspepsia. Such causes, likewise, as operate more directly in weakening the uterus, as for instance abortion, or excessive venery, may produce, for a longer or a shorter period, a suppression of the men- strual discharge. Suppression of the menses may be likewise suddenly occa- sioned by the operation of such causes, during menstruation, as can interfere with, or give disturbance to the action; such as cold, and passions of the mind. The suppression so pro- duced may be quickly followed by disagreeable effects; and either owing to these effects injuring the health, or to the uterus not speedily recovering from the original affection, the suppression may continue for some months. The immediate, and remote effects of suppression, are much modified by the previous state of the system, particu- larly with regard to irritability and plethora; and also by the condition of individual organs*, which, if already dis- posed to disease, may thus be excited more speedily into a morbid action. In many cases, nausea, tumor of the belly, and other indications of pregnancy, are produced. It also sometimes happens, that in consequence of suppres- sion of the menses, hemorrhage takes place from the nose, lungs, or stomach; and these discharges do, occasionally, observe a monthly period, but oftener they appear at irre- gular intervals.. When suppression of the menses takes place in conse* quence of some chronic and obstinate disease, such as con- sumption or dropsy, it would be both useless and hurtful to attempt, by stimulating drugs, to restore menstruation. But in those cases, where the menses are suppressed in conse- quence of cold, fear, or some removeable cause, inducing de- bility of the frame, it is proper to interfere, both as the • Baillou has observed, that both in young girls, and elderly women, when the menses are obstructed or irregular, the spleen sometimes swells; and subsides again, when the menses become regular.- De Virgin, et Mulier. Morbis. Tomus IV. p. 75. IIS suppression is a source of anxiety to the patient, and also as the rational means of restoration tend to amend the health. It is proper, in our curative plan, to recollect, that the suppression may take place in different circumstances of the constitution. It may occur with a debilitated chlorotic condi- tion, in which case we are to proceed much in the same way as in retention of the menses; and along with the tonic plan of treatment, it will be proper to have recourse to the use of emmenagogue medicines, such as savin*, helleboref myrrh, madder, or nitrous acid; and of these, the two first are the most active-4(tt) About the time when the menses are ex- * From 5 to 10 grains of the powdered leaves may be given three or four times a day. t A drachm of the tincture may be given twice or thrice daily. \ In suppression of the menses, evidently connected with atony of the uterus, I have had some success with the tinct. cantharid. I give it in the dose often drops, morning noon, and night, gradually increasing the quan- tity till it amounts to two or three drachms in the day. The most obvious effects of this medicine, which I have observed, are an increase in the force of the pulse, and a very copious flow of urine. From the sp. terebinth. I have also, under similar circumstances derived some advantage. In one case of this complaint, in which there was general torpor of the- system, accompanied with a low degree of temperature, I administered a phosphorus, but its use was interruped too soon, by the prejudices of the pa- tient, to judge of its efficacy. The phosphorus is a most powerful medicine, and requires great care in its administration. I gave of it, a tenth of a grain intimately blended with olive oil. Even, in this small dose it produced a universal glow and excitement. When properly regulated, phosphorus is both a safe, and I believe, an eminently useful remedy. In the armies of France, it has recently been employed, I am told, with extraordinary suc- cess in typhus fever, gangrene, &c. Does it not also promise to do good in many other diseases, such as para- lysis, epilepsy, chronic mania, &c. &c C. (u) To the above list of emmenagogue medicines, may be added the poly- gala senega, first used in this complaint, as far as I know, by Dr. Harts- home of this city, and introduced to the notice of practitioners generally, by Dr. Chapman, in a paper on this subject inserted in the Eclectic Repertory for October, 1811; in which some interesting cases and remarks, in illustra- tion of the use of this powerful article of the materia medica are given. The mode in which it is prepared and used, is as follows. In making the decoction, a pint of boiling water is added to an ounce of the senega bruh- 113 pected to appear, it is sometimes of advantage to exhibit an emetic, and to make use of the warm bath or scmicupium or pediluvium. Tourniquets have, about this time, been applied to the thighs, but not with much benefit. Electricity, direct- ed so as to act on the uterus, is occasionally of service* When along with suppression of the menses, there is a febrile state, marked by heat of the skin, frequent pulse, flushing of the face, and irregular pains in the chest or abdo- men, stimulating medicines are hurtful. It is, in this state, of advantage, to keep the bowels open, by the daily use of some saline purgative, dissolved in a considerable quantity of water: and should there be dyspnoea, with pain about the chest, increased by inspiration, it will be proper to take away some blood. Should the skin still remain hot, the common saline julap will be of service. The febrile symptoms being removed, much advantage may be derived from a combina- tion of myrrh, oxyde of iron, and the supercarbonate of pot- ash; and should emmenagogues be thought advisable, the black hellebore is the best. When a woman, upon the sudden suppression of the men- strual discharge, complains immediately of pain in the back and uterine region, or in the bowels, with or without febrile symptoms, the semicupium, and opiates combined with ipe- cacuanha, or the saline julap, will be of great service; or, if ed, in a close vessel; and it is suffered to simmer over the fire, till the quan- tity is reduced one-third; to prevent nausea, it is best to make the addition of an aromatic, such as the orange peel or cassia. Four ounces of this decoc- tion at a medium, is to be given during the day. But at the time when the menstrual effort is expected to be made, and till the discharge is actually in- duced, the dose is to be pushed as far as the stomach will allow. In the in- tervals of the menstrual periods, the medicine is directed to be laid aside for a week or two; as without these intermissions it becomes nauseous and dis- gusting to the patient. While under a course of the senega, it is recom- mended to keep the general system properly regulated; and it is observed, that excessive excitement or debility is to be equally obviated by the use of the appropriate remedies. For fuller information on this subject than can be compressed into the limits of a note, the reader is referred to the interesting paper by Dr. Chapman, above alluded to. * Blisters applied to the region of the uterus, at this time, are exceedingly useful. C. P 114 the symptoms be severe, some blood must be taken from the arm, and the bowels are to be opened. Should the menses not return at the next period, we must proceed as has been already directed. Chlorosis, succeeding to abortion, laborious parturition, or fever, is often attended with symptoms much resembling phthisis pulmonalis. In many instances the pulse continues long frequent; there is nocturnal perspiration; considerable emaciation, with cough and pains about the chest; and yet the person is not phthisical, she suffers chiefly from debility; but if great attention be not paid to improve the health, the case may end in consumption; and hence many consumptive women date the commencement of their complaints from an abortion, or from the birth of a child, succeeded by an he- morrhage. In chlorosis, the symptoms "are induced, not by previous pulmonic affections, but by some other evident cause of weakness; the pulse, although frequent, is not liable to the same regular exacerbation, as in hectic; a full inspi- ration gives no pain, and little excitement to cough; the per- son can lie with equal ease on either side; the cough is not increased by motion, nor by going to bed, but it is often worse in the morning, and is accompanied with a trifling expecto- ration of phlegm. It is not short, like that excited by tuber- cles, but comes in fits, and is sometimes convulsive; whilst palpitation, and many hysterical affections, with a timid and desponding mind, accompany these symptoms. The bowels are generally costive, and the person does not digest well. In chlorosis, attended with symptoms resembling phthisis, it is of considerable utility, to administer occasionally, a gen- tle emetic, and at the same time the bowels must be kept open. Myrrh, combined with the oxyde of zinc, is, I think, of approved efficacy; and the ammonia, given in the form of an emulsion with oil, very often is effectual in relieving the cough. A removal to the country, and the use of moderate exercise on horse-back, will contribute greatly to the reco- very. The diet ought to be light, but nourishing. In many cases, milk agrees wTell with the patient, but it is not neces- sary to restrict her from animal food. Pain in the side may 115 be removed, by the application of a warm plaster; and, if the cough be troublesome, the squill may be used as an expecto- rant, and an opiate should be given at bed-time. If the skin be permanently hot, or irregularly hot and cold, without weakening perspiration, the tepid bath is of service, or small doses of saline julap may be given. Should the person be of a phthisical habit, and the symptoms increase or continue obstinate, it will be proper to remove her to a mild climate, or the southern part of the island. Emmenagogues are either useless or detrimental.*(y) § 2. FORMATION OF AN ORGANIZED SUBSTANCE. It sometimes happens, that the uterus, instead of discharg- ing a fluid every month, forms a membranous or organized substance, which is expelled with pains and hemorrhage, like abortion. Morgagnif describes this disease very accurately. The membrane, he says, is triangular, corresponding to the shape of the uterine cavity; the inner surface is smooth, and seems as if it contained a fluid; and that it does so, I have no doubt from my own observation; the outer surface is rough and irregular. According to Morgagni, the expulsion is fol- lowed by lochial discharge.(w) • In chlorosis, and indeed, in all the forms of amenorrhcea, I have found purges, I think, very beneficial. Calomel and aloes combined, I have prefer- red in these cases. To be useful it is necessary to continue this plan of treat- ment for weeks. Professor Hamilton of Edinburgh, who is a most skilful practitioner in female complaints, advises very strenuously, a mixture of digitalis and the sp. aether, nitros. in chlorosis. The former, he directs in large doses, as much as ten drops of the tincture every hour. It would seem that digitalis is only applicable to those cases of the disease, which are attended with oedematous swellings, but he does not thus restrict its administration. I have never had occasion to try the medicine. But certain it is, that among the best of the emmenagogues, are the active diuretics. C. (v) In these cases blisters are strongly recommended. Vide a paper " on the connexion that subsists in certain pases, between amenorrhcea and phthi- sis pulmonalis, as Cause and Effect, by William Shearman, M. D." Eclectic Repertory, Vol. I. p. 453. t Vide Epist. XLVII1. art. 12. (w) For the purpose of expelling this membrane, the volatile tincture of gum guiaicum has been recommended, but in general it has failed in afford- 116 Dr. Denman supposes, that no woman can conceive who is affected with this disease; but some cases, and amongst others, that related by Morgagni, are against this opinion. Mercury, bark, cbalyheates, inyrrh, and injections, have all been tried, but without much effect. Time, in general, re- moves the disease better than medicine, which is only to be advised for the relief of pain, weakness, or any other symp- tom which may attend, or succeed to this state. A knowledge of this disease may be of great importance to the character of individuals. § 3. DYSMENORRHEA. Some women menstruate with great pain, and the dis- charge generally takes place slowly. This disease is called dysmenorrhea. It seems to be dependent on an imperfect menstrual action; and this opinion is supported by observing, that mild emmenagogues give relief, but those of a stimu- lating quality are not so proper. Saffron, madder, or rue, arc often of service; at the same time, the warm bath, or semi- cupiuin, is to be employed for a day or two previous to men- struation, and should be related every night, during its continuance. Opiates, combined with ipecacuanha, or ano- dyne clysters should also be given, to abate the pain; and the bowels are to be kept open, by mild saline laxatives.* Spasm of the bowels, and suppression of urine or strangury ing relief, as far as my experience goes. It is in cases of this description, that Dr. Chapman particularly recommends the polygala senega; and thinks that its use is theoretically supported, by the analogy of its peculiar power in detaching the membrane of the croup. • Nothing I have found to afford more relief in painful menstruation than large doses of opium and camphor. This medicine, however, will often faili The extracts of hyoscyamus has been highly extolled. But it is certainly in- ferior to epium. It would be well, I think, to try the datura stramonium, not only in this, but in amenorrhea generally. Blisters, in those cases, should not be omitted. When applied to the sa- crum, or the lowest of the lumbar vertebra, they will sometimes remove the pain and bring on a free discharge of the menses. There is, however, unfor- tunately in private practice a great repugnance to the application of blisters to these parts. C 117 accompanying this disease, are relieved by the semicupium and antispasmodics. § 4. MENORRHAGIA. The menses may be abundant in quantity, at the regular period; or they may return too copiously, once in three weeks, or even more frequently. This morbid condition, which is called menorrhagia, may take place, either along with a considerable frequency of pulse, and febrile heat, sometimes preceded by chilliness; or with languor, cold skin, and marks of torpor, and debility of the arterial system. In both cases, the discharge is generally accompanied with pain in the back and uterine region. The fluid evacuated is of two kinds; the menstrual secretion increased in quantity, which does not coagulate, but is sometimes preceded, and succeeded by a slight discharge of brownish serum; and pure blood, which often forms coagula in the vagina.* All profuse discharges are of this last kind. In some cases, there is a constant stillicidium of blood, except for a day before and after menstruation. When the hemorrhage is considerable, or frequently re- peated, it produces the usual effects of loss of blood, and may thus either immediately or remotely prove a cause of death. When the hemorrhage is more moderate, or when the men- strual discharge is only somewhat increased in quantity, or repeated at shorter intervals than a lunation, the constitution suffers more slowly, and in many cases very slightly, the woman being only somewhat weaker than usual. This state, however, may dispose to other diseases, and it proves a cause of sterility. Copious menstruation often proceeds from irritation of the uterus, or the repeated excitement produced by excessive 0 This is a correct distinction. I have repeatedly observed profuse hemor- rhages from the uterus. They often recur with the periodical regularity of menstruation. In these cases, the uterus, owing to some morbid derange- ment, is unable to perform it6 true secretory action. Nor are- these hemor- rhages peculiar to the uterus. There is, indeed, hardly a part of the body from which vicarious discharges of blood, under sucli circumstances, have not taken place- C. 118 venery. It may also be occasioned by debility of the uterine system, brought on by abortion, or frequent and laborious parturition; or it may be connected with general feeble- ness of the constitution. In some cases, it appears to arise from that state of the arteries which disposes to hemorrhage; and that is particularly the case in those who are of a deli- cate make, and inclined to phthisis. Hemorrhage from the uterus is different from copious men- struation, and is generally dependent either upon those remote and occasional causes which produce hemorrhage from other vessels, or on an enfeebled, but overacting state of the uterine vessels, existing during the time of menstruation: and hence, in low fevers, a very copious discharge of blood sometimes takes place from the uterus, and proves fatal with great rapidity.(a?) Married women arc much more subject to increased men- strual discharge than virgins; and it is very rare for the lat- ter, especially if healthy, to be affected with hemorrhage from the womb. The hemorrhage from the uterus is to be managed upon general principles. When it depends upon plethora, or strong action of the vessels, we must have, if the pulse re- quire it, recourse to blood-letting, and give digitalis to make the circulation slower.(t/) If the pulse be not full and strong, and the patient robust, blood-letting is improper. In every case, unless she be cold and exhausted, we apply cold both generally and locally. The patient always must be kept at rest in an horizontal posture; and opiates arc to be given if there be much pain and irritation. The food ought to be sparing, and every thing warm is to be avoided. If neces- (x) This was found to be frequently the case, during the prevalence, in this city, of the epidemic fever of 1793, and the subsequent years; as will be fresh in the memories of those physicians, who practised in the midst of that fatal disease. 00 Digitalis must be used with great caution and discrimination in ute- rine hemorrhages. Where it has been injudiciously exhibited, it has been known to increase the flow; particularly where the inordinate discharge de- pends upon a topical relaxation of the vessels, which this medicine must necessarily tend to aggravate- 119 sary, the vagina is to be plugged.(«) If a great effect have been produced upon the system by the hemorrhage, then the strength must be supported by nourishment and cordials, and liberal doses of opium will be found of much benefit. In order to prevent a return, the patient, if plethoric, must be put on spare and dry diet, the sleep abridged, the exercise increas- ed, the bowels kept open by mild laxatives, but not clysters, and, at the same time, the constitution is to be invigorated hy the cold bath, which is by no means incompatible nor in- consistent with the other means. When the hemorrhage de- pends on debilitating causes, such as typhus fever, we trust chiefly to the plug, and support the strength by cordials. In neither case have astringents given internally, any very great effect, but if any are to be employed, alum whey or sulphuric acid are the best. Styptic injections are often of singular utility. In repeated discharges, emetics are some- times of service, by exciting uterine contraction. M. Gen- dron, in the seventh volume of the Recucil Periodique, re- lates an excellent instance of their effects on a woman, who had obstinate and alarming hemorrhage, which resisted even the use of the plugs, and caused frequent syncope. The discharge stopped after giving ipecacuanha. Stillicidium is best cured by astringent injections. In copious, or too frequent menstruation, we must, if the patient be plethoric, the skin warm, and the pulse above the usual standard, sometimes detract blood; but generally it is better to keep the bowels lax, and give occasionally saline julaps or antimonials, till the febrile state be removed: after which the disease may go off, but if not, tonics will then do (z) This by the French physicians is termedle tampon. It is, perhaps, most readily effected, by taking a pretty large pieee of soft cloth, dipping it in oil, and then wringing it gently. It is to be introduced by the finger, portion after portion, until the lower part of the vagina is well filled. The remain- der is then to be pressed firmly on the orifice, and held there for some time. This acts by giving the effused blood time to coagulate. It gives no pain, and produces no irritation. It is strongly recommended by Osborne and Burns. In obstinate cases, before introducing the tampon, it has been recom- mended to insert a little powdered ice, tied up in a rag. Vide Burns' Obser- vations on Abortion, p. 102. 120 good. In the great majority of cases, however, there is rather an opposite state of the system, requiring a directly invigo- rating plan, such as the cold bath, preserving the bowels in a regular state, gentle exercise in the country, the use of a nourishing and easily digestible diet, with wine and tonic medicines, or chalybeate water, such as that of Tunbridge. Sometimes the use of the aqua ammonise, in considerable doses, is attended with great advantage: cold water may, with much benefit, be poured daily upon the back, and inject- ed frequently into the vagina. In obstinate cases, emetics, such as ipecacuanha, or the sulphate of zinc, are of service. It is necessary to avoid whatever may act as an exciting cause, such as heated and crowded rooms, much dancing, long walks, venery, &c* * Hitherto, those uterine hemorrhagies which observe a periodical regu- Jarity in their recurrence, have been, very commonly, confounded with an increased flow of the menses. To this error we are, perhaps, to impute, in some degree, the uncertainty of our practice in these complaints. My own experience confirms the observation of Mr. Burns, " that all profuse dis- charges from the uterus are hemorrhagies." These are often to an extent to threaten immediate danger. Menorrhagia, on the contrary, even when most copious, is never alarming, except in its remoter consequences. The former complaints may be commonly checked, like other hemorrhagies. by the ace- tate of lead, by combinations of opium and ipecacuanha, by bleeding where the pulse is full and excited, &c But the latter, as resulting from a natural secretory action of the uterus, will run on to the usual period of its termina. tion, whatever may be done, unless the discharge be suppressed by some rash and violent interference. In menorrhagia proper, litUe else is required during the flow than rest, a cool room, some acidulated drink, as cremor tar- tar, to open the bowels, and occasionally, if there be pain or irritation, an anodyne. But, in the intervals of menstruation, we should endeavour by various means to make such an impression on the system as will restore to the uterus its healthy actions. The remedies, in these cases, are well known. Before dismissing this subject, it may, however, be useful to mention, that professor Hamilton, of Edinburgh, urges the most intrepid employment of opium in periodical hemorrhagies. He says, that he has given, in a case, as much as twelve grains of it in twenty-four hours with singular advantage. Though it is difficult with me to reconcile the efficacy of such doses of opi- um in hemorrhagy with the views I have adopted of the mode of operation of the medicine, yet from my faith in the judgment of Dr. Hamilton, I would, if necessary, not hesitate to make the experiment. C 121 Sometimes the woman menstruates every fortnight, btit the discharge which continues for the usual time, is alter- nately red and albuminous. This state seems to depend on weakness, and is cured by tonics. Symptomatic discharges, produced by polypus* cancer, &c. have already been considered* CHAP. XIII. Of the Cessation of the Menses. About the period when the menses should cease, they become irregular, and sometimes are obstructed for two or three months, and then for a time return. This obstruction, like many other cases of retention and suppression of the menses, is accompanied with swelling of the belly, sickness, and loathing of food. These effects are frequently mistaken for pregnancy: for, as La Motte remarks, many women have such a dislike to age, that they would rather persuade them- selves they are with child, than suppose they are feeling any of the consequences of growing old; and this persuasion they indulge like Harvey's widow, donee tandem spes omnis infatum et pinguedinem facesseret. In this situation, the belly is soft and equally swelled, and enlarges more speedily after the obstruction, than it does in pregnancy. No motion is felt, or if it be, it is from wind in the bowels, and shifts its place. Exercise, chalybeates and laxatives, are the proper reme- dies in this case. The period at which the menses cease, or «the time of life," is considered as critical, and, without doubt, it is an important epoch. If there be a tendency to any organic dis- ease, it is greatly increased at this time, more especially, if it exist in the uterus or mammse: and, indeed, the cessation of the menses does of itself seem, in some cases, to excite cancer of the breast. Diseases of the liver, also, make great- er progress at this period, or first appear soon after it. Dys- peptic affections arc still more frequent. When there is ne 122 tendency to loeal disease, it is very common for women, after the menses cease, to become corpulent, and sometimes they enjoy better health than formerly. From an idea of the cessation of menstruation being uni- formly dangerous, some, by the use of emmenagogues, tried to prolong the discharge, others, by issues, endeavoured to prevent bad effects. The first of these means is foolish and hurtful, the last is not necessary. When the health is good, no particular medicines are requisite; but if there be a ten- dency to any peculiar disease, then the appropriate remedies must be employed. The bowels must be kept open.(a) CHAP. XIV. Of Conception. Conception seems to depend upon the influence of the >(*men exerted on the ovaria, through the medium of the rest of the genital system; for women have conceived, when semen has been applied merely to the vulva, the hymen be- ing entire.* In consequence of this, an ovum is excited into action; it enlarges; the peritoneal covering becomes more vascular, and is made to protrude a little. Then that part which covers the vesicle is absorbed, whilst the vesicle itself escapes into the fallopian tube, which had, at the time of impregnation, embraced the ovarium; and thus it is convey- ed into the uterus. When the ovum is received into the tube, and either carried into the womb, or brought a certain way along the canal, the tube loosens from the ovarium, and the absorbed spot on the surface of the ovarium is perceptible. («) For some very interesting practical remaks on this subject, the stu- dent is referred to a paper by the justly celebrated Dr. John Fothergill, on «' The Management proper at the Cessation of the Menses," in Medical Observations and Inquiries, vol. V. Also in the collection of his Works. * A collection of cases of this kind will be found in a work entitled, " Speculations on Impregnation." C< 123 This afterwards forms a kind of cicatrix, called corpus lute- uin.* It would appear, that although an ovum be impregnated, yet, by various causes, the process afterwards may be inter- * Amid the uncertainty which exists on the subject of generation, there seem to be some points very accurately ascertained. Thus, from the expe- riments of De Graaf on rabbits, we long since learned, 1. That the ovaries are the seat of conception. 2. That one or more of their vesicles become changed. 3. That the alteration consists in an en- largement of them, together with a loss of transparency in their contained fluid, and a change of it to an opaque and reddish hue. 4. That the number of vesicles thus altered, corresponds with the number of foetuses, and from the former are formed the true ova. 5. That these changed vesicles, at a cer- tain period after they have received the stimulus of the male, discharge a substance, which, being laid hold of by the fimbriated extremity of the fallo- pian tube, and conveyed into the uterus, soon assumes a visible vascular form, and is called an ovum. 6. That these rudiments of the new animal, which, for a time, manifested no arrangement of parts, afterwards begin to elaborate and evolve the different organs of which the new animal is com- posed. To these facts we may add, that the calyx, or capsula, which form- ed the parietes of the vesicles, thickens, by which the cavity is diminished. This cavity, together with the opening through which the foetal rudiments escaped, becomes obliterated, and from the parietes of the vesicles having acquired a yellowish hue, they are called corpora lutea. Such was pretty nearly the extent of our information respecting this mysterious function, when the celebrated Mr. Haighton some few years ago, engaged in an expe- rimental investigation of the subject, and established, among others, the fol- lowing additional points. 1. That the existence of the corpora lutea, as was previously alleged by De Graaf, is incontestible proof of impregnation having preceded. 2. That, contrary to the opinions of most physiologists, neither the vesi- cle of the ovary is ruptured, nor the fallopian tube applied to the ovary dur- ing the act of coition; but, that several days elapse before the vesicle arrives at sufficient maturity to discharge its contents, till which time, the fallopian tube does not change its ordinary position. 3. That, in contradiction to the observations of De Graaf, Malpighi, and Cruikshank, the substance which passes from the ovary is merely a gela- tinous fluid, which assumes nothing of the circumscribed vesicular character of the ovum till a considerable period after it is deposited in the uterus. 4. That the semen masculinum is applied to the ovary neither by the fallo- pian tubes, nor by absorption, nor in the form of aura seminalis. He concludes, therefore, that fecundation is performed by that " law of the animal system termed sympathy, or consent of parts." The doctrine is thus stated: 124 ruptcd; the ovum shrivels, and is absorbed. If there be an impervious state of the tubes, or any conformation or condi- tion, rendering it impossible for a child to be supported, the ovum decays, and the woman is barren. Or if such a state be induced after impregnation, and before the ovum descends, the process stops*. In the human subject, only one ovum is generally impreg- nated by one seminal application, but sometimes two or more may be carried down into the uterus; and even after one ovum has reached the uterus, and grown to a certain degree within it, we find, that it is possible for a second to be excit- ed into action, and brought down into the womb, where it is nourished and supported!. From the experiments of Mr. Hunter^, it is probable, that each ovarium is capable of producing only a certain number of ova: and that if one ovarium be removed or rendered use- less, the constitution cannot give to the other the power of producing as many ova as could have been done by both. It has been attempted to ascertain what age, and what season was most prolific. From an accurate register made by Dr. Bland, it would appear, that more women between the age of twenty-six and thirty years, bear children, than at any other period. Of 2102 women, who bore children, 85 "Were from fifteen to twenty years of age; 578 from twenty- The semen first stimulates the vagina, os uteri, cavity of the uterus, or all of them. By sympathy, the ovarian vesicles enlarge, project, and burst. By sympathy the tubes incline to the ovaries, and having embraced them, convey the rudiments of the foetus to the uterus. By sympathy the uterus makes the necessary preparations for perfecting the formation and growth of the foetus: and finally, By sympathy the breasts furnish milk for its support after birth. C. * Dr. Haighton found, that by dividing the tubes, after a rabbit was im- pregnated, the ova were destroyed. Or if only one tube was cut, and the female afterwards became impregnated, corpora lutea were found in both ovaria, but no ova were found in the tube or horn of the uterus, on the injur- ed side. Phil. Trans. Vol. LXXXVII. p. 175, &c. f Vide Med. and Phys. Journ. Vol. XVII. p. 489. i Vide Phil. Trans. Vol. LXXVII. 1*5 one to twenty-five; 699 from twenty-six to thirty; A07 from thirty-one to thirty-five; 291 from thirty-six to forty; 36 from forty-one to forty-five; and 6 from forty-six to forty-nine. At Marseilles, M. Raymond says, women conceive most readily in Autumn, and chiefly in October; next in Summer; and lastly in Winter and Spring; the month of March having fewest conceptions. M. Morand again says, that July, May, June, and August, are the most frequent dates of conception; and November, March, April, and October, the least fre- quent in the order/in which they are enumerated. I have been favoured with a register, for ten years, of an extensive parish in this place; from which it appears, that the great- est number, both of marriages and births take place in May, and the fewest births in October. From this we would con- sider August and September to be most favourable to concep- tion; but it is evident, that these conclusions are liable to great uncertainty. Women are supposed to conceive most readily immediately after the menstrual evacuation, but it is doubtful how far this opinion is correct; and therefore, in calculating the time when labour should be expected, it is usual to count from a fortnight after the last appearance of the menses, or to say that the woman will be confined at the end of the for- ty-second week from that period. The process of gestation usually requires forty weeks, or nine calendar months for its completion; but many circum- stances may render labour somewhat premature, and it is even possible for the process to be completed, and the child perfected to its usual size, a week or two sooner than the end of the ninth month. On the other hand, it is equally cer- tain, that some causes, which we cannot explain nor discover, have the power of retarding the process, the woman carry- ing the child longer than nine months (&); and the child, when (6) The ancient laws of France allowed that a legitimate birth might take place ten months after the connexion of the sexes: in Scotland, the law con- siders a child born six months after the marriage of the mother, or ten months after the death of the father, as legitimate. The English law, which has been adopted in the United States, considers all children as legiti- 1*0 horn, being not larger than the average size. How long it is possible for labour to be delayed beyond the usual time, can- not easily be ascertained: but it is wry seldom protracted beyond a few days, counting the commencement of preg- nancv, from the dav preceding that on which the menses ought to have appeared, had the woman not conceived. CHAP. XV. Of the Gravid Uterus. § 1. SIZE AND POSITION. When we compare the unimpregnated with the gravid uterus at the full time, we must be astonished at the change which has taken place during gestation, in its magnitude alone. In the ninth month, the size of the womb is so much in- creased, that it extends almost to the ensiform cartilage of the sternum; and this augmentation it receives gradually, but not equally, in given times; for it is found to enlarge much faster in the latter, than in the earlier months of preg- nancy. This is true, however, only with regard to the abso- lute increase; for in the first month, the uterus perhaps dou- bles its original size, but it does not go on in the same ratio. It is not twice as large in the ninth as in the eighth month. For a considerable time after conception, the uterus in- stead of rising higher up into the belly, falls rather lower down. It is not till towards the end of the third month, that the uterus can be felt rising above the pubis; although at this period, it generally measures from the mouth to the fun- dus above five inches, one of which belongs to the cervix. In the fourth month, it reaches a little higher, and measures five inches from the fundus to the beginning of the neck. In the mate, who are born in lawful matrimony, or within about forty weeks after the dissolution of the marriage by the death of the husband. It endeavours to avoid enquiring when, or by whom the child may have been begotten; the general rule being presumitur pro legitimation*. 127 fifth, it has become so much larger, as to render the belly tense, and may be felt, like a ball, extending to a middle point between the pubis and the navel, and measures about six inches from the cervix to the fundus. In other two months, it reaches to the navel, and measures about eight inches. In the eighth month, it ascends still higher, reach- ing to about half way between the navel and the sternum. In the ninth month, it reaches almost to the extremity of that bone, at least in a first pregnancy, when the tightness of the integuments prevents it from hanging so much forward as it afterwards does. At this time, it generally measures, from top to bottom, ten or twelve inches, and is oviform in its shape. For the first month, the shape of the uterus is not altered ; it is enlarged in every direction. But after this it swells before and behind, and soon becomes globular, having the cylindrical undistended cervix depending from it; after the fifth month it becomes more oblong, and by the seventh it resembles a balloon. These calculations are not invaria- bly exact, suiting every case, but admit of modifications. In pregnancy, the mouth of the uterus is directed back- ward, whilst the fundus lies forward. This obliquity, how- ever, does not take place until the uterus begins to rise out of the pelvis, and it always exists in a greater degree in those who have born many children. From this position it appears, that the intestines can ne- ver be before the uterus, but must lie behind it and round its sides. § 2. DEVELOPEMENT OF THE UTERUS AND STATE OF ITS CERVIX. Previous to the descent of the ovum, the uterus begins to enlarge, especially at its upper part, or fundus; and it is worthy of notice, that the posterior face of the uterus always distends more than the anterior one, as we ascertain by ex- amining the situation of the orifices of the fallopian tubes. When the fundus begins to increase, it not only grows heavier, but also presents a greater surface for pressure to the intestines above: it, therefore, will naturally descend lower down in the pelvis, and thus project farther into the 123 vagina. In this situation the uterus will remain, until it be- comes so large as to rise out of the pelvis. Until this ascent of the uterus, which takes place about the fourth month, the fundus and body form the whole of the ca- vity ; but then the cervix begins also to be developed: so that by the end of the fourth month of pregnancy, one quarter of its length has become distended, and contributed to augment the uterine cavity; the other three fourths, which remain projecting, become considerably softer, rather thicker, and more spongy. In another month, one half of the cervix is dis- tended, and the rest is still more thickened, or the circum- ference of the projecting part greater: the uterus has also risen farther up, consequently the vagina is more elongated. In the sixth month, the neck is still more stretched. In the seventh, we may, with the finger, distinguish the head of the child pressing on the lower part of the uterus, which we can seldom do before this. In the eighth month, the neck is com- pletely effaced, and its orifice is as high as the brim of the pelvis. The ninth month affects the mouth of the uterus chief- ly. The alterations of the cervix are discovered, by introduc- ing the finger into the vagina, and estimating the distance betwixt the os uteri and the body of the uterus, which we feel expanding like a balloon. The mouth of the uterus is merely the termination or ex- tremity of the cervix, and consists of two lips of the same con- sistence with the rest of the uterus. When the womb is not gravid, these are always open, and will admit the tip of the finger. But, soon after conception, the os uteri is closed, ex- cept at the very margins, at the same time that it gradually becomes softer. In proportion as pregnancy advances, and the cervix stretches, the lips shorten, until they sometimes totally disappear; but more frequently they continue to pro- ject a little, until labour commences. The lower part of the cervix, in the course of gestation, and the inner border of this opening, in the ninth month, for about an inch round, is full of glandular follicles, which secrete a thick viscid mucus. This extends from the one side to the other, and fills up the mouth of the uterus very perfectly, being thus interposed as 1^9 a guard betwixt the membranes and any foreign body. By maceration, it may be extracted entire, when a mould of the lacuna* will be obtained by floating it in spirits, saturated with fine sugar. § 3. MUSCULAR FIBRES. Vesalius describes three strata of muscular fibres, trans- verse, perpendicular, and oblique. Malpighi describes them as forming a kind of net-work ; whilst Ruysch maintains, that they appear at the fundus, in concentric planes, forming an orbicular muscle. Dr. Hunter paints them as transverse in the body of the uterus, but, at the fundus, describing concen- tric eircles around each of the fallopian tubes. These contra- dictions of anatomists serve to shew, what may readily be seen by examining the uterus, that the fibres are not very regu- lar, and distinct in their course, but exhibit confusion, rather than any well marked figure. The increased size of the uterus is by no means chiefly owing to the addition of muscular fibres.^ These become in- deed larger, and better developed, but do not contribute so much to the increase, as the enlargement of the blood vessels, and perhaps the deposition of cellular substance. This gives the uterus a very spongy texture, and makes it so ductile, that a small aperture may be greatly dilated, without tear- ing. From examination, it appears, that although the whole uterus does not grow thinner in proportion to its increase, it yet does, at the full time, become thinner nea* the mouth; whilst the fundus continues the same, or perhaps grows a little thicker, at least where the placenta is attached, § 4. LIGAMENTS. No one, who understands the anatomy of the ligaments of the unimpregnated uterus, will be surprised to find a great change produced in their situation and direction, by preg- nancy. The broad ligament, which is only an extension of the peritoneum from the sides of the uterus, is, in the ninth month, by the increase of the viscus, spread completely over R 130 Hs surface ; and consequently, were we to search for thin ligament, we would be disappointed. Its duplicatures are all separated, and laid smoothly over the uterus. It will there- fore be evident, that we can no longer find the ovaria and fal- lopian tubes floating loose in the pelvis, nor the round liga- ments running out ?.t an angle from the fundus uteri to the groin. All these are contained within duplicatures of the peritoneum, or ligamcntum latum; and therefore, when this is spread over the uterus, it follows, that the ovaria, tubes, and round ligaments, cannot now run out loosely from the uterus, but must be laid flat upon its surface, and hound down by the stretched peritoneum. This description applies only to the state of the uterus in the full time. Earlier, we may readily observe the broad ligament flying out, and allowing the ovaria free play. The loose extremity of the tube be- comes more expanded, and very vascular. On the ovarium we observe a corpus luteum. This is a sub- stance something like a gland, divisible into cortical and me- dulary matter, placed immediately under the membrane of the ovarium, and adhering to the ovarium by cellular sub- stance. By separating this, it can be turned out. It is of a yellowish colour, and is largest soon after conception. There is a corpus luteum for every foetus. § 5. VESSELS. The origin, and distribution of the blood-vessels of the uterus have been already noticed; I have only to add, that in pregnancy, they become prodigiously enlarged. Even be- fore the ovum enters the uterus, we find the uterine artery as large as the barrel of a goose quill, and sending large branches round the cervix uteri, and up the sides of the womb. As pregnaney advances, the trunks, but especially the branches, become still larger, particularly near the im- plantation of the placenta. The veins are enlarged in the ^ame proportion with the arteries. They are destitute of valves, and receive the name of sinuses. The lymphatics are very large and very numerous. The nerves have already been described, 131 § 6. OF THE FCETUS, Although many opportunities have occurred to anatomists, of examining not only abortions, but also the uterus itself, at an early period of gestation; yet it has not been exactly determined at what precise time the ovum enters the womb, or when the foetus first becomes visible. This may depend, partly on wrant of information respecting the exact number of days which have intervened betwixt impregnation and our examination; and partly, perhaps, upon irregularities of the process in the human female, induced by various causes. We know that considerable changes take place in the ca- vity of the uterus, before the ovum descends, and these ge- nerally are not accomplished in less than twenty or thirty days. In a very accurate dissection performed by the late Mr. Hunter, and related by Mr. Ogle,* no ovum could be found either in the uterus or the tubes, although there is rea- son to suppose that nearly a month had elapsed from the time of impregnation. I have examined very carefully three uteri about the same period, and have not been able to dis- cover either ovum or foetus. If we admit analogical evidence on this subject, we shall be more confirmed in a belief that the ovum does not, in the human female, enter the uterus, until at least three weeks after conception!. In the rabbit, whose period of gestation is only thirty days, the ovum is not to be found in the uterus earlier than the fourth day, ac- cording to Mr. Cruikshank:}:, or the sixth according to Dr. Haighton; and the foetus is not visible till the eighth day, when it may be seen by dropping vinegar on the ovum§. Haller found, that in the sheep, whose term of gestation is five months, the ovum does not enter the uterus till the • Transactions of a Society» &c. vol. II. Art. vi- t Dr. Combe possessed a preparation, where there was an appearance of a very minute fxtus. From peculiar circumstances, two and twenty days were supposed to have elapsed from the time of conception. Vide Dr. Hun- ter's Anatom. Descrip. p. 87. \ Phil. Trans. Vol. LXXXVII. i Phil. Trans. VoL LXXXVII. p. 204. 132 seventeenth day*, and the foetus is not \isible till the nine- teenth. The ovum, at first, contains no visible embryo; nothing but vesicular involucra appear. This point is fully establish- ed by examining the inferior animals, and is especially con- firmed by the incubation of the eggs of fowls. When the human foetus is first distinctly visible through the membranes, it is not above a line in length, and of an ob- long figure. By the sixth week, it is seen slightly curved, resembling, as it floats in the water, a split pea. In the seventh week, it is equal in size to a small bee ; and, by the conclusion of the second month, it is bent and as long as a kidney bean. The embryo, at first, appears like two oval bodies of un- equal size, united together by a neck. The one of these is the head, the other the trunk. The head is a membranous bag, which is large in proportion to the body ; but after the first month of its growth, the relative size decreases : on opening it, nothing but a soft pulp is found within. In a lit- tle time, the face appears, the most prominent features of which are the eyes ; these are proportionally larger in the embryo than in the advanced foetus, and are placed low down. The face itself is small, compared to the cranium. The nose does not appear until the end of the second month ; but somewhat sooner, we may observe two apertures in the si- tuation of the nostrils. The mouth, at first, is a round hole, but by degrees lips appear; and after the third month, they are closed, but do not cohere. The external ear is not formed at once, but in parts, and is not completed before the fifth month; even then, it differs in its shape from the ear after birth. It is at first like a gently depressed circle. The extremities early appear like the buds of a plant. The arms are directed obliquely forward, toward the face, and are larger than the inferior extremities. The genitals, for a time, are scarcely to be observed; but in the third month, they are large in proportion to the body. • Elementa, Tom. VIII. p. 59.—Opera Minora* Tom. II. p. 4S4. 133 The foetus does not grow in an uniform ratio, bHt, as has been observed, by the learned anatomist, Dr. Soemmering,(e) the increment is quicker in the third than in the second month. In the beginning of the fourth it becomes slower, and continues so until the middle of that month, when it is again accelerated. In the sixth month, it is once more retarded, and the progression remains slow during the rest of gesta- tion. The proportion between the weight of the foetus and its involucra, is reversed at the beginning and the end of gesta- tion. When the embryo does not weigh more than a scruple, the membranes are as large as a small egg. Even when the foetus is not larger than a fly, the membranes resemble, in shape and size, a large chesnut. On the other hand, at the full time, when the foetus weighs seven pounds, the placenta and membranes do not weigh a pound and a half, and the proportion of liquor amnii is greatly lessened. In the twelfth week, the foetus weighs nearly two ounces, and mea- sures, when stretched out, about three inches. The mem- branes are larger than a goose's egg, and weigh, if we in- clude the liquor amnii, several ounces. In the fourth month, the foetus is about five inches long. In the fifth month, it measures six or seven inches. In the sixth month, the foetus is perfect and well formed, measures eight or nine inches, and weighs about one pound troy; whilst the placenta and membranes weigh about half a pound, exclusive of the liquor amnii. The foetus is now so vigorous in its action, that there bave been instances, though most rare, of its continuing to live, if born at so premature a period. In the seventh month, it has gained about three inches in length, and is now more able to live independent of the uterus; though even at this (c) The student is particularly requested, where that most valuable work is within bis reach, to compare this description of the foetus in its different stages of progressive developement and growth, with the most accurate and elegant plates of Soemmering, entitled, Icones Embryonum Humanorum. Dr. Hunter's plates of the gravid uterus, are also highly worthy of inspec- tion. These invaluable works may be almost said to supply the place of anatomical preparations; so closely and minutely has nature been copied by the faithful pencil and graver of the artist; 131 time, the chance of its surviving six hours from birth is much against it. In the eighth month, it measures about fifteen inches, and weighs four, or sometimes five pounds, whilst the involucra weigh scarcely one. These calculations vary according to the sex of the child, and also the conformation of the parents. Male children generally weigh more than females. Dr. Roederer* concludes, from his examinations, that the average length of a male, at the full time, is twenty inches and a third, whilst that of a female is nineteen inches and seventeen eighteenths. Dr. Joseph Clarke has given a table of the comparative weight of male and female children at the full time, from which it appears, that although the greatest proportion of both sexes weigh seven pounds, yet there are more females than males found below, and more males than females above that standard. Thus, whilst out of sixty males, and sixty females, thirty-two of the former, and twenty-five of the latter, weighed seven pounds, there were fourteen females, but only six males, who weighed six pounds. On the other hand, there were sixteen males, but only eight females, who weighed eight pounds. Taking the average weight of both sexes, it will be found, that twelve males are as heavy as thirteen females. The placenta of a male, weighs, at an average, one pound two ounces and a half, whilst that of a female weighs half an ounce less. Fe- male children, who, at the full time, weigh under five pounds, rarely live; and few males, who even weigh five pounds, thrive. They are generally feeble in their actions, and die in a short time. When there are two children in utero, the weight of each individual is generally less than that of the foetus who has no companion; but their united weight is greater. When a woman has twins, it either usually happens, that both chil- dren are small, or one is of a moderate size, and the other is diminutive; though I have known instances, where both the children were rather above, than under the usual standard. The average weight of twelve twins, examined by Dr. Clarke, was eleven pounds the pair, or five and a half each. * Comment, Gottin. 1753. 13d Twins require more pabulum from the mother, and a greater degree of action in the uterus; for two placentae must have their functions supported. The uterus is also generally more distended, and produces greater irritation; it .has more blood circulating in it; and the weight of its contents, to that with a single child, has been stated as twenty to fifteen. Twin gestation often produces a greater effect on the sys- tem, making the women more disposed to disease, and less able to bear it: hence the chance of recovery has been sup- posed to be four times less in them, than in those who have single children. The children, being generally feebler than when only one is contained in the uterus, are more disposed to disease; and, as the mother is less able to suckle children after a twin labour, many perish, who might have been pre- served, by providing a good and careful nurse, soon after birth, for the weakest child. When the number of children increases above two, the aggregate weight does not increase. Thus Dr. Hull of Man- chester met with a delivery of five children, who did not weigh two pounds and a quarter; they measured from eight to nine inches in length, and two of them were born alive. Calculations have been made of the proportion of single births, to those where there were a plurality of children. In the Dublin hospital, one woman in fifty-eight had twins. In the British lying-in hospital, one in ninety-one. In the Westminster hospital, one in eighty. In my own practice, about one in ninety-five.(ci) In the Dublin hospital, triplets have not occurred above once in five thousand and fifty times.(e) More than three are not met with, once in twenty thousand times. (d) In the lying-in hospital, called l'Hospice de la Maternite at Paris, about 1 in 89 had twins, as appears from Baudelocque's Tableau des Ac- couchemens- In the lying-in ward of the Philadelphia alms-house, as appears from a regular record kept for five years, ending May 23, 1813, one woman in about 107 had twins. The number of males to females born within the above period, was as 117 to 99. (e) In l'Hospice de la Maternite" at Paris, triplets occurred but twice i« 12,605 women delivered- 136 The proportion of male children, born in single births, is greater than of females. In an extensive parish in this place, the number of males, born in a given time, was to that of females, as 3716 to 3177. In the Westminster hospital,'it was as 972 to 951; but in the same hospital, it is worthy of re- mark, that the number of male twins was only 16. whilst that of females was 30.(/) § 7. ITS PECULIARITIES. The foetus has many peculiarities which distinguish it from the adult, and which are lost after birth, or gradually removed during gestation. In particular, the liver is of great size, by which the abdomen is rendered more prominent than the thorax. It appears very early, and increases rapidly till the fourth month, after which its growth is slower. In the child, after birth, the greatest quantity of blood in the liver is venous, and from this the bile seems to be secreted. But in the foetus, the blood is more nearly approaching in its nature to arterial; and no bile, but a fluid different in its properties, is secreted. The gall bladder is filled with a green fluid, which, before birth, becomes darker, with a tinge of blue, but is said not to have a bitter taste. The umbilical vein, which contains blood, changed in the placenta, enters the liver, and sends large branches to the left side; the vena porta enters the liver, and ramifies on the right side; whilst a branch, or canal of communication, is sent from the umbi- lical vein to the vena portse. By this contrivance, the left side is supplied altogether with pure blood from the placenta, and the right side is supplied with a mixture of pure and im- pure blood, which does not form perfect bile. After birth, as the circulation from the placenta is stopped, the branches of the. umbilical vein, which supplied the left side, would be empty, did not the canal, which formerly served to carry a portion of blood from this vein to the vena porta, now per- mit this latter vessel to fill the branches in the left side, (f) Of 12,751 infants born in the lying-in hospital at Paris, above alluded to, 6,524 were males, and 6,227 females. 137 whicb henceforth form a part of the vena porta. The whole liver is thus supplied with blood entirely venpus. Bile is formed, and sometimes in very considerable quantity. The blood of the foetus differs from that of the adult. It forms a less solid coagulum, for, in place of fibrous matter, it yields a soft tissue, almost gelatinous. It is not rendered florid by exposure to air*, and it contains no phosphoric salts. But soon after the foetus has respired, the colouring matter, exposed to oxygen, acquires the vermillion tint; and sails are formed, particularly the phosphate of lime. The stomach is smaller in the foetus, tlian in the child af- ter birth. The intestines, which at first, are seen like threads arising from the stomach, are redder, and said to be longer in proportion to the body in the foetus, than in the child. They are at first uncovered, but, after some time, the abdo- minal muscles and integuments form a complete inclosure. They contain a soft substance like ointment, of a dark green colour, called meconium. The testicles of the male, and the ovaria of the female, lie on the psoa muscles, but, before birth, the testicles pass into the scrotum. The kidneys are large and lobulated, and the ureters thick. The glandulse renales are large, and contain a reddish fluid. The bladder is more conical and lengthened out, than in the adult. The lungs are dense and firm, and a large gland, called thymus, is contained in the thorax. The heart is very different from its adult state. In the chick, we find that there is in the situation of the heart, a single cavity which afterwards corresponds to the left ven- tricle. At the forty-sixth hour, the ventricle and bulb of the aorta are visible. Then an auricle is formed by the vena cava: this auricle does not adhere directly to the ventricle, until the sixth day, but is connected with it till that time by a short duct, called canalis auricularis. In about ninety six hours the auricle begins to exhibit marks of a division into two cavities, or a right and a left side; and sometime afterwards, the * Bichat made experiments, to ascertain this upon guinea pigs, and al- ways found the fatal blood black. Anatomie Generale, Tome II. p- 343. s 138 right ventricle and lungs are evolved. The structure of the heart, however, is still different from that which obtains af, ter birth; for though the auricles are divided into two cavi- ties, yet these are seen, in the human foetus, to communicate freely by a vacancy in the septum; and even after this is sup- plied, it is only with a valve, which allows the blood to pass from the right to the left side. This is the foramen ovale, which is shut up afterbirth. Another peculiarity of the foetal heart is, that the pulmonary artery, although it divide into two branches for the lungs, yet sends a third, and still larger branch, directly into the aorta, just at its curvature, and this is the ductus arteriosus. The blood is received in a purified state from the placenta, by the umbilical vein, which, after giving off branches in the liver, sends forward the con- tinuation of the trunk, to terminate in the vena cava, or largest of the hepatic veins, and this continuation is named ductus venosus. The mixed blood which is thus found in the vena cava, is carried to the right auricle, and thence to the corresponding ventricle. By the pulmonary artery it ought to be conveyed to the lungs, but this would be useless in the foetus, and therefore the greatest part of it passes on by the ductus arteriosus'to the aorta. But it follows from this, that as little blood is carried to the lungs, so little can be brought from them by the pulmonary veins to the left auricle. Now, to obviate this, and fill that auricle at the same time with the right, the foramen ovale is formed; and thus, as the blood can pass freely from the right to the left, the two auri- cles are to be considered as one cavity, being filled and emp- tied at the same time. The aorta is distributed to the different parts of the body; but this singularity prevails, that the hypogastric vessels run up all the way to the navel, and pass out to form the umbilical arteries. After birth, these arteries are obliterated in their course to the navel; and the foramen ovale, and ducr tus arteriosus become impervious. The head of the foetus is, at first, membranous, and the brain a pulp, soluble in aqua kali puri. By degrees, distinct cartilaginous plates are formed over the brain, which are 139 gradually converted into bones. These, at birth, are only tinited by intermediate membranes. The pupil of the eye, till the seventh month, is shut up by a membrane; and the eye-lids, for some months, adhere toge- ther. The skin is covered with va white substance, which, though unctuous to the feel, does not melt, but dries and crackles by heat. It is miscible with spirits, or with water, through the medium of soap or of oil. The male foetus differs from the female, in having the head larger, but less rounded, and flatter at the back part. The thorax is longer, and more prominent, and formed of stronger ribs than in the female. In her, it is wider from the upper part to the fourth rib, and narrower below; the belly, also, in the female, is more prominent, and the symphysis pubis projects more. The upper extremities are shorter than those in the male; the thighs are thicker at the top, and more tapering to the knees. Dr. Soemmering says, that the spi- nous processes of the lower dorsal, and upper lumbar verte- bra, make in the male an eminence like a yoke, in tha female a sinuosity. I may remark, that as the clitoris is large in the young foetus, females sometimes pass in abor- tions for males. When in utero, the foetus assumes that posture which occu- pies least room. The trunk is bent a little forward, the chin is pushed down on the breast, the knees are drawn up close to the belly, and the legs are laid along the back part of the thighs, with the feet crossing each other. The arms are thrown into the vacant space betwixt the head and knees. This is the general position, and the child thus forms an oval figure, of which the head makes one end, and the breech the Other. One side of it is formed by the spine and back part of the head and neck, and the other by the face and contract- ed extremities. The long axis of this ellipse measures, at the full time, about ten inches, and the short one five or six. In the eighth month, the long axis measures about eight inches. In the sixth, betwixt four and five. In the fourth month, it measures nearly three inches and a half: and in the third, uo about an inch less. In the earh months, however, there is no regular oval formed, and these measurements are taken from the head to the breech, which afterwards-form the ends of the distinct ellipse. The extremities are at first small and slender, and bend loosely toward the trunk. § 8. bmbiik \i. conn. The umbilical cord is an essential pari of the ovum, con- necting the foetus to its involucra. It is found in oviparous and viviparous animals, and also in plants; but in these dif- ferent classes, it appears with many modifications. In the human subject, it consists of three vessels; of which two are arteries, and one is a vein. These are imbedded in gluten, and covered with a double membranous coat. The two arte- ries are continuations of the arteria hypogastrica of the child, and passing out at the navel, run in distinct and un- connected trunks, until they reach the placenta, where they ramify and dip down into its substance. When they reach the placenta, the one artery, in some cases, sends across a branch to communicate with the other. The vein commences in the substance of the jdacenta, forms numerous rays on its surface, corresponding to the branches of the arteries; and near the spot where the arteries begin to give off branches, these rays unite into a single trunk, the area of which is ra- ther more than that of the two arteries. None of these ves- sels are furnished with valves. The umbilical vessels run in a spiral direction, within the covering of the cord, and the twist is generally from right to left. Besides this twisting, we also find, that the vessels, especially the arteries, form very frequently coils, loosely lodged in the gluten. The cord does not consist entirely of vessels, but partly of a tenacious transparent gluten, which is contained in a cel- lular structure; and these numerous cells, together with the vessels, are covered with a sheath, formed by the reflection of both chorion and amnion from the placenta, and of neces- sity, the amnion forms the outer coat of the cord. The cho- rion adheres firmly to the cord every where, but the amnion does not adhere to the chorion j it is not even in contact with 141 it at the placental extremity, but forms there a slight expan- sion, which, from its shape, has been called by Albiniis, the processus infundibuliformis. The proportion of gluten is larger in the early than in the advanced stage of gestation; and the vessels, at first, run through it in straight lines. In some instances, the cells dis- tend or augment in number, so as to form tumours on the cord, which hang from it like a dog's ear. There is a small sac, or bladder, found on the placenta, at or near the extremity of the cord, in the early part of ges- tation. It is most distinct betwixt the third and fourth month of pregnancy, and is placed exterior to the amnion. It is fill- ed, though not quite distended, with a whitish fluid, on which account, it is called the vesicula alba*. From this, a very fine vessel proceeds along the cord, adhering firmly to the amnion; but, without a glass, it cannot be traced all the way to the navel. It has been supposed to be subservient to the nourishment of the foetus in its early stage. A small artery and vein pass along the cord from the navel, to the vesicle which is between the chorion and amnion. These arc the omphalo-mesentcric vessels. Besides the blood vessels, there is in brutes another ves- sel, which is a continuation of the fundus vesica. It passes out at the navel, and, running along the cord, terminates in a bag, which is placed betwixt the chorion and amnion. The bag is called the allantois, and the duct the urachus. In the human subject, in place of the urachus, we find only a small White impervious cord. There is of course no allantois. When the ovum is first visible in the uterus, there is no cord, the embryo adhering directly to the involucra, but it soon recedes; and about the sixth week, a cord of communi- cation is perceptible. The cord at the full time varies in length, from six inchest to four feetj; but its usual length is two feet. When it is too • Vide Albinus, Annot. Acad, lib.i. cap. xix. p. 74. et tab. I. fig. 12. t Hildanus, cent. II. obs. 50. \ Mauriceau has seen it a Paris ell and a third, obs. 401.—Hebenstreit 40 inches—Haller Disp. Anat. Tom. V. p. 675.—Wrisberg 48 inclies—Vide Com. Gotting. Tom. IV. p. 60. 143 long, it is often twisted round the neck or body of the child, or occasionally has knots formed on it,* most frequently, per- haps, by the child passing through a coil of it during la- bonr.f The vessels of the cord sometimes become varicose, and form very considerable tumours. These, occasionally, so far impede the circulation, as to interfere with the growth of the child, or even to destroy it altogether. Sometimes the ves- sels burst, and blood is poured into the uterus, which pro- duces a feeling of distension, and excites pain. There can, however, be no certainty of this accident having taken place until the membranes burst, when clots of blood are discharg- ed. If the foetal and maternal vessels should communicate, the mother is weakened, and may even faint; and, in every instance, the child suffers, but does not always dief. Deli- very must be resorted to, either on account of the effects1 produced on the mother, or to prevent the destruction of the child. The cord may by a fall, or violent concussion of the body, be torn at a very early period of gestation. In this case, the child dies, but is not always immediately expelled. It may be retained for several weeks; afterwards the ovum is thrown off, like a confused mass, inclosing a foetus, corresponding in size to the period when the accident happened^. The cord may be filled with hydatids. The cord has been found unusually small and delicate, or, on the contrary, very thick. In the latter case, it is always proper to apply two ligatures, instead of one, on the portion which remains attached to the child**. It has happened, that, by the shrinking of the cord under the ligature, the child has died from hemorrhageff. • Vide Mauriceau, obs. 133 and 156. f Dr. Hunter thinks he has twice seen these formed, previous to birth. J Vide Baudelocque 1' Art, note to section 1084. $ Vide Case by M. Anel, in Mem. of Acad, of Sciences, 1714. ••This was proposed by Mauriceau. in consequence of meeting with an in- stance, where the child suffered much from loss of blood, obs. 256. tf Vide Case by M. Degland, in Recueil Period- Tome V. p. 345- 143 Two cords have been met with, connected with one pla- centa, or with two placenta belonging to one child. In other instances, the vessels are supernumerary or deficient. Sto- ries have been told of the cord being altogether wanting, but these are incompatible with the foetal oeconomy. § 9. PLACENTA. A placenta, or something equivalent to it, is to be found connected with the young of every living creature. We find it requisite that a pabulum should be supplied to every animal, and that certain changes should be performed on the blood, qualifying it for supporting life. In oviparous animals, two different parts of the ovum perform these sepa- rate functions. The umbilical vessels of the chick ramify on the membrane of the albumen, and thus come in contact with the air, which is absorbed through the pores of the shell; and, by this contrivance, changes analogous to those effected by respiration, are produced on the blood. From the inner sur- face of the membrane of the vitellus, a nourishing flood is absorbed, which is conveyed to the intestine by a proper duct; and, before the chick is hatched, the remainder of this fluid, inclosed in the membrane of the vitellus, is taken with- in the abdomen, and covered with the abdominal integu- ments1. In many quadrupeds we find, that, after impregnation, certain portions of the inner surface of the uterus enlarge, and form protuberances, having many hollows or foramina, from which a milky fluid can be squeezed. From the chorion, corresponding vascular efflorescences arise, which shoot into these apertures; and thus an union is effected betwixt the mother and foetus. In the sow and the mare there is no projection from the uterus, but its surface is every where smooth and vascular. There is no efflorescence from the chorion, but it has nume- rous vessels disposed over it, which are the extremities of the umbilical arteries and veins. In these animals, then, we have no distinct placenta, the chorion alone serving that purpose. 144 The cetacea have uteri like quadrupeds, but I am unac- quainted with the precise mode of connection betwixt the moth;-!-and the foetus. The monkey differs from other quadrupeds, in Inning no permanent papilla; but the maternal part of the placenta is deciduous, like that of women. In the human subject, the placenta is a flat circular sub- stance, about a span in diameter, and, when uninjected, an inch in thickness. It becomes gradually thinner from the centre to the circumference, by which it ends less abruptly in the membranes. Its common shape is circular; but it is sometimes oblong, or divided into different portions. The umbilical cord may be fixed into any part of the pla- centa, or sometimes into the membranes, at a distance from the placenta. When this happens, the vessels run in distinct branches to the placenta, without forming any spongy sub- stance on the membranes. Most frequently, however, the cord is inserted at a point about half way between the centre and the circumference of the placenta. From this the umbi- lical vessels spread out, like a fan, ramifying over the sur- face, and dipping their extremities into the substance of the placenta itself. That surface of the placenta which is attached to the uterus, is divided into lobes, with slight sulci between them, and is covered with a layer of the decidua, like clotted blood. On the surface which is next the child, we see the eminent branches of the umbilical vessels, over which we find spread the chorion and amnion. If we inject, from the umbilical vessels of the human foetus, we find that the placenta is rendered turgid, and vessels are to be found filled in every part of it; but always between their ramifications, there remains an uninjected substance. Even the uterine surface of the plaeenta is not injected, for the foetal vessels do not pass all the way to that surface. If we inject from the uterine arteries, we, in like manner, render the placenta turgid, but nothing passes into the umbi- lical vessels; and, when we cut into the placenta, we find cells full of injection, and covered with a fibrous uninjected 145 matter. Hence we may infer, that the placenta consists uni- formly of two portions. The one is furnished by the decidu- ous coat of the uterus, the other by the vessels of the chorion; and these two portions may, during the first three months, be separated, by maceration, from each other. The structure of the foetal portion, so far as we know, ap- pears to be similar to that of the pulmonary vessels, the artery terminating in the vein. But the other portion is somewhat different: there is not a direct anastomosis, but the artery opens into a cell, and the vein begins from this cell; for, by throwing in wax by the uterine artery, we may frequently inject the veins. These cells communicate freely with each other in every part of the placenta, and may be compared to the corpora cavernosa penis. From the general principles of physiology, as well as from experiments on the chick in ovo, and from the fatal effects which instantly follow compression of the cord whilst the child is in utero, it is allowable to infer, that the placenta serves to produce a change on the blood of the foetus, analo- gous to that which the blood of the adult undergoes in the lungs; and from considering, that the foetus itself cannot cre- ate materials for its own growth and support, we may far- ther infer, that the placenta is the source of nutrition also. The placenta may be formed at any part of the uterus, but, in general, it is found attached near the fundus. Its structure is sometimes changed, part of it being ossi- fied or indurated, or on the contrary unusually soft. These changes may produce either hemorrhage, or retention of the placenta. Hydatids may form in the placenta; or fleshy tu- mours may grow in its substance. In neither of these cases does the child necessarily die. § 10. MEMBRANES AND LIQUOR AMNII. The ovum, when it descends into the uterus, consists of two membranes, one within the other. These inclose the em- bryo, and contain a quantity of fluid. The innermost membrane, or amnion, is thin, pellucid, and totally without the appearance of either vessels or re- T 146 gular fibres; yet, in the end of pregnancy, it is stronger than all the rest taken together: it lines the chorion, covers the placenta, and mounts up on the navel string, affording a coat to it all the way to the umbilicus, where it termi- nates. The sac, formed by the amnion, is filled with a fluid, which appears to be composed chiefly of water, with a very little earth, mucus, and saline matter. As this water is contained within the amnion, it has received the name of liquor amnii. The quantity of water, upon an average, which is contain- ed within the amnion, at the full time, is about two English pints; but sometimes it is much more, and at other times scarcely six ounces. In the early periods, the quantity is larger, in proportion to the size of the uterus, than after- wards. The chorion, like the amnion, is thin and transparent, ad- heres firmly to the placenta, and covers all the vessels which run on its surface; but it does not dip down with them into the substance of the placenta. When the ovum first descends, the chorion is every where covered with vessels, which sprout out from it. These form a covering to it, which, from its appearance, has been called the shaggy, or spongy chori- on. § 11. DECIDUA. The last coat to he described, is one yielded entirely by the uterus, and serves to connect the uterus with the foetal vessels of the chorion together. This, as Harvey observes, is - not a covering of the foetus, but a lining of the uterus, which falls off after delivery; and therefore it is called the caduc- ous coat, or the membrana decidua. The illustrious Haller supposed, that this was formed by naked vessels shooting out from the uterus. Dr. Hunter im- magined, that the arteries of the uterus poured out coagu- lable lymph, which was afterwards changed into decidua. His brother, Mr John Hunter, attributed its origin to coagu- lated blood, which formed a pulpy substance on the inner sur- face of the uterus. iW Having been so fortunate as to meet with three or four opportunities of investigating the state of the uterus, within a month after conception, I shall describe what appears to me to be the structure of the decidua. Very speedily after impregnation, and always before the embryo enters into the womb, its size is increased, its fibres are softer and more se- parated from each other, and its vessels very much enlarged. On cutting it up, its cavity is found to be considerably broader and longer, and somewhat wider than in the unim- pregnated state; and all the fundus and body have their sur- face covered with a dense coat, which adheres firmly to the uterus. If the vessels have been injected, this evidently is seen to consist of two different substances, namely vessels, and a firm tough gelatine. It seldom happens that all the vessels can be equally filled, and therefore some spots are redder than others. The vessels do not pass on to the surface of this coat, but are seen shining through it. They proceed directly from the surface of the womb, and project at right angles to the plane which yields them; they are intermixed with a little gelatine, and consist of both arteries and veins. Over their extremities is spread a layer of gelatinous matter, which very early is observed to contain fibres, forming a kind of net-work. Thus the decidua consists of two layers, one highly vascular, proceeding directly from the uterus; the other, which is most probably formed by these vessels, is more fibrous and gelatinous; and when this is removed, the primary vessels, or outer layer, may be seen like a fine efflorescence, covering the surface of the uterus. In some cases the decidua extends a little into the fallopian tubes; in other instances it does not. In no case does the cervix form decidua. It is only produced by the fundus and body of the womb; and immediately above the cervix, the decidua stretches across, so as to form a circumscribed bag within the uterus. In some instances, however, I have observed this continuation to be wanting, although the parts were opened with care. In all other circumstances, these uteri resembled those where the decidua was continued across; but, perhaps, notwithstanding this, there may have been a difference of 148 two or three days in the period of impregnation, occasioning this variation. In every case, the decidua, consisting thus of two layers, is completely formed before the ovum descends. When the embryo passes down through the tube, it is stop- ped, when it reaches the uterus, by the inner layer, which goes across the aperture of the tube, and thus would be pre- vented from falling into the cavity of the uterus, even were it quite loose and unattached. By the growth of the embryo, and the enlargement of the membranes, this layer is distend- ed, and made to encroach upon the cavity of the uterus, or more correctly speaking, it grows with the ovum. This dis- tention or growth gradually increases, until at last the whole of the cavity of the uterus is filled up, and the protruded portion of the inner layer of the decidua comes in contact with that portion of itself which remains attached to the outer layer. We find then, that the inner layer is turned down and covers the chorion; from which circumstances, it has been called the reflected decidua.(^) Thus we see, that whenever the ovum descends, it is en- circled by a vascular covering from the uterus, which unites, in every point, with those shaggy vessels which sprouted from the chorion, and which made what was called the spongy chorion. One part of these vessels forms placenta, and the rest gradually disappear, leaving the chorion covered by the decidua reflexa. This obliteration hegins first at the under part of the chorion. (g) By others it is thus explained, viz. That after the cavity of the uterus is completely lined with the secreted decidua, the ovum passes into it from the fallopian tube, and in passing along its parietes, involves and covers it- self completely over every point of its surface with a coat of the decidua, which at that period may be compared to a coat of white paint; as the ovum increases in size, the decidua immediately covering it, (called decidua reflexa) ultimately comes into intimate contact with that portion of the de- cidua, which continues to line the cavity of the uterus, and forms apparently but one membrane. 149 CHAP. XVI. Of Sterility. Sterility depends either on malformation, or imperfect action of the organs of generation. In some instances the ovaria are wanting, or too small; or the tubes are imperfo- rated; or the uterus very small. In these cases the menses generally do not appear, the breasts arc flat, the external organs small, or they partake of the male structure, and the sexual desire is inconsiderable. In a great majority of instances, however, the organs of generation seem to be well formed, but their action is imper- fect or disordered. The menses are either obstructed or sparing, or they are profuse or too frequent, and the causes of these morbid conditions have been already noticed. It is extremely rare for a woman to conceive, who does not menstruate regularly; and on the contrary, correct men- struation generally indicates a capability .of impregnation on the part of the woman. A state of weakness and exhaustion of the uterine system occasioned by frequent and promiscuous intercourse with the other sex, is another very common cause of barrenness in women, and hence few prostitutes conceive. A morbid state of the uterus and ovaria, often accompanied with fluor albus, may likewjge be ranked amongst the causes of sterility, and this is known by its proper characters. When sterility depends upon organic disease, we have it seldom in our power to remove it; but when there is no mark of the existence of such a state, and we have ground to sup- pose that it is occasioned by debility, or imperfect action of the uterine system, we are to employ such means as have been pointed out in considering the diseased states of men- struation. In many cases, much success attends the tonic plan of treatment, particularly the use of the cold bath, and chalybeate medicines. A temporary separation from the hus- band is of service, especially when the menses are profuse, and, in most cases, frequent intercourse should be avoided. 150 Women who arc very corpulent, arc often barren, for their corpulence either depends upon want of activity of the ovaria; spayed, or castrated animals generally becoming fat: or it exists as a mark of weakness of the system. In both cases, moderate exercise, and chalybeate water or nitrous acid, may be of service, but it musi be confessed, often fail. These remarks are also applicable to women who are of a spare, delicate habit. Should a woman, who has been for some years barren, conceive, she must be very careful dur- ing gestation, for abortion is readily excited. In some cases, the uterine system is capable of being act- ed on by the semen of one person, but not of another. CHAP. XVII. Of Extra-uterine Pregnancy. § 1. SYMPTOMS, PROGRESS AND SPECIES. It sometimes happens, that the ovum does not pass down into the womb, but is retained in the ovarium, or stops in the tube, or is deposited among the bowels. Of all these species of extra-uterine pregnancy, the tubal is the most frequent. The symptoms of extra-uterine pregnancy are not, at first, very definite; but generally the usual sympathetic effects of pregnancy, or the diseases of g^tation, are more distressing than if the foetus were contained in utero, nor do they cease so early. In some cases, they even increase in violence, as pregnancy advances.* The symptoms, though often more violent, are, however, similar in kind, to those of common pregnancy. The belly swells, the uterus itself enlarges, and may be felt to be hea- vy ; but, after some time, it does not correspond in its size, and in the state of its cervix, to the supposed period of ges- tation. The menses are often obstructed, though in some cases they have continued to appear for two or three months. * tide Paper by Dr. Garthshore, Lond. Med. Journ. Vol. VIII. p. 344. 151 The breasts enlarge, the morning sickness takes place about the usual period1, and the child quickens at the proper time, but it is felt chiefly upon one side. Occasionally in the early stage of pregnancy, pains2 re- sembling those of colic are felt, and these are often so severe as to excite syncope*, or convulsions*; and it has happened, that during these pains, the tube or ovarium has burst, and the person died, owing to the internal hemorrhage. When these pains either do not occur, or are removed, we gene- rally find, that at the end of eight, nine, or ten months from the commencement of gestation, appearances of labour4 take place; the woman suffers much from pain, and there may be a sanguinous discharge from the uterus. The pains go off more or less gradually!, the motion of the child ceases, and milk is secreted!. ln a few instances, very little farther inconve- nience is felt, the tumour of the belly remaining for many years, and the child being converted into a substance resem- bling the gras des cimetieres, whilst the sac which contains it becomes indurated. More frequently, however, considerable irritation is produced5, inflammatory symptoms supervene, and hectic takes place. The sac adheres to the peritoneum, or intestines; and after an uncertain period, varying from a few weeks or months to several years, it either opens exter- nally, or communicates with the abdominal viscera. Very foetid matter, together with putrid flesh, bones, and coagula, are discharged through the abdominal integuments^, or by the rectum6, vagina7, or bladder8. Sometimes, even an entire foetus has been brought away from the umbilicus9, or by the rectum10. It is worthy of notice, that the placenta, in this pro- cess, always is ultimately destroyed11, and discharged among the putrid fluid. Often, time is not allowed for this process to be accomplished, but the person dies at an early period. * Vide Dr. Fern's case, and a case by Mr. Jacob, in Lond. Med. Jour. Vol. VIII. p-147. t In Mr. Bell's case, the pains continued, though gradually abating, for three weeks. Med. Comment, Vol. II. p. 72. Jin Mr. Bell's case, milk continued to be secreted for several years. In Mr. Turnbull's case, a fluid was secreted, rather like pus than milk. « This termination is noticed so long ago as by Albucasis, lib. II. c. 76. 153 Thus it appears, that there are different terminations of the extra-uterine pregnancy.* The sac may burst, and the person die speedily of hemorrhage12; or the child may escape into the abdomen, and be inclosed in a kind of cyst of lymph*; or the sac may remain entire, the child being retained many years13, and the parts become hard; notwithstanding this, the menses may return, and the woman conceive again14. But the most frequent termination is that of inflammation ending in abscess, attended with fever and pain, under which the patient either sinks, or the foetus is expelled in pieces, and the cure is slowly accomplished. From a review of cases it appears, that a majority ultimately recover, or get the better of the immediate injury: of the rest, some have sunk speedily, either from hemorrhage or inflammation, or exhaustion produced by ineffectual attempts to expel the child; or more slowly from hectic fever; or in consequence of some other disease being called into action, by the violence which the constitution has sustained. In some cases, the sac rises quite out of the pelvis. In others, it falls down between the rectum and vagina, forming a tumour, accompanied with symptoms of retroversion15 of the uterus; but the urine is not so constantly suppressed, and the os uteri, though pressed to the symphysis, is not so much turned up as in retroversion!. In such cases, the sac inflames, and bursts into the rectum or vagina. Sometimes, when parturient efforts are made, the head descends into the pelvis, though it wras not there before; but either no os uteri can be felt, or it is felt directed to the pu- bis, and it is not affected by the pains.(^) It is curious to observe, that generally the uterus enlarges somewhat16, and in most instances, I imagine, decidua17 is • Vide a case by La Croix, in La Med. Eclaire'e, Tome IV. p. 349. f Vide Mr. Mainwarring's case, in Trans, of a Society, &c. Vol. II. p. 287- (b) It is very probable that some of these cases have in reality originated from retroversions of the uterus, which, as Merriman has proved, may even continue in that state until the full period of utero-gestation. This subject: shall be more fully explained, when retroversion of the uterus comes to be treated of. In the mean time the student is referred to a review of Dr. Mer- timan's Work, in the Eclectic Repertory, Vol. I. p. 338. 153 formed. In a remarkable case,, related by the ingenious Mr. Hay* of Leeds, the placenta was formed in the uterus/whilc the foetus lay in the tube. Tubal pregnancy sometimes does not proceed farther than the second month, the tube bursting at that time; or, to speak more correctly, I believe the tube slowly inflames, and slough- ing takes place. In a great majority of instances, however, the tube goes on enlarging for nine months, and acquires a size nearly equal to that of the gravid uterus, at the same stage of gestation!. The placenta differs from a uterine pla- centa, in being much thinner and more extended. External examination discovers little difference, at the full time, be- tween this and common pregnancy. Ovarian18 is much more rare than tubal pregnancy, and it is seldom that the ovarium acquires a great size. It either bursts early19, or inflammation and abscess take place; or the foetus dies, and is converted into a confused mass; or it ex- cites dropsy of the ovarium20. The ovarian pregnancy, until inflammation has taken place, produces a circumscribed moveable tumour, like dropsy of the ovarium. In ventral pregnancy, the most rare of the three species, the motions of the child are felt more freely, and its shape is ■ readily distinguished through the abdominal integuments. The expulsive efforts come on as usual, and the head of the child is sometimes forced into the pelvis. It dies, and the usual process for its removal is carried on, if the woman do not sink immediately under the irritation. The placenta is found attached to the mesentery or intestines21. § 2. TREATMENT. In the treatment of extra-uterine pregnancy, much muet depend on the circumstances of the case. In the early stage, if the sac be lodged in the pelvis, we must procure stools, and have the bladder angularly emptied, as in cases of retrovert- • Vide Med. Obs. and Inq. Vol. III. p. 341. t Among many other cases, in proof of this, I may refer to one very a?cu- rately detailed by Dr. Clarke, in the Trans, of a Society, &c. Vol. II. p. 1. IT ? 154 cd uterus. Attacks of pain, during the enlargement of the tube, require blood-letting and anodynes, laxatives and fo- mentations. The same remedies arc indicated when convul- sions take place. Ovarian requires a similar management with tubal pregnancy, except that if it be complicated with dropsy, relief may be obtained by tapping. When expulsive efforts are made, and the head is felt through the vagina, and the nature of the case distinctly as- certained, it may be supposed, that much suffering may b« avoided, by making an incision through the vagina, and de- livering the child; but, as yet, experience has not fully ascer- tained the utility of this practice*. It has been proposed, in these and other circumstances, to perform the csesarean ope- ration!, in the usual manner, upon the accession of labour; but there is not only great danger from the wound, but like- wise from the management of the placenta, which if removed, may cause hemorrhage, especially in ventral pregnancy, and, if left behind, may produce bad effects. The last, however, is the safest alternative. The result of the numerous cases upon record, will cer- tainly justify, to the fullest extent, our trusting to the pow- ers of nature, rather than to the knife of the surgeon. Allay- ing pain and irritation in the first instance, by blood-letting, anodynes, and fomentations; and avoiding, during all the in- flammatory stage, stimulants and motion, whilst, by suitable means, we palliate any particular symptom, constitute the sum of our practice. A tendency to suppuration is to be encouraged by poulti- ces; and the tumour, when it points externally, is either to be opened, or to be left to burst spontaneously, according to the sufferings of the patient, and the exigencies of the case22. The passage of the bones, and different parts of the foetus. may often be assisted; and the strength is to be supported • In a case, probably of this kind, related by Lauverjat, and quoted by Sabatier, the child was extracted by an incision through the vagina, and the woman recovered. De la Med. Operat. Tome I. p. 136. | M. Colomb performed the cesarean operation, but it ended fatally. Re- cue'il des Actes de la Societe de Lyon. 155 under the hectic which accompanies the process. After the abscess closes, great care is still necessary, for, by fatigue or exertion, it may be renewed, and prove fatal23. When no process is begun for removing the foetus, but it is retained and indurated, our practice is confined to the pal- liation of such particular symptoms as occur. CHAP. XVIII. Of the Signs of Pregnancy. Some women feel, immediately after conception, a parti- cular sensation, which apprizes them of their situation; but such instances are not frequent; and generally, the first cir- cumstances which lead awTomanto suppose herself pregnant, are the suppression of the menses, and an irritable, or dys- peptic state of the stomach. She is sick or vomits in the morn- ing, and has returning qualms or fits of languor during the forenoon; is liable to heartburn through the day or in the evening, and to that disturbed sleep through the night, which so frequently attends abdominal irritation. In some instan- ces, the mind also is affected, becoming unusually irritable, changeable, or melancholy. The breasts often at first be- come smaller, but about the third month they enlarge, and occasionally become painful; the nipple is surrounded with a brown circle or areola; and often, even at an early period, a serous fluid begins to ooze from it. The woman loses her looks, becomes paler, and the under part of the lower eye-lid is of a leaden hue. The features become sharper, and some- times the whole body begins to be emaciated, whilst the pulse quickens. In many instances, particular sympathies take place, causing salivation, toothach, jaundice, &c. In other cases, very little disturbance is produced, and the woman is not certain of her condition, until the child quickens, which happens about the fourth or fifth month of pregnancy; in a few instances, at the end of the third.(i) This quickening is (*) Professor Roederer kept a correct account of one hundred women, no- ting the time when it was presumed they were impregnated, the period at 156 attended with a sensation of motion, or fluttering in the lower belly, and is not unfrequently accompanied with faintishness or hysterical irritation. Such affections, however, do not usu- ally last long, and the morning sickness also generally abates after this period, and the mind becomes more equable, whilst the corporeal system is also improved. In the commencement of pregnancy, the abdomen docs not become tumid, but, on the contrary, is often rather flat- ter than formerly; and, when it does first increase in size, it is rather from inflation of the bowels, than from expansion of the uterus. As an increase of bulk, together with many of the other symptoms of gestation, may proceed from suppression of the menses, we cannot positively, from those signs, pro- nounce a woman to be with child. The enlargement of the belly is at first accompanied with tension or uneasiness about the navel. When women have any doubt, with regard to their situa- tion, they generally look forward to the end of the fourth month, as a period which can ascertain their condition. For, at this time, or a little sooner or later, in different women, the motion of the child is first perceived, or it is said to quicken ;(&) and, in some cases, a few drops of blood flow which they quickened, and again, the time when they were delivered. Out of this number we are informed, that eighty quickened at the fourth month, a portion of the remainder quickened at the third month, and the rest went on to the fifth. Therefore, we may with great propriety consider four months as the general time of quickening; and upon finding that a woman has quickened, within a day or two, we may with great confidence calculate that shahas five months to go. (i) The term quickening is certainly not the most accurate phrase that could be selected, to express the simple fact of the uterus rising above the brim or cavity of the pelvis. It is well known, that the impregnated uterus generally remains in the pelvis, as we have just observed, until the latter part of the fourth month; and that after this period, as it enlarges, it necessarily rises above that ca- vity into the abdomen: but it is to be remarked, 1. The ascent of the impregnated uterus from its position in the pelvis to its subsequent station, is sometimes gradual and unobserved ; of course, the sensation of quickening is not then felt. 157 from the uterus at this period. The motion is first felt in the hypogastrium, and is languid and indistinct, but by degrees it becomes stronger. It is possible for women to mistake the effects of wind for the motion of a child, especially if they have never borne children, and be anxious for a family. But the sensation produced by wind in the bowels is not confined to one spot, but very often is referred to a part of the abdo- men, where the motion of the child could not possibly be felt. Many women suppose, that, by examining the blood drawn from the veins, their pregnancy may be ascertained. Very soon after impregnation, the blood becomes sizy; but it dif- fers from the blood of a person affected with inflammation. In the latter case, the surface of the crassamentum is dense, firm, and of a buff colour, and more or less depressed in the centre. But in pregnancy the surface is not depressed, the coagulum is of a softer texture, of a yellow, and more oily appearance. It is not possible, however, to determine posi- tively, from inspecting the blood; for a pregnant woman may have some local disease, giving the blood a truly inflam- matory appearance; and, on the other hand, it is possible for suppression of the menses, accompanied with a febrile state, to give the blood the appearance wliich it has in preg- nancy. Examination of the uterus itself is a more certain mode of ascertaining pregnancy. About the second month of ges- 2. The uterus is sometimes so impacted in the cavity of the pelvis, as not to reach its final station within the abdomen, -without the assistance of art, producing the disease called retroverted uterus, during which, quickening is never felt. 3. At other times, and those frequent, though not constant, there exists some slight impediment to the ascent of the uterus, which being suddenly over- come, this viscus rises at once into the abdominal cavity, constituting vihat has been referred to the foetus, under the term quietening. The sudden intrusion, therefore, of the volume of the uterus among the abdominal viscera, accompanied by as sudden a removal of pressure from the iliac vessels, is supposed to be equal to produce the sensation we have above noticed. We may then state, "That the sensation of quickening is felt in transitu, at the moment when the uterus, removing from the pelvis, enters the abdo- minal cayityi" Vide Eclectic Repertory, Vol. HI. p. 30. October. No. IX. 158 tation, the uterus may be felt prolapsing lower in the vagina than formerly; its mouth is not directed so much forward as before impregnation; it is shut up, and the cervix is felt to be thicker, or increased in circumference. When raised on the finger, it is found to be heavier, or more resisting. Some have advised, that the os uteri should be raised upward and forward, so as to retrovert the womb, in order that its body may be felt, but this is not expedient. Examination, at this period, is liable to uncertainty, because the uterus of one woman is naturally different in magnitude from that of ano- ther. But in the third month we can arrive at tolerable cer- tainty, the womb being then felt decidedly to be heavier, and more easily balanced on the finger. In the fourth month it is found to be higher than when unimpregnated: a kind of fluc- tuation may be perceived, and by placing the hand on the lower part of the belly, so as to press on the fundus of the womb, it can be made to give more resistance to the finger applied per vaginam, and may by it be rolled about. After quickening, if we pat with the finger on the cervix uteri, we can generally make the child strike gently, so as to be felt. About this time, and still more distinctly afterwards, we can, if the abdominal muscles be relaxed, feel the uterus extend- ing up from the symphysis pubis, and, in proportion as preg- nancy advances, can more readily distinguish the members of the child, and feel its jerks or motions. Examination, per vaginam, informs us of those changes of the cervix and os uteri, which were noticed in a former chapter. CHAP. XIX. Of the Diseases of Pregnant Women. § 1. general effects. Pregnancy produces an effect on the general system, marked often by a degree of fever, and always by an altered state of the blood. This state is the consequence of local in- creased action, which irritates and excites the system, in the 159 same way as when an organ is inflamed. There would appear to be, likewise, a tendency to the formation of more blood than formerly, and the nervous system is evidently rendered more irritable. The gravid uterus, also, has an effect by sympathy, on other organs or viscera; and likewise produces changes in them, mechanically, by its bulk and pressure. All these effects, however, vary much in degree in different wo- men The effects of pregnancy vary much, both in degree, and in the nature and combination of the symptoms, according to the constitution of the woman, and the natural or acquired irritability of different organs. In a few cases, a very salu- tary change is produced on the whole system, so that the person enjoys better health during pregnancy, than at other times. But in most instances, some troublesome or inconve- nient symptoms are excited, which are called the diseases of pregnancy, and which in some women, proceed so far, as not only to deprive them of all enjoyment and comfort, but even to produce considerable fear of their safety. As these proceed from the state of the uterus, it follows, that when they exist in a moderate degree, they neither ad- mit of, nor require any attempts to cure them; for their re- moval implies a stoppage of the action of gestation, which is their cause. But when any of the effects are carried to a troublesome extent, then we are applied to, and may palli- ate, though we cannot take them away. This palliation we procure by lessening plethora, if necessary, by blood-letting, and allaying the increased irritability of the system by the regular use of laxatives. These remove that particular state of the bowels, which is so apt to cause restlessness and ner- vous irritation. If these are not altogether successful, the camphorated julap, is a useful medicine.* Besides this * Petit, and many after him, have been of opinion, that opium is hurtful during gestation ; and there can be no doubt that it generally is so when given frequently. It is detrimental, both by its effects upon the stomach and bowels, and on the system at large. In severe spasms, or great irritation, it may be necessary, but it never ought to be often repeated, as it ultimately increases the irritabititv and injures the bowels, as it would do in chorea 160 general plan, we must diminish the febrile state of the sys- tem, where such exists, by regulation of the diet, and suitable remedies. Individual symptoms must be treated on general principles. There is a great diversity, both in the effects of pregnancy, and also in the period at which these manifest themselves; for whilst some begin to suffer very early from the irritation of the uterus, and are much relieved from the effects thereof after the child quickens, others feci very little inconvenience till towards the end of pregnancy, or the last quarter, when the womb is greatly enlarged, and the abdominal viscera dis- turbed. § 2. febrile state. In many cases, the pulse becomes somewhat quicker soon after impregnation, and the heat of the skin is at the same time a little increased, especially in the evenings. In the later months of pregnancy, the febrile symptoms in some in- stances are extremely troublesome; the pulse is permanently frequent, but in the evenings it is more accelerated, whilst the skin becomes hot, and the woman restless; she cannot sleep, but tosses about till day-break, when she procures short unrefrcshing slumber, occasionally accompanied with a partial perspiration. In the morning, the febrile symptoms are found to have subsided; but in the afternoon they return, and the following night is spent alike uncomfortably. This state is attended with more emaciation, and greater sharpness of the features, than is met with in pregnancy, un- der different circumstances; but it is wonderful how well the strength is kept up in spite of the want of rest, and of the uneasiness which is produced, from this disease being some- times conjoined with intolerable heat about the parts of gen- eration. In slight degrees of this febrile state, all that is necessary is sedulously to keep the bowels open, and take away a little blood. But when it becomes urgent towards the last months of gestation, we are under the necessity of taking away blood more frequently, but not in great quantity at a time. 161 The saline julap is of considerable service, by producing a gentle moisture, but a copious perspiration is neither neces- sary nor useful. The julap may either be given in repeated doses through the day, or merely one or two doses in the morning, or early part of the night according to circum- stances. The bowels are to be kept open by a mild laxative, such as the aloetic pill, or rhubarb and magnesia, or cream of tartar, if the person be not much distressed with heart- burn; and in the same circumstances, the sulphuric aeid is a very good internal medicine. The restlessness is best allayed by sleeping with few bed-clothes; and sometimes great relief is obtained, by dipping the hands in water, or grasping a wet sponge. Opiates very_seldom give relief, and ought not to be pushed far, as they*make the woman more uncomfortable, and are supposed even to injure the child; at all events, if the occasional exhibition, on any emergency of a moderate dose of opium or hyoscyamus, fail to procure comfortable sleep, no benefit is to be expected from increasing the quan- tity. Frequently nothing does much good, the state continu- ing until the woman is delivered. There is a species of fever, which may affect women about the middle of pregnancy, and makes its attack suddenly, like a regular paroxysm of ague. It soon puts on an appearance rather of hectic, combined with hysterical symptoms. The head is generally at first pained, or the patient complains of much noise within it, sleeps little, has a loathing at food, with a foul dry tongue, and a considerable thirst, whilst the bowrels are constipated. Sometimes she talks incoherently, or moans much during her slumber, and has frightful dreams: occasionally a cough, or distressing vomiting supervenes. This disease is very obstinate, and often ends in abortion; after which, if the woman do not sink speedily under the ef- fects of the process, she begins to recover, but remains long in a chlorotic state, which if not removed, may terminate in phthisis. I strongly suspect that this disease originates from the bowels, and bears a great analogy to the infantile remit- ting fever. It is usually preceded by costiveness, and is sometimes apparently excited by irregularities in diet. We x 162 ought on the first attack of the cold fit to check it by warm diluents, with the saline julap. If the proper opportunity be lost, or these means fail, we must lessen irritation by detract- ing some blood; open the bowels freely, and afterwards pre- vent feculent accumulation, keep the surface moist, and pal- liate troublesome symptoms. If the tongue be early loaded, and the patient is sick or squeamish, a very gentle emetic will be proper. The strength is to be supported. In a state of convalescence, gentle exercise and pure air are useful, but every exertion must be avoided. § 3. VOMITING. 9 \ omiting is a very frequent effect of pregnancy, and occa- sionally begins almost immediately after conception. Gene- rally it takes place only in the morning, immediately after getting up, and hence it has been called the morning sick- ness, hut in a few instances, it does not come on till the af- ternoon. It usually continues until the period of quickening, after which it decreases or goes off, but sometimes it remains during the whole of gestation. Some women do not vomit, and have very little if any sickness; others begin, after the fourth month, to feel an irritation about the stomach and other viscera; and some remain free from inconvenience till the conclusion of pregnancy, when the distension of the womb affects the stomach. The fluid thrown up is generally glary or phlegm, and the mouth fills with water previous to vomiting; but if the vomiting be severe or repeated, bilious fluid is ejected. Generally there is no occasion to prescribe any remedies. Puzos, and others, even considered vomiting as salutary; but in some cases, it goes to a very great length, recurring whenever the woman eats, or sometimes even when she abstains from eating, and continues for days or even weeks so obstinate, that she is in danger of miscarrying*, or of suffering from want of food. It is a general rule, in such • It is worthy of remark, that abortion is very seldom occasioned by this cause, though emetics are apt to produce it. 163 cases, to take away early a small quantity of blood, a quantity proportioned to the vigour and fulness of the habit, and state of the pulse. Of the utility of this practice, the general testi- mony of practitioners, and my own observation, fully con- vince me. Narcotic substances, such as opium or hyoscyamus, have been tried internally, either without blood-letting or subsequent to it, but uniformly with little advantage. In a few instances, a cloth wet with laudanum applied to the pit of the stomach has done good. More certain relief is obtain- ed by mild laxatives, in small bulk, such as pills, and in every case costiveness must he avoided. The severity of the vomiting may also be greatly mitigated by effervescing draughts, or the aerated alkaline water: the last of which, if it do not check the vomiting, renders it much easier. Even cold water has been employed with advantage. A light bitter infusion is sometimes of service. Obstinate vomiting, espe- cially if accompanied with pain, or tension in the epigastric region, may be relieved by the application of leeches to that part, which have been much recommended by Dr. John Sims, and M. Lorentz. I have so often found advantage from this remedy, that I speak of it with confidence. If these means fail in procuring speedy relief, it is necessary to refrain for a time from eating, and have recourse to nourishing clysters, or to give only a spoonful of milk, soup, &c. at a time. When the vomiting is bilious, and accompanied with pain in the right side and shoulder, cough, and other symptoms of hepatitis, a seton should be immediately introduced into the side, and a very gentle course of mercury given; for if the medicine be given freely, it produces much debility, or abortion, and sometimes accelerates the fate of the patient. When vomiting is troublesome in the conclusion of preg- nancy, it is proper to detract blood, and confine the person to bed. Cloths, dipped in laudanum, should be applied to the pit of the stomach, and a grain of solid opium may be given internally; but if this do not succeed, it is not proper to give larger and repeated doses. Gentle laxatives must be em- ployed. 164 § 4. HEARTBURN, Heartburn often takes place very early after conception, but sometimes not till after the fourth month. This is a com- plaint so very common, and so generally mitigated by ab- sorbents, such as magnesia or chalk, that we are seldom con- sulted respecting it. But when it becomes very severe and intractable, it is requisite to try the most powerful of these means, such as calcined magnesia, combined with pure am- monia.^) When these fail, the aerated alkaline water, or the chalk mixture, with a large proportion of mucilage, may give relief. In obstinate cases, venesection and laxatives are useful. Emetics have been proposed by Dr. Denman, but they may sometimes cause abortion. They are only allowable where there is a constant screatus of disagreeable phlegm, In every severe case the diet must be carefully attended to, Pyrosis is to be relieved chiefly by laxatives, such as the aloetic pill or rhubarb and magnesia, and rubbing the epi- gastric region with anodyne balsam. § 5. FASTiniOUS TASTE. Women, during gestation, are subject to many bizarreries in their appetite, and often have a desire to eat things they did not formerly like. This desire is common in cases of ab- (/) The late much regretted Dr. Young, of Maryland, in his ingenious ex- periments on the digestive process, has almost reduced it to a certainty, that the acid which exists in the stomach is to be referred to the liquor gastricus; that it is the phosphoric acid, and that the acidity of dyspeptic and ) .egnant women, is owing to the morbid quantity of this acid. .Hence, as he justly re- marks, the superiority of lime water as a corrector, from its great affinity to phosphoric acid. The following formula is also recommended by experienced practitioners for the same purpose. I have used it with advantage. ]£,. Magnesia ustx gj. Aquae purse 3VSB- Sp. Cinnamon giij. Aqux Ammoniac purs 3j m- Two or three spoonsful to be taken either occasionally, or when the symp- toms are more continual, immediately after every meal- 165 dominal irritation, as we see in those who are afflicted with worms, or have indurated or morbid faeces in the intestines. These longings, it has been thought dangerous to deny; for as it was supposed, that they depended upon some peculiar state of the child affecting the mother, it was imagined, that if this was not removed, the infant would sustain an injury, or might even bear the mark of the thing longed for. Into this doctrine, it is now unnecessary to enter, and it will be sufficient to add, that when the desire is placed upon any article of diet, it may be safely gratified, and, indeed, gene- rally the inclination leads to some light and cooling regimen. § 6. SPASM OF STOMACH AND DUODENUM. Spasm of the stomach, or duodenum, may often be attri- buted to some irregularity of diet, to the action of cold, or to the influence of the mind. It is necessary to interfere prompt- ly, not only because the pain is severe, but also because it may excite abortion, though I must own I have never known it have that effect. A full dose of laudanum, with ether, fol- lowed immediately by a saline clyster, is almost always suc- cessful; but when the attacks are renewed, then we must endeavour to prevent them by tonics, such as colomba, oxyde of bismuth, or preparations of steel. It is at the same time, essential that the bowels be kept open. Blood-letting is of service. When spasm of the stomach takes place in the end of preg- nancy, or about the commencement of parturition, with a sense of fulness or uneasiness in the head, it is necessary to detract blood, lest the patient be seized with convulsions. This remedy is likewise proper, when the pain is accompa- nied with tenderness about the epigastric region, heat of the skin, full pulse, and ruddy face. When pain proceeds from the passage of a biliary calculus, it is to be treated more so- lito. § 7. COSTIVENESS. Costiveness is a general attendant on pregnancy, partly owing to the pressure of the uterus on the rectum, and part- 166 ly owing to the increased activity of the womb producing a sluggish motion of the bowels. We must not, however, neglect this state, because it naturally attends gestation, for it may occasion many evils. It certainly increases the irritability of the system, as well as some of the stomachic ailments; and is apt to cause irritation of the bowels, or piles. It may also either excite premature labour, or give rise to much incon- venience after delivery. Magnesia is a very common remedy, because it at the same time relieves heartburn; but, when it fails, or is not required for curing acidity in the stomach, the common aloetie pill, or a combination of aloes with extract of hyoscyamus, should the former gripe, may be employed. Castor oil is also given, either alone, or made into an emulsion with mucilage. Rodc- ric a Castro advises the woman to attempt to have a stool every day, in order to keep up the habit. It sometimes happens, that indurated faeces are accumu- lated in the rectum or colon, producing considerable irrita- tion. This causes not only pain, but also an increased secre- tion of the intestinal mucus, which is passed either alone, or with blood, together with pieces of hard faeces. This state, like dysentery, is often accompanied with great tenes- mus; but it may be readily distinguished, by examining per vaginam, for the rectum is found to be filled with faeces. Our first object ought to be to remove the irritating cause, which might ultimately produce abortion. Clysters are of great efficacy, because they soften the faeces, and assist in empty- ing that part of the intestine which is most distended. These are to be, at first, of a very mild nature, and must be fre- quently repeated. It may even be requisite to break down the feculent mass, with the shank of a spoon, or some such instrument.(m) After the rectum is emptied, laxatives, such as castor oil, or small doses of sulphate of magnesia must be (m) The reader is referred, for a very interesting case of alvine concre- tion, where it became necessary to introduce a long flexible catheter through the hardened and impacted faeces, occupying the superior part of the pelvis, for the purpose of injecting an enema, to Hey's Practical Observations on Surgery, chap. XVIII. case 3. 167 given to evacuate the colon; and when the faeces arc brought into the rectum, clysters must be again employed. After the bowels are emptied, hyoscyamus should be given, to^allay the irritation; or if this be not sufficient, and the pain and secre- tion of mucus, with tenesmus, still continue, an anodyne must be administered, but next day it is to be followed by a mild laxative. And if there be fever or considerable pain in the abdomen, blood-letting will be necessary. If this costive state be neglected near the time of delivery, the labour is of- ten protracted; and after delivery masses of indurated faeces come down from the colon, producing considerable pain and frequency of pulse. When there is much irritation and sen- sibility, upon pressing on the abdomen, either before or after delivery, it will be proper to detract blood, at the same time that we use the remedies already pointed out. § 8. DIARRHOEA. The bowels, instead of being bound, may be very open; or costiveness and diarrhoea may alternate with each other. The diarrhoea is of two kinds; a simple increase of the peristaltic motion, and increased mucous secretion; or a more obstinate disease, depending on debilitated and deranged ac- tion of the bowels. In the first kind, the discharge is not altered from the natural state, except in being thinner; the appetite is pretty good, and the tongue clean, or only slight- ly white. This is not to be checked, unless it go to a consi- derable extent, or continue long, or the patient be weakened by it, or be previously of a debilitated habit. Anodyne clys- ters, or the confeetio catechu, will then he of service. Should the pulse be frequent, and any degree of heat or tension be felt in the abdomen, venesection will be useful. In the second kind, the appetite is lost or diminished, the tongue is foul, and the patient has a bitter or bad taste, and occasionally vomits ill tasted or bilious matter; the breath is offensive, and often the head aches. The stools are very offensive, and generally dark coloured. In this case, small doses of rhubarb give great relief, and some are in the habit of adding two grains of ipe- cacuanha to each dose of the rhubarb. A light bitter infusion 166 is also a useful remedy. Attention must he paid to the diet, which is to be light, and the food taken in a small quantity at a time. Considerable benefit is derived from the soda water; which generally abates the sickness. When the tongue be- comes cleaner, and the stools more natural, anodyne clysters may be administered. In all cases of continued diarrhoea, it is useful to have the surface kept warm with flannel; and sometimes a flannel roller, bound gently round the abdomen, gives great relief. § 9. PILES. Pregnant women are very subject to piles. This may be partly owing to the pressure of the womb upon the vessels of the pelvis, but is chiefly to be attributed to a sluggish state of the intestinal canal, communicating a similar torpor to the hemorrhoidal veins. As this state is attended with costivc- ness, the disease has been considered as dependent on the mechanical action of the faeces; but whatever truth may be in this opinion in some cases, yet generally it is without foundation; and it is no unusual thing for those who are sub- ject to piles, to he able to foretell an attack, by the appear- ance of peculiar symptoms, indicating diminished action of the alimentary canal. The treatment of this disease is two- fold. We are to remove the cause by such means as give a brisker action to the bowels, such as bitters and laxatives; which last are also of great service, by removing the irrita- tion of the faeces from the rectum, and rendering them softer, by which the expulsion gives less pain. For this purpose, cream of tartar alone, or combined with sulphur, has been generally employed; but we may, with equal advantage, give small doses of castor oil, or of any of the mild neutral salts, dissolved in a large quantity of water. Besides removing the cause, we must likewise Jessen the effect, by such local means as abate irritation and sensibility. When the pain, in- flammation, and swelling, are great, it is of service to detract blood topicially, by the application of leeches, or by making small punctures with a lancet. If there be considerable fever, blood-letting may be necessary, and the diet should be spare; 169 all stimulants and cordials must be avoided. Cooling and ano- dyne applications to the tumour are also very proper, sucl), as an ointment containing a small quantity of aceta»e of lead, or a weak solution of the acetate of lead in rose w ater, or a mixture of the acetum lithargyri and cream. Sometimes as- tringents are of service, such as the gall ointment; or narco- tics, such as opium* or belladona. If these means fail, it will be proper to give an anodyne clyster, and apply fomentations or emollient poultices to the tumour. In some cases, the tu- mour becomes slack, and subsides gradually; in other in- stances it bursts, and more or less blood is discharged. If the hemorrhage be moderate, it gives relief; but if profuse, it causes weakness, and must be restrained by pressure and astringents. Great pain, or much hemorrhage, are both apt to excite abortion. § 10. AFFECTIONS OF THE BLADDER. The bladder is often affected by pregnancy. In some in- stances like the intestines, it becomes more torpid than for- merly ; so that the woman retains her water long, and ex- pels it with some difficulty, and in considerable quantity at a time. This state requires great attention, for retroversion of the uterus may, at a certain stage of gestation, be readily occasioned. There is not much to be done with medicines in, this case; for, although soda, and similar remedies, some- times give relief, yet more reliance must be placed on the re- gular efforts of the patient. Should these be delayed too long, then the catheter must be employed. More frequently the bladder is rendered unusually irrita- ble, especially about its neck, and the urethra participates in this state. There is also, in many instances, an uneasi- ness felt in the region of the bladder itself. This state re- quires a very different treatment from the former, for.here it is our object to avoid every saline medicine which might ren- der the urine more stimulating. Relief is to be expected by • Dr. Johnston advises the following ointment to be applied, and then a poultice to be laid over the tumour. R. 01. Amygd. g i. 01. Succini ^ ss. Tinct. Opii. 3 ii. M. System p. 125. T 170 taking away blood, giving small doses of castor oil, and, oc- casionally, the extract or tincture of hyoscyamus, and en- couraging the patient to drink mucilaginous fluids, which, if they do not reach the bladder as mucilage, at least afford a bland addition to the blood, from which the urine is secret- ed. This state of the bladder is sometimes productive of a slight irritation about the symphysis of the pubis, rendering the articulation less firm and more easily separated. In such circumstances, when the pubis is tender, blood-letting and rest are the two principal remedies. A very distressing affection, which is often conjoined with this state of the bladder and urethra, but which may also take place without it, is a tender and irritable state of the vulva, producing great itching about the pudendum, especi- ally during the night, and generally the urine is felt very hot. This distressing condition is often alleviated by blood- letting and laxatives; and when the itching is great, a sponge, dipped in cold water, or in a cold solution of cerussa acetata, should be applied. If much fever exist, the saline julap, combined with a little tincture of opium, is useful. Incontinence of urine is not uncommon, in the end of ges- tation, and is produced by the pressure of the uterus on the bladder, by which the urine is forced off involuntarily, when- ever the woman coughs or moves quickly; or at least she cannot retain much of it, being obliged to void it frequently, but without strangury. For this complaint there is no cure; and many consider it as a favourable omen, that the child's head is resting on the os uteri. When the uterus is very pendulous, some advantage may be obtained, by supporting the belly with a proper bandage attached to the shoulders. § 11 JAUNDICE. Connected with the state of the alimentary canal, is the jaundice of pregnant women. This disease appears at an early period, and is preceded by dyspeptic symptoms, which generally increase after the yellowness comes on. In some instances, the tinge is very slight, and soon disappears. In other cases, the yellow colour is deep and long continued, 171 and the derangement of the stomach and bowels consider- able. Emetics, and other violent remedies, which are some- times used in the cure of the jaundice, are not allowable in this case; and in every instance, when young married wo- men are seized with jaundice, we should be very cautious in our prescriptions. Gentle doses of calomel, or of other lax- atives, with some light bitter infusion, are the most proper remedies; and generally the complaint soon goes off. Jaun- dice may also take place in the end of gestation; and in this case, it proceeds most frequently from pressure on the gall duct. Sometimes, however, it is dependent on a disease of the liver itself, which may occur at any period of gestation, and is marked by the usual symptoms. In this case, the danger is very great, and can only be averted by taking cautious measures for removing the hepatic disease. § 12. COLOURED SPOTS. In some cases, the skin is partially coloured ; the mouth. for instance, being surrounded with a yellow or brown cir- cle, or irregular patches of these colours appearing on difr ferent parts of the body. This is an affection quite inde- pendent of the state of the bile, and seems rather to be con- nected with certain conditions of the alimentary canal. It goes off after delivery, and does not require any peculiar treatment. § 13. PALPITATION. The thoracic viscera not unfrequently suffer during preg- nancy. Palpitation of the heart is a very common affection, and extremely distressing. It is a disease so well known, that it is needless here to describe it; but it may not be im- proper to observe, that women themselves sometimes mistake for it a strong pulsation of the arteries, at the upper part of the abdomen. It may make its attack repeatedly in the course of the day ; or only at night, before falling asleep; or at the interval of two or three days ; and is very readily excited by the slightest agitation of the mind. It is generally void 172 of danger; but in delicate women, and in those who are dis- posed to abortion, it sometimes occasions that event; and if long continued, it may excite pulmonic disease in those who are predisposed to it. Absolute rest, with antispasmodics, are requisite during the paroxysm. Hartshorn, ether, and tincture of opium, may be given, separately or combined. Rodcric a Castro prescribes a draught of hot water. The at- tacks are to be prevented by the administration of tonics, such as tincture of muriated iron; and of foetids, such as va- lerian and asafoetida. Fatigue and exertion must be avoided, and the mind kept tranquil. If the person be plethoric, it is sometimes useful to take away a little blood. The bowels are to be carefully kept open. The diet must be attended to; for it is often produced by a disordered stomach. A tendency to nervous or hysterical diseases is to be pre- vented, in those who are liable to them, by occasional blood- letting, the use of laxatives, and camphor, or foetids. Opi- ates are only to be given for the immediate relief of urgent symptoms. § Ik SYNCOPE. Another distressing affection of the heart, attendant on pregnancy, is syncope. This may take place at any period of gestation, but is most frequent in the three first months, or about the time of quickening. It may succeed some little exertion, or speedy motion, or exposure to heat; but it may also come on when the person is at perfect rest. The pa- roxysm is sometimes complete, and of long duration; at other times, the person does net loose her knowledge of what is go- ing on, and soon recovers. A recumbent posture, the admis- sion of cold air, or application of cold water to the face, the use of volatile salt, and the cautious administration of cor- dials, constitute the practice during the attack. Should the fit remain long, we must preserve the heat of the body, other- wise a protracted syncope may end in death. Those who are subject to fainting fits, must avoid fatigue, crowded or warm rooms, fasting, quick motion, and agitation of the mind. Tonics are sometimes useful. 173 There is a species of syncope, that I have.oftcner than once found to prove fatal in the early stage of pregnancy, which is dependent, I apprehend, on organic affections of the heart, that viscus being enlarged, or otherwise diseased, though perhaps so slightly as not previously to give rise to any troublesome, far less any pathognomonic symptoms. Al- though I have met with this fatal termination most frequent- ly in the early stage, I have also seen it take place so late as the sixth month of pregnancy. § 15. DYSPNCEA AND COUGH. Sudden attacks of dyspnoea in those who were previous- ly healthy, are generally to be considered as hysterical, and are readily removed by antispasmodics. There is, however. a more obstinate and protracted symptom, not unfrequently connected with pregnancy, namely cough. This may come in paroxysms, which are generally severe, or it may be al- most constant, in which case it is short and teasing. Some- times a viscid fluid is expectorated, but more frequently the cough is dry. During the attack, the head is generally pain- ful, and the woman complains much of the shaking of her body, especially of the belly. All practical writers are agreed with respect to the danger of this disease, for it is ex- tremely apt to induce abortion; and it is worthy of remark, that after the child is expelled, the cough often suddenly ceases. But exposure to cold frequently brings it back; and should there be a predisposition to phthisis, that disease may be thus excited. Blood-letting must be early, and sometimes repeatedly employed; the bowels kept open; and lozenges. containing opium or hyoscyamus, must be occasionally used, to allay the cough. A large burgundy pitch plaster, applied betwixt the shoulders, is of service. Should abortion take place, and the cough continue, tonics, such as myrrh and oxyde of zinc, ought to be administered. § 16. HEMOPTYSIS AND ILEMATEMESIS. In some instances, haemoptysis or haematemesis take place in pregnancy, especially in the last months, and these are 174 very dangerous affections. Blood-letting is the remedy chief- ly to be depended on; and afterwards laxatives should be given, acids and hyoscyamus may be employed to allay irri- tation. If these means do not succeed, the patient dies. Should the hemorrhage take place during labour, or should pains come on prematurely, and the os uteri dilate, as some- times happens, it will be prudent to accelerate the delivery. § 17. HEADACH AND CONVULSIONS. Headach is a v cry alarming symptom, when it is severe, constant, and accompanied with symptoms of plethora. If the eye be dull or suffused, and the head giddy, especially when the person stoops or lies down, with a sense of heaviness over the eyes, or within the skull, great danger is to be appre- hended, particularly if the woman be far advanced in her pregnancy. This is still more the case, if she complain of ringing in the ears, and flashing of fire in the eyes, or indis- tinct vision. In such circumstances, she is seized cither with apoplexy or epilepsy. These diseases are to be prevented by having immediate recourse to blood-letting and laxatives; and the same remedies are useful, if either one or other of these diseases have already taken place. The quantity of blood which is to be detracted, must be determined by the severity of the symptoms, the habit of the patient and the effect of the evacuation; but, generally, moderate evacuation will prevent, whilst very copious depletion is requisite to cure these diseases. If the headach be accompanied with oedema, the digitalis is a useful addition to the practice. I shall not at present enter farther into the history or treat- ment of epilepsy, as the subject will be hereafter resumed. It is farther proper to remark, that, if the patient is seized with apoplexy, there is seldom any attempt made to expel the child*, and, in my own practice, I have never known that event take place. In epilepsy, on the contrary, if the pa- roxysm be protracted, there is generally an effect produced on the uterus; its mouth opens, and the child may be expel- * Mr. Wilson's case is an exception to this- Vide Med. Facts, vol. V. p. 96. 175 led, if the patient be not early cut off by a fatal coma. When- ever expulsive effects come on, we must conduct the labour according to rules hereafter to be noticed. In some instances, palsy either succeeds an apoplectic attack, or follows head- ach and vertigo. This disease does not commonly go off until delivery have taken place; but it may be prevented from be- coming severe, by mild laxatives and light diet; and, after the woman recovers from her labour, the disease gradually abates, or yields to appropriate remedies. All headachs, however, do not forbode these dismal events, for often they proceed from the stomach, and evidently de- pend on dyspepsia, or nervous irritation. These are gene- rally periodical, accompanied with a pale visage, they feel more external than the former, and are often confined to one side of the head. They are attended with acidity in the stomach, eructations, and sometimes considerable giddiness or slight sickness, with bitter taste in the mouth. They are relieved by the regular exhibition of laxatives, by sleep, the moderate use of volatiles, and the application of ether exter- nally. § 18. TOOTHACH. Toothach not unfrequently attends pregnancy, and, some- times, is a very early symptom of that state. The tooth may be sound or diseased, but, in neither case, ought we to extract it, if it be possible to avoid the operation. I have known the extraction followed in a few minutes by abortion. Blood-let- ting frequently gives relief, and, sometimes, a little cold wa- ter taken into the mouth abates the pain. In other cases, warm water gives more relief. § 19. SALIVATION. Salivation is, with some women, a mark of pregnancy. It has been supposed that there is a sympathy existing between the pancreas and salivary glands, and that the phlegm reject- ed by vomiting proceeded from the former, whilst, in many instances, the latter yielded an increased quantity of viscid 176 saliva. This is a symptom which scarcely demands any medicine, but, when it does, mild laxatives are the most efficacious. § 20. MASTODYNI V. Pain and tension of the mammae frequently attend gesta- tion, and these symptoms arc often very distressing. If the woman have formerly had a suppuration of one mamma, that breast is generally most painful, and she is afraid of abscess again forming. In other instances, the pain, being accompa- nied with increased hardness of the breast, produces appre- hension of cancer. These fears are generally groundless; but if suppuration do take place, it is to be treated on general principles. Blood-letting often relieves the uneasy feeling in the breast, which is also mitigated by gentle friction with warm oil. Nature often gives relief, by the secretion of a serous fluid which runs out from the nipple; but if this be much encouraged by suction, Chambon remarks, that the foetus may be injured. The discharge is in some instances so great about the seventh month, or later, as to keep the woman very uncomfortable. The diet in this case should be dry. The sudden abatement of the tension, and fulness of the breasts, with a diminution of size, are unfavourable circum- stances, indicating either the death of the child, or a feeble action of the womb. § 21. OEDEMA. In the course of gestation, the feet and legs very generally become oedematous; and sometimes the thighs, and labia pu- dendi participate in the swelling. The swelling is by no means proportioned always to the size of the womb, for, as has been remarked by Puzos, those who have the womb un- usually distended with water, and those w ho have twins, have frequently very little oedema of the feet. This disease is partly owing to the pressure of the uterus, but it also seems to be somewhat connected with the pregnant state, indepen- dent of pressure; for in some instances, the oedema is not 177 confined to the inferior extremities, but affects the whole body. A moderate degree of oedema going off in a recum- bent posture is so far from being injurious, that it is occasi- onally remarked, that many uneasy feelings arc removed by its accession; but a greater and more universal effusion indi- cates a dangerous degree of irritation, and may be followed by epilepsy. In ordinary cases, no medicine is necessary ex- cept aperients; but, when the oedema is extensive or per- manent, remaining even after the patient has been for seve- ral hours in bed, it may be attended with unpleasant or dangerous effects, such as convulsions; or, it may predispose to puerperal diseases; we must therefore lessen it by means of those agents which alleviate the other diseases of pregnan- cy, namely, blood-letting and purgatives. These means are always proper, unless the strength be much reduced; in which case, we only employ the purgatives and cordials pru- dently, with acetate of pot-ash, or sweet spirit of nitre. Diu- retics, generally, are not successful, and many of them, if given liberally, tend to excite abortion. Friction relieves the feeling of tension. § 22. ASCITES. Ascites may, like oedema, be excited, in consequence of some condition connected with gestation, or may be indepen- dent of it, arising from some of the ordinary causes of dropsy, especially from a disease of the liver. In the last case, medi- cine has seldom much effect in palliating or removing the dis- ease ; and the woman usually dies, within a week or two after her delivery, whether that have been premature, or delayed till the full time. When ascites is not occasioned by hepatic disease, it is generally connected with the oedema- tous state above mentioned, and seldom appears until the woman has been at least three months pregnant. If it be not attended with other bad symptoms, such as headach, fever- ishness, drowsiness, &c. it abates and goes off, a little before, or soon after delivery, which is often premature. I have seen diuretics given very freely in these cases, but most frequent- ly without any benefit. On this account, and also from the z 178 danger of these exciting abortion, or premature labour, lam inclined to dissuade from their use, except in urgent eases. Then the mildest ought to be emplovcd, such as cream of tar- tar, juniper tea, acetate of pot-ash, &c. If any of these pro- duce much irritation of the urinary organs, they must In exchanged for others. Purgatives and blood-letting are more useful. If this, or any other dropsical affection, appear as a symptom rather of a broken constitution than as connected with pregnancy, mild diuretics and calomel arc chiefly to be employed. If the water is not absorbed soon after delivery, immedi- ate recourse must be had to tapping,(n) and afterwards to diuretics. (h) Instances have occurred, where, in cases of ascites combined with pregnancy, the operation of paracentesis has been performed, although this is a practice by no means to be commended. In the eighth Vol. of the Lon- don Med. Facts and Observations, there is a case related by Mr. Simmons, of a pregnant woman with symptoms of ascites being twice tapped, first, in the second month of pregnancy, when fourteen quarts of water were drawn off, and the second time, when five months advanced, when only a few ounces of blood followed the withdrawing of the trocar; at the full time she was delivered of a healthy child, having suffered no inconvenience from the operation. Another case is related in the seventh Vol. of the London Med. and Phys. Journal, by Dr. Vieusseux, of Geneva, where a woman in the fifth month of pregnancy was tapped, but it appears that the consequence of this operation was an abortion, although the patient soon recovered. Both these cases are related by the gentlemen under whose observation they fell, to prove that the paracentesis has been performed, and even the uterus perfo- rated, [which they suppose was the case in both these instances,] without material injury to the patient. In the same work is related a case of a woman, who was tapped no less than five times during pregnancy: at the full period she was, notwithstand- ing, delivered of a fine child, and recovered completely from the puerperal state. These cases prove, how much the system will sometimes suffer with impu- nity, but at the same time we must acknowledge, that it is best not to pre- sume too far on the preservative energies of nature. Sometimes pregnancy has been, from gross inaccuracy, mistaken for drop- sy, and the paracentesis been performed with a fatal effect; the patient in one instance fainting, and expiring almost instantaneously. Upon examina- tion after death, it was found that the trocar had not only perforated the uterus, but had also penetrated the foetus! 179 § 23. REDUNDANCE OF LIQ.U0R AMNII. When the liquor amnii is in too great quantity, much in- convenience is produced, and not unfrequently the child perishes. This disease is known, by the woman being un- usually large at an early period of gestation, for generally by the seventh month, she is as big as she ought to be in the ninth. It is distinguished from ascites, by the motion of the child being felt, though obscurely by the mother, and the breasts enlarging. Per vaginam we can ascertain, that the uterus contains a substance, which alternately recedes and descends as the finger strikes on the lower part of the womb. This is to be considered as a dropsical affection of the ovum, but the health of the woman seldom suffers so much as in dropsy; the tongue, however, is white, and the urine is di- minished in quantity. The legs are less apt to swell than in a common pregnancy. The distension may, in the advanced stage, prove troublesome. When the quantity of water is greatly increased, the child is seldom kept till the full time, but is generally expelled in the eighth month, or sooner, and the labour is apt to be accompanied or succeeded by uterine hemorrhage. In some instances, the child occupies the upper part of the uterus, and the water the under, at least during labour. Twice in the same woman, in succeeding pregnan- cies, I found, the child contained in the upper part of the ute- rus, and embraced by it as if it were in a cyst, whilst several pints of water lay between it and the os uteri. When the wa- ter came away, filling some basons, then the child descended to the os uteri, but was born dead, with the thighs turned firmly up over the abdomen, and other marks of deformity. This is a disease of the ovum and not of the mother, for even the foetus itself is often malformed, or at least blighted. The affection in toto, may be considered as a species of mon- strous conception. Some particular condition of the parent may, however, in certain cases, occasion it. For instance, it may be connected with a syphilitic taint in either the father or mother; or with some less obvious cause impairing the 180 action of the womb, but not directly producing a miscarri- age; with lunacy or idiot ism; or with a state of general or uterine debility; or with an original imperfection of the ova in the ovarium: for a woman may, without any apparent cause, have repeatedly this kind of pregnancy. All of these causes do not operate uniformly to the same extent, but the foetus suffers in proportion to their operation. It is either horn very feeble and languid, and is reared with difficultv, or it dies almost immediately, or it perishes before labour commences; and this is generally the case when the diseased state exists to any great degree. The period of the child's death is usually marked by a shivering fit, and cessation of motion in utero, at the same time that the breasts become flaccid. Afterwards irregular pains come on, with or without a watery discharge. Sometimes the woman is sick or fever- ish for a few days before labour begins. If the liquor amnii be not increased greatly beyond the usual quantity, the woman may go the full time, but, from the distension of the uterus, is apt to have a lingering labour. Tonics, the cold bath, dry diet, with occasional venisec- tion, and the use of laxatives, during pregnancy, may be of service, but frequently fail. Diuretics do no good. A course of mercury conducted prudently, previous to conception, is the only remedy, when we suspect a syphilitic taint. It may be necessary to prescribe it to both parents. When it pro- ceeds from some more latent cause, I think it is useful, for pre- venting a repetition of the disease, to make the mother nurse. even although her child be dead. Mercury ought also to be tried. When the distension produces much distress, it has been proposed to draw off the water by the os uteri; or this has been done in one case by the common operation of para- centesis, the woman surviving, and labour taking place on the twenty first day*. This practice is, however, generally improper, and is seldom requisite, pains usually coming on whenever the symptoms become severe. When the os uteri * Vide case by Noel Desmarais, in Recueil Period. Tom. VI. p. 349. M- Baudelocque, gives a memoir on this subject in the same volume. 181 is considerably dilated by the pains, it may be proper to rup- ture the membranes, as has been advised by Puzos. § 24. WATERY DISCHARGE. Discharges of watery fluid from the vagina are not unfre- quent during pregnancy, and generally depend upon secre- tion from the glands about the cervix uteri. It has been sup- posed, that in every case they proceeded from this cause, or from the rupture of a lymphatic, or the evacuation of a fluid collected between the chorion and amnion, or the water of a blighted ovum, in a case of twins; for in every instance where the liquor amnii has been artificially evacuated, labour has taken place. But we can suppose, that the action of gestation may, in some women, be so strong, as not to be in- terrupted by a partial evacuation of the liquor amnii. Even granting the water to be collected exterior to the chorion, there must be a strong tendency to excite labour, if the quan- tity discharged be great*; and if the uterus can resist this, it may also be unaffected by the evacuation of liquor amnii. I have known instances, where after a fright or exertion, a considerable quantity of water has been suddenly discharg- ed, with subsidence of the abdominal tumour, or feeling of slackness; and even irregular pains have taken place, and yet the woman has gone to the full timef. These prove, as far as the nature of the case will admit of proof, that the wa- ter has been evacuated. Sometimes, only one discharge has taken place, but oftener the first has been followed by others ? and these are often tinged with blood. The aperture seems to heal, if gestation go on; for during labour, a discharge of water takes place. Much more frequently labour does take * Vide Dr. Alexander's case, in Med. Comment. Vol. III. p 187. \ Dr. Pentland relates a very distinct case, where the liquor was, in the third or fourth month, discharged in a fit of coughing. The belly fell, but she still went on to the full time, and had a good labour. Dublin Med. and Phys. Essays, No. I. art. 3.—I have known a discharge of water take place, at short intervals, for some weeks ; and then the funis umbilicalis protruded, without any exertion or any pains to rupture the membranes, which is a de- monstration that the membranes had been previously open, and that the discharge of liquor did not speedily flKcite labour. 182 place. Even when the discharge proceeds only from the vessels or glands about the os uteri, if the woman be not care- ful, a hemorrhage may take place, followed by labour. This is most likely to happen if there have been a copious dis- charge. The practice, in these cases, is to confine the patient for some time to bed. An anodyne ought also to be given, and may be repeated occasionally, if she be affected either with irregular pain, or nervous irritation; previous venesection often renders this more useful. The bowels arc to be kept open. If we suppose the discharge to be from the glands or vessels about the os uteri, we may, with advantage, inject some astringent fluid, such as a solution of sulphate of alu- mine. It sometimes happens, that a large hydatid is lodged be- tween the ovum and the os uteri, and it may be expelled se- veral weeks before parturition. If care be not taken, this may be followed by hemorrhage. § 25. VARICOSE VEINS. Varicose tumours sometimes appear on the legs. They are not dangerous, but are often painful. By pressure, they can be removed; but I am not sure that it is altogether safe to apply a bandage round the legs, so tight as to prevent their return. It is better, in ordinal cases, to do nothing at all; but where there is much pain, a recumbent posture, and mo- derate pressure give relief. § 26. MUSCULAR PAIN. From the distension of the abdominal muscles, pain may be produced, either about the extremities of the recti mus- cles, or the origins of the oblique or transverse muscles. These pains are not dangerous, but give unnecessary alarm if the cause be not known. It is impossible to remove them, but they may be mitigated by anodyne embrocations. If the pain be severe along the edge of the ribs, relief may be ob- tained by applying round the upper part of the abdomen a narrow band of leather, spread with adhesive plaster. 183 There is another cause of pain, which sometimes affects these muscles, but oftener those about the pelvis and hips. This seems to consist in a diminished power of the muscles, in consequence of the uterine action, and thus the fibres are not capable of the same exertion as formerly. A long walk, or some little fatigue, may produce such an effect, as to ren- der them painful for a long time; or even without any unu- sual degree of motion, they may ache, and produce the sen- sation of weariness. These pains have been supposed to be most frequent when the woman has twins, but this is far from being a general rule. They may occasion an apprehension that she is going to miscarry. Rest is the principal remedy, but if they be severe, relief may often be obtained by venesec- tion. Pain in the side, particularly the right side, is sometimes at an advanced period of gestation, both muscular, and also connected with the state of the bowels, especially of the co- Ion. It is frequently most severe, and may be rendered still more distressing by being combined with violent heartburn, or vvater-brasb. It comes on chiefly at night, and instead of being relieved by lying down, is often increased on going to bed. It is usually accompanied with much motion of the child. Venesection sometimes gives relief, but generally more advantage is derived from rubbing with anodyne bal- sam, attending to the state of the bowels, and regulating the diet. Although the pain be very severe, it seldom brings on labour. § 27. SPASM OF URETER. Spasm of the ureter, or some violent nephritic affection, may occur during gestation. The pain is severe, the pulse slow and soft, and the stomach often filled with wind. The symptoms are attended with distressing strangury, and, if not soon removed, may cause premature labour. Decided re- lief is obtained by giving a saline clyster, and, after its ope- ration, injecting eighty drops of laudanum, mixed with a little starch. A sinapism is to be applied to the loins? and if these means fail, blood must be taken awav. 181 § 2S. CRAMP. Spasms in the inferior extremities are often very distress- ing. These may come on suddenly, but occasionally they are preceded by a sense of coldness, and accompanied with a feeling of heat. They are removed by change of posture, and gentle friction. They have, by some, been thought to indicate a wrong presentation of the child, but this opinion is not supported by experience. They proceed from the pressure of the uterus on the nerves in the pelvis. § 29. DISTENSION OF THE ABDOMEN. In a first pregnancy, the abdominal muscles generally pre- serve a greater degree of tension than they do afterwards; and therefore the belly is not so prominent as in succeeding pregnancies. Sometimes the muscles and integuments yield so readily to the uterus, that it falls very much forward, producing a great prominence in the shape, inconvenience from the pressure on the bladder, and pain in the sides, from the increasing weight of the projecting uterus. In such cases, benefit may be derived from supporting the abdomen with a bandage connected with the shoulders. In other in- stances, the muscles and integuments do not yield freely, but the belly is hard and tense; the woman feels shooting pains about the abdomen, and sometimes miscarries. This state is relieved by blood-letting and tepid fomentations. When the skin does not distend freely, and becomes tender and fretted, or when these effects are produced by very great distension, benefit is derived from fomenting with decoction of poppies, and afterwards applying a piece of soft linen, spread very thinly with some emollient ointment. There is sometimes a disposition to distend unequally, so that one side yields more than the other, or even part of one side, or one muscle more than the rest, producing a peculiar shape. This is attended with no inconvenience. § 30. HERNIA. It is very usual for the navel of pregnant women to become prominent, even at an early stage. In some instances, such 185 a change is produced, as to allow the intestine or omentum to protrude, forming an umbilical hernia; or if the woman have been formerly subject to that disease, pregnancy tends to increase it, whilst, on the other hand, the intestines be- ing soon raised up by the ascending uterus, inguinal and fe- moral hcrnise are not apt to occur, or are even removed if they formerly existed. Umbilical hernia ought to be either kept reduced by a proper bandage, or at least prevented, by due support, from increasing; and during delivery, we must be careful that the intestine be not forcibly protruded, as it might be difficult to replace it. After delivery, a bandage must be applied. In some cases, during gestation, the fibres of the abdo- minal muscles separate, so that a ventral hernia is formed. The same circumstance may take place during parturition; and the laceration is sometimes so large, that afterwards, whenever the muscles contract, as, for instance, in the act of rising, a quantity of intestine is forced out, forming a hard tumour like a child's head. It is necessary in this, and in all other cases of large hernia, to be careful that compression be applied immediately after delivery, and also during the ex- pulsion of the child. By neglecting this, syncope and uterine hemorrhage have been occasioned. Hernise of the bladder should always be reduced in the commencement of labour, for it may interfere with the pro- cess of parturition, or the bladder may be exposed to injury. § 31. DESPONDENCY. It is not uncommon to find women very desponding dur- ing pregnancy, and much alarmed respecting the issue of their confinement. This apprehensive state may be the con- sequence of accidents befalling others in parturition; but not unfrequently it proceeds from a peculiar state of mind, de- pendent on gestation. Some, who at other times enjoy good spirits, become always melancholy during pregnancy, whilst others suffer chiefly during lactation. Little can be done by medicine, except to obviate all cause of disease or uneasi- Z A 186 ness of the body; the mind is to be cheered and supported by those who have most influence with the patient. § 32. RETROVERSION OF UTERUS. Retroversion of the. uterus was described by Levret and Grcgoire, but was in this country first accurately explained by Dr. Hunter in 175i<. It is an accident, which is always at- tended with very serious, and sometimes fatal consequences, chiefly owing to the effect produced on the bladder. If the pelvis be of the usual size, it may take place at any time be- tween the third and fourth month of pregnancy, or when- ever the womb is enlarged to a certain degree by disease1. We recognise retroversion of the uterus chiefly by its effects on the bladder, and also by difficulty in voiding the f«ces; for although the patient may be distressed sometimes with tenesmus, she usually passes little at a time. When the re-v troversion is completed, bearing-down pains maybe excitod, as if an attempt were made to expel or force down the uterus itself. These are much connected also with the state of the bladder, being most severe when it is distended, and abating when the urine is evacuated. The acute symptoms produced by the distension of the bladder, or the inability to pass the urine freely, first of all call the attention of the woman to the disease; and when we come to examine her, we find a 1 umour betwixt the rectum and vagina2. This is formed by the fundus uter^, which is thrown backwards and downwards, whilst the os uteri is directed forward, and sometimes so mueh upwards, as not to be felt by the finger. This is a disease which we would think cannot be mistaken, and yet it is some- times difficult to distinguish it: for in extra-uterine pregnancy, it has happened, that the symptoms have been nearly the same with those of retroversion*; and tumour of the ovarium has sometimes produced similar effects. Perhaps the diagno- sis cannot, in every case, be accurately made, but this is of less immediate importance, as the indications in such in- » Vide Mr. Giffard's case, in Phil. Trans. Vol. XXXVI. p. 435; and Mr White's very instructive case, in Med. Comment Vol. XX. p. 254. 187 stances must be the same, namely, to evacuate the bladder, and procure stools. Retroversion may take place slowly, and it has been said that its progress could be ascertained from day to day3; but in most instances, and in every case that I have seen, it has taken place pretty quickly; and occasionally the woman has been sensible at the time, of a tumbling or motion within the pubis. Sometimes the urine dribbles away involuntarily, or can be passed in small quantity, especially during the com- mencement of the disease; but often, within a few hours, it becomes almost completely obstructed, with pains about the loins, tenderness in the lower belly when it is touched, and a severe bearing-down sensation. The great danger pro- ceeds from the distension4 of the bladder, which either bursts5 or inflames6, and an opening takes place, in consequence of gangrene; or the bladder adheres to the abdominal parietes, its coats becoming thickened and diseased7. If the urine can- not be drawn off, of which I have never yet met with an in- stance, death is preceded by abdominal pain, vomiting, hic- cup, and sometimes convulsions. The duration of these symp- toms is variable*. Inflammation and gangrene of the vagina and external parts have also been produced. If the disease do not prove rapidly fatal, so much urine escaping as to pre- vent a speedy termination, it occasionally happens, that hec- tic fever is produced. The pulse becomes frequent, the body wastes, and purulent urine is voided8; or the person may be- come oedematous, and the disease pass for dropsy9; occasi- onally the water is not quite obstructed, but it is voided with difficulty for a week or two, and then the symptoms become" more acute, and forcing pains are excited. Our first object is to relieve the bladder, by introducing a catheter10, which may be slightly curved, the concavity being directed to the sacrum; or we may employ an elastic cathe- ter; but in general, the common instrument succeeds. If it do not pass easily, we may derive advantage from introdu- cing the finger into the vagina, and endeavouring to do " Dr Perfect's patient died thus on the sixth day. Cases in Midwifery, Vol. I. p. 304. 188 press the os uteri, or press hack the vaginal tumour11. If the catheter cannot be introduced, we have been advised to tap the bladder12; but this, fortunately, is seldom requisite. We must not be deceived with regard to the state of the bladder, by observing that the woman is able to pass a small quantity of watciyfor it may, nevertheless, be much distend- ed. We must examine the belly, and attend to the sensa- tion produced by pressure on the hypogastric region. Even although the catheter have been employed, only part of the urine may have been drawn off, particularly if the complete evacuation has not been assisted by moderate pressure over the bladder. It has happened, that only so much has been taken away as to give a little relief, and alter the position of the uterus so much as to lessen the pressure on the orifice of the bladder. Jn this case, on getting up, a great quantity of urine has flowed spontaneously, and the womb immediate- ly returned to its proper state. The urine being evacuated, and the most immediate source of alarm being thus removed, we must, in the next place, procure a stool, by means of a clyster; detract blood, if there be fever or restlessness; and give an anodyne injection, if there be strong bearing-down efforts. This is, in general, all that is requisite; and I wish particularly to inculcate the ne- cessity of directing the chief attention to the bladder, which ought to be emptied at least morning ?nd evening. By this plan, we generally find, that the uterus resumes its proper situation in the course of a short time, perhaps in forty-eight hours;13 and seldom is the retroversion continued for more than a week, unless the displacement has been very complete. The precise time, however, required for the ascent of the womb will be determined coeteris paribus, by the degree to which it has been retroverted, and the attention which is paid to the bladder. If the fundus he very low, the ascent may be tedious, or it may even be requisite to use means to raise it; but I consider myself as warranted from experience to say, that in every moderate degree of retroversion, in every recent case, it is sufficient to empty the bladder regu- larly, witliout making any attempt to push up the womb. But 189 if the uterine tumour be very low, and near the perineum, it may be necessary, and certainly it is allowable, to endeavour to replace the womb. This is also proper, if there be much irritation excited by the state of the womb, and which does not give way to the use of the catheter, and of anodyne clysters. The attempt to replace the uterus is to be made by intro- ducing two fingers of one hand into the rectum, and a suffi- cient number of those of the other hand, or the whole hand itself, into the vagina. The uterine tumour is then to be pressed up slowly, firmly, and steadily; and this may some- times be assisted by elevating the breech of the woman. Forcible and violent attempts are, however, to be strongly reprobated: they give great pain, and may even excite abor- tion, inflammation, or convulsions. They can only be justified on the principle of preventing a great danger. Now we know that the chief risk proceeds from the distension of the bladder; if, therefore, it can be emptied, the danger is usu- ally at an end. When the retroversion ceases, the uterus usually resumes completely its-proper situation; but it some- times happens, especially if the vagina have been much re- laxed, that when the retroversion is removed, the uterus is found very low, forming a prolapsus, which continues for some time. It requires, chiefly, attention to the urine and stools; for it may occupy the pelvis fully, and pretty firmly; and almost the whole foetus can be felt by the finger through the uterus. When the uterus ascends, occasionally a little blood is dis- charged*; but abortion does not take place unless much in- jury has been sustained. Thus the woman has miscarried quickly after the bladder had burst, as in Mr. Lynn's pati- ent; or when inflammation had taken place, as in the cases related by Drs. Bell and Ross. When this happens, the ute- rus rises indeed, but the patient is cut off by peritoneal in- flammation14, followed by vomiting of dark coloured stuff. Abortion will also take place, if the liquor amnii have beeff discharged. * M. Roger's case, in Act. Havn. Tom. II. art If- 190 That the uterus docs generally rise spontaneously, if the urine be regularly evacuated, is a fact of which I am fully convinced from my own experience, as well as from the ob- servations of others. But it is nevertheless possible for it to continue in a certain degree of malposition even to the end of gestation15. In this case, the uterus cannot, indeed, at last be said exactly to be retroverted; for it has enlarged so much, that it occupies nearly as much of the abdomen as usu- al; but it has enlarged in a peculiar way, the os uteri being still directed to the symphysis pubis, or even perhaps raised above it. In such a case, which is exceedingly rare, the la- bour will be very tedious and severe. The os uteri will be very long of being felt, and will be first perceived at the pubis.(o) [And in consequence of the impediment to delivery (o) The first case of this kind that has been accurately stated as such, is to be met with in a small, but judicious work, by Dr. H. S. Jackson, entitled, " Cautions to Women respecting the State of Pregnancy. London, 1798:" and was attended by several qf the most respectable practitioners of Lon- don; the next case which has been made public, was that which fell under the immediate notice of Dr. Merriman, and by him minutely detailed in the London Medical and Physical Journal, for 1806; and afterwards published m a distinct and separate work, entitled, " A Dissertation on Retroversion of the Womb, including some Observations on Extra-uterine Gestation. Lon- don: 1810." It will be found by consulting Dr. Merriman's paper and work above al- luded to, that he considers, and with some appearance of probability, that certain of those cases of difficult labour, which by Deventer have been re- ferred to his supposed obliquity of the uterus, and others, which have by different authors, been considered as cases of extra-uterine conception, were in fact, cases of retroversions of the uterus continuing, in a certain degree, until the full period of utero-gestation, and then impeding delivery. He likewise observes, that it is not unlikely, that some of those cases which are found in Smellie's and other collections, where the os uteri is described as grown together and impervious, were actually retroversions of the uterus. In these cases, incisions have been frequently made within the vagina, into the uterus. [Vide Sabatier Medicine Operatoire, Vol. I. p. 316] There is also another class of cases, of which many are recorded by wri- ters on Midwifery, which may probably owe their origin and cause to a retroverted state of the uterus. We here aJlude to those cases of extra-ute- rine foetuses discharged per anum, or through an ulcerated opening in the vagina, after having remained for many years in the abdomen of the mother. [Vide Mainwaring, in 2d vol. of Transactions of the Society for the Im- 191 per vias naturales, rupture of the uterus may take place; the foetus being expelled into the abdominal cavity, and ulti- mately, perhaps, discharged by ulceration, through the rec- tum, vagina, or parietes of the abdomen.] In order to prevent retroversion, we must understand its cause, which most frequently, if not always, consists in dis- tension of the bladder. The os uteri is thus elevated, and the fundus falls in the same proportion backward. Now in the unimpregnated state, the fundus is not sufficiently heavy or large to fall down; and after the fourth month of preg- nancy, the uterus is too heavy to be much raised by the bladder, and too large to fall into the pelvis. If, however, the pelvis be very wide, and the uterus have consequently been longer than usual of rising, it may be retroverted at a later period. It would appear, that agitation, or violent exertion16, may cause this state to take place more readily than would otherwise happen; but whether concussion, or other circum- stances, can produce retroversion, without some previous distension of the bladder, is not positively proved, though some facts favour the supposition. provement of Med. and Chirurg. Knowledge, and Coleman in 2d vol. of Med. and Phys. Journal, and Giffard, in Eclectic. Repertory, vol. I. p. 346, & seq.] When foetuses have been found in the cavity of the abdomen entirely dis- engaged from the uterus, it is probable that a rupture of this viscus, or an ulcerated opening through its parietes, in consequence of its deranged situ- ation, bad permitted the escape of the foetus after it had ceased to live, and not that the conception had advanced to maturity, in a part apparently so illy adapted to such a purpose. By this explanation, we may solve what has hitherto been to many a diffi- culty in the history of these cases. It has, for instance, been observed in every case of foetus carried, as it was supposed, in the abdomen beyond the period of nine months, that near the usual time of parturition, the pains of labour have regularly come on, and strong efforts appear to have been made by the uterus, as if for the expulsion of the child. Now, as it has been well observed, it is difficult to assign any reasons for these contractions of the uterus, if the foetus has no connection with that or- gan; but if the foetus is contained in the partially retroverted uterus, or in any of the appendages of the uterus, -the occurrence of these contractions might naturally be expected. Vide Dr. Merriman's paper and work above referred to. 192 The same woman has been known to have the uterus re- troverted in two successive pregnancies*. § 33. ANTIVERSION. The uterus is also said to be sometimes antiverted, that is, the fundus is thrown forward, so as to compress the neck of the bladder, and its mouth is turned to the sacrum17. Of this accident I have never seen an instance, and, from the nature of the case, it must be very rare. The urine should be eva- cuated, and the fundus raised up. § 3i. RUPTURE OF UTERUS. Rupture of the gravid uterus may take place at any peri- od of gestation. The moment of the accident is generally marked by severe pain, occasionally by vomiting, and fre- quently by a tendency to syncope, which, in some instances, continues for a length of time to be the most prominent symp- tomf. The pain sometimes resembles labour, but more fre- quently colic, and its duration is variable. In some cases, hemorrhage takes place from the vagina, but the greatest quantity of the blood18 flows into the abdomen. At the time of the accident, and for a little thereafter, the child is felt to struggle violently. Then the motion ceases, the woman feels a weight in the belly, and, if the pregnancy be far advanced, the members of the child can be traced through the abdomi- nal parietes19. The tumour of the belly generally20 lessens, and milk is secreted, indicating the death of the child. If hemorrhage, or peritoneal inflammation, do not quick- ly carry off the patient, we find, that at the end of some time, occasionally of the ninth month of gestation, pains like those of labour come on, which either gradually go off, and the child is retained for many years:}:, being inclosed in • Vide case by Dr. Senter, in Trans, of Coll. of Phys. of Philadelphia, p. 130. Both times it was reduced by the hand. f Vide Dr. Underwood's case, in Lond. Med. Journ. Vol. VII. p. 321. \ In Dr. Percival's case, the foetus was retained for 22 years, and then discharged by the rectum. 193 a kind of cyst; or inflammation and abscess take place, and the child is discharged piece-meal21. In some instances, it would appear, that the ovum may be expelled entire into the abdomen; and in that case, it is pos- sible for the child to live for some time, and even to grow, although out of the uterus. When this happens, its motions arc felt more freely and acutely than formerly. As the os uteri opens a little after the expulsion, and a sanguineous discharge takes place, the woman has sometimes been sup- posed to miscarry. If she survives, the womb slowly decreases in size, and returns to the unimpregnated state22, which will assist materially in the diagnosis, between this and extra- uterine pregnancy existing from the first. The menses re- turn, and though the belly does not subside completely, yet the person continues tolerably well, unless inflammation come on. She may even bear children before the extra-ute- rine foetus be got rid of*. If the case is to prove fatal, the pulse becomes quick and small, the belly painful, the strength sinks, and sometimes continued vomiting ushers in dissolu- tion23. Rupture of the uterus may be the consequence of men- tal agitationf, but in most cases it is owing to external vio- lence24^. • Vide Journ. de Med. Tom. V. p. 422. f Dr. Percival's patient attributed her accident to a fright; Dr. Under/ wood's referred hers to mental agitation. } The uterus may be ruptured by a variety of causes. 1. By external violence, as by blows, falls, pressure, &c. 2. By rude attempts to turn the child, and especially, after the waters are discharged. This has often happened. 3. By convulsions. 4. By the inordinate action of the uterus, constituting what is termed spon- taneous rupture. This last is, by much, the most common cause. But when rupture is thus produced, we may suspect that an improper treatment has been pursued. We can, undoubtedly, by copious bleeding, and the subsequent administration of opium, so far overcome the resistance, and mitigate the violence ofthe pains, as to prevent its occurrence. The same remedies will, moreover, obviate, in most instances, rupture from convulsions; and should never be neglected as precautionary means, where there are any apprehen- sions of the accident from turning the child. C. 2 B 194 Three modes of treatment present themselves. To leave the case to nature; to deliver per vias naturalcs; and to per- form the caesarean operation. To dilate the os uteri forcibly, and thus extract the child, is a proposal so rash and hazard- ous, that I know none in the present day w ho would adopt it. I question if the woman would live till the delivery were accomplished. The csesarean operation is safer, and in every respect preferable; but we cannot yet,from experience, de- termine its advantages, and certainly it ought not to be per- formed unless we can thereby save the child. The third proposal, therefore, to leave the case to nature, like an extra- uterine pregnancy, is.most likely to be successful, more especially when the rupture happens in the early months of gestation. We find, from the result of cases, that the woman has the best chance of recovery, if we are satisfied with obvi- ating symptoms, and removing inflammation in the first in- stance ; and supporting the strength of the patient through the progress of the disease, should it not prove rapidly fatal; enjoining rest, giving mild diet, and favouring the expulsion of the bones, by poultices and fomentations, and, if necessary, by enlarging the abscess if it point externally.* • This negative sort of practice has, undoubtedly, met with many very re- spectable advocates. There are, even at the present day, several eminent practitioners, besides Mr. Burns, who strenuously recommend it. Notwith- standing, however, the weight of authority in its favour, I cannot believe it to be right. The powers of nature seem to me to be totally incompetent in such cases. By prompt delivery we can only hope to do good. This, then, we should always attempt. In some cases the forceps may be used, but they are few, as the rupture commonly takes place before labour is sufficiently advanced to admit of their application. We, therefore, turn the child, and bring it away by the feet. Delivery in this manner has been more than once effected, and the woman preserved, even where the child had escaped through the rupture of the uterus into the abdominal cavity. I allude no*, more particularly, to the case recorded by Dr. Douglass, and to one which occurred to Dr. J. Hamilton. To these, I may also add, as showing, at least, the practicability of delivery under such circumstances, a case, related by my friend Dr. James, in the Medical Repository of New York. Were the rupture to happen in the earliest stage of labour, I should ne- vertheless not be deterred from adopting this practice. I would forcibly, but not violently, dilate the uterus. It does not strike me that the attempt would be *' rash and hazardous." We often in other emergencies do it with 193 §35. ABORTION ANB TREATMENT 01 PREGNANT WOMEN. The usual period of utero-gestation is nine months, but the foetus may be expelled much earlier. If the expulsion take place within three months of the natural term, the wo- man is said to have a premature labour; if before that time, she is said to miscarry, or have an abortion. The process of abortion consists of two parts, detachment and expulsion; but these do not always bear a uniform relation to each other in their degree. The first is productive of hemorrhage, the second of pain; for the one is attended with rupture of ves- sels, the other with contraction of the muscular fibres. The first may exist without being followed by the second, but the second always increases, and ultimately completes the first. The symptoms then of abortion, must be those produced by separation of the ovum, and contraction of the uterus. To these, which are essential, may be added others more acci- dental, induced by them, and varying according to the con- stitution and habits of the patient. advantage, as in labour attended with hemorrhage or convulsions. Why may it not also be done in lacerated uterus ? But if, by deformity of the pelvis, or contraction of the uterus, (the child being in the cavity of the abdomen) or indeed from any other circumstances, there exist insuperable impediments to delivery per vias naturales, 1 would, without hesitation, resort to the cesarean section. In deliberating on the ex- pediency of adopting this dreadful alternative, we should constantly bear in recollection that we are not without examples of the success of the opera- tion. Two cases with favourable results are related, one by Dr. Barlow and the other by Dr. J. Hamilton. In the latter case, the bones of the pelvis were so mashed by the wheel of a cart as altogether to prevent delivery by the natu- ral passages. On opening the abdomen, the child was found in the cavity, and the Uterus'considerably lacerated. But notwithstanding the extent and severity of the injury, the woman entirely recovered. Let it not, however, be understood that I am at all sanguine as regards the two remedies which I have proposed. I am, on the contrary, persuaded that in most instances, they will wholly fail. But what else can be done in these tremendous cases I To leave them to nature, " like an extra-uterine con- ception," would be, either to consign the woman to immediate death, or what is still worse, to death from protracted and torturing illness. C 196 The ovum may he thrown off at different stages of its growth; and the symptoms, even at the same period, vary in duration and degree. The process of gestation may be check- ed, even before the foetus or vesicular part of the ovum has descended into the uterus, and when the decidua only is formed. In this case, which occurs within three weeks after impregnation, the symptoms are much the same with those of menorrhagia. There is always a considerable, and often a copious discharge of blood, which coagulates or forms clots. This is accompanied with marks of uterine irritation, such as pain in the back and loins, frequently spasmodic affections of the bowels, and occasionally a slight febrile state of the system. In plethoric habits, and when abortion proceeds from over-action, or hemorrhagic action of the uterine ves- sels, the fever is idiopathic, and precedes the discharge. In other circumstances it is either absent, or, when present, it is symptomatic, and still more inconsiderable, arising merely from pain or irritation. As the primary vessels arc very small, and arc soon displaced, they cannot be detected in the discharge. Nothing but coagulum can be perceived; and this, as in other cases of uterine hemorrhage, is often so firm, and the globules and lymph so disposed, as to give it, more espe- cially if it have been retained for some time about the uterus or vagina, a streaked or fibrous appearance, which some- times gives rise to a supposition, that it is an organized sub- stance. The discharge does not cease when the primary vessels are destroyed, but generally continues until the small vesicle passes out of the fallopian tube. Then it stops, and an oozing of serous fluid finishes the process. The only interruption to the discharge in this case of abortion, proceeds from the formation of clots, which, how- ever, are soon displaced. Women, if plethoric, sometimes suffer considerably from the profusion of the discharge; but, in general, they soon recover. If the vesicle have descended into the uterus, the symp- toms are somewhat different. We have an attempt in the uterus to contract, which formerly was not necessary; we have pains more or less regular in the baejt and hypogastric 197 region; we have more disturbance of the abdominal viscera, particularly the stomach. The discharge is copious, and small bits of fibrous substance can often be observed. Some- times the vesicle may be detected in the first discharge of blood, and will be found to be1 streaked over with pale ves- sels, giving it an appearance as if it had been slightly ma- cerated. When all the contents are expelled, a bloody discharge continues for a few hours, and is then succeeded by a serous fluid. At this time, and in later abortion, if the symptoms take place gradually, we may sometimes observe a gelatinous matter to come away before the hemorrhage appears. If the uterus contain more vascular and organized mat- ter, as in the beginning of the third month, the vesicle never escapes first; but we have for some time a discharge of blood, accompanied or succeeded by uterine pain. Then the inferior part, or short stalk of the ovum may be expelled gorged with blood, and afterwards the upper part equally injured. Sometimes the whole comes away at once and en- tire ; but this is rare. As considerable contraction is now re- quired in the uterus, the pains are pretty severe. The derangement of the stomach is also greater than formerly, giving rise to sickness or faintness, which is a natural con- trivance for abating the hemorrhage. When the membranes come to occupy more of the uterus, and a still greater difference exists betwixt the placenta and decidua, we have again a change of the process; we have more bearing-down pain, and greater regularity in its attack; we have a more rapid discharge, owing to the greater size of the vessels; but there is not always more blood lost now than at an earlier period, for coagula form readily from temporary • fits of faintness and other causes, and interrupt the flow un- til new and increased contraction displaces them. Often the membranes give way, and the foetus escapes with the liquor amnii, whilst the rest of the ovum is retained for some hours or even days*, when it is expelled with coagulated blood • In all cases the placenta is retained much longer after the expulsion of the child in abortion, than in labour at the full time. 198 separating and confounding its different parts or layers. At other times the foetal and maternal portions separate, and the first is expelled before the second, forming a very beautiful preparation. In some rare instances we find the whole ovum expelled entire, and in high preservation. After the expul- sion, the hemorrhage goes off, and is succeeded by a dis- charge, somewhat resembling the lochia. In cases of twins, after one child is expelled, either alone or with its secundines, the discharge sometimes stops, and the woman continues pretty well for some hours, or even for a day or two, when a repetition of the process takes place, and if she has been using any exertion, there is generally a pretty rapid and profuse discharge. This is one reason, amongst many others, for confining women to bed for several days after abortion. There is frequently, for a longer or shorter time before the commencement of abortion, a pain and irregular action in the neighbouring parts, which give warning of its ap- proach before either discharge or contraction take place*, unless when it proceeds from violence, in which case the dis- charge may instantly appear. This is the period at which we can most effectually interfere for the prevention of abor- tion. I need not be particular in adding, that we are not to confound these symptoms with the more chronic ailments which accompany pregnancy. A great diversity obtains in different instances with re- gard to the symptoms and duration of abortion. In some cases the pains are very severe and long continued; in others, short and trifling; nor is the degree of pain always a correct index of the force of contraction. Sometimes the hemorrhage is profuset and alarming; at other times, although circum- stances may not be apparently very different, it is moderate or inconsiderable. Often the sympathetic effects on the sto- * In some cases, shooting pains and tension are felt in the breasts before abortion, and the patient is feverish. f Those who are plethoric generally lose most blood, unless the contrac- tion have been brisk. In some cases six or seven pounds of blood have been lost in a few hours. 199 Hiach and bowels are scarcely productive of inconvenience, whilst in a greater number of instances they are very pro- minent symptoms. I may only add, that, caiteris paribus, we shall find, that the farther the pregnancy is advanced beyond the third month, and the nearer it approaches to the end of the sixth, the less chance is there of abortion being accompanied, but the great- er of its being succeeded, by nervous affection. As there is a diversity in the symptoms, so is there also in the duration of abortion: for, whilst a few hours in many, and not above three days in the majority of cases, is sufficient to complete the process, we find other instances in which it is threatened for a long time, and a number of weeks elapse be- fore the expulsion take place. In some cases the child appears to be dead for a consider- able time before the symptoms which accompany expulsion occur. But in a great majority of cases it is living, when the first signs of abortion are perceived, and in some instances is born alive. The signs by which we judge that the child in utero is dead, are the sudden cessation of the morning sick- ness, or of any other sympathetic symptom which may have been present. The breasts become flaccid. If milk had been formerly secreted, it sometimes disappears, but in other in- stances the contrary happens, and no evident secretion takes place until the action of gestation, or at least the life of the child be lost. In almost every case, however, the breasts will be found to have lost their firmness. If the pregnancy had advanced beyond the period of quickening, the motion of the child will be lost, and a feeling of heaviness will be felt about the pelvis. When all these signs are observed, and when they are followed by discharge, and especially when this is attended with pain, there can be no doubt that expulsion will take place, and it would be improper to prevent it. We are not, however, to conclude that the child is dead, merely be- cause it does not move; and when abortion is threatened be- fore the term of quickening, this sign does not enter into our consideration. 200 When the ovum perishes at a very oarly period, and is not immediately discharged, we find that the sympathetic signs of pregnancy disappear, and not unfrequently a serous or milky fluid comes from the nipples. The woman feels lan- guid and hot at night, or has fits of sickness, or hysterical symptoms; a discharge of foetid dark coloured fluid takes place from the vagina, and is often mixed with particles like snuff. This continues till all the remains of the ovum have come away, and then the health and spirits are restored. If at a more advanced period, the ovum remains after the child dies, it is converted either into a mole or hydatid; and this may also happen even at a very early stage of pregnan- cy. These cases have already been considered. It is gene- rally most prudent to obviate symptoms, and wait until the os uteri open and pains come on. Then we are to be directed by existing circumstances. Whether the ovum become pu- trid, or undergo a change into hydatids, it is reasonable to expect that the vessels of the uterus being; no longer employ- ed in the growth of the foetus should diminish, and become in the first case merely sufficient to nourish the uterus; and, in the second, to supply the necessities of the substance attach- ed to the inner surface of the womb; for there is a com- munication between them, and a discharge of blood attends the expulsion of either a mole or hydatid; whereas, on the other hand, if the ovum has perished completely and become putrid, the discharge is rather a foetid sanies than red blood. Abortion may very properly be divided into accidental and habitual. The exciting causes of the first class may, in gene- ral, be easily detected; those giving rise to the second are often more obscure; and, without great attention, the woman will go on to miscarry, until either sterility, or some fatal disease, be induced. In many cases there can be no peculiar predisposing cause of abortion; as, for instance, when it is produced by blows, rupture of the membranes, or accidental separation of the decidua: but when it occurs without any very percepti- ble exciting cause, it is allowable to infer, that some pre- disposing state exists; and this frequently consists in an im- sol perfect mode of uterine action, induced by age, former mis» carriages, and other causes. It is well known, that women can only bear children until a certain age; after which, the uterus is no longer capable of performing the action of ges- tation, or of performing it properly. Now, it is observable, that this incapability or imperfection takes place sooner in those who are advanced in life before they marry, than in those who have married and begun to bear children earlier. Thus we find, that a woman who marries at forty, shall be very apt to miscarry; whereas, had she married at thirty, she might have borne children when older than forty; from which it may be inferred, that the organs of generation lose their power of acting properly sooner, if not employed, than in the connubial state. The same cause which tends to induce abortion at a certain age in those, who have remained until that time single, will also, at a period somewhat later, induce it in those who have been younger married; for in them we find, that, after bearing several children, it is not uncommon to conclude with an abortion; or, sometimes after this incom- plete action, the uterus, in a considerable time, recruits, as it were, and the woman carries a child to the full time, after which she ceases to conceive. In the next place, I mention that one abortion paves the way for another; because, setting other circumstances aside, it gives the uterus a tendency to stop its action of gestation at an early period after conception, and therefore it is diffi- cult to make a woman go to the full time, after she has mis- carried frequently. This fact has also been explained upon the principle of repeated abortion weakening the uterus*, and this certainly may have some influence. The renewed operation of those causes which formerly induced abortion, may likewise account in many cases for its repetition. But I am also inclined to attribute the recurrence, sometimes, to habit alone, by which I understand that tendency which a part has to repeat or continue those modes of acting which it • Per hanc vero consuetudinem nihil aliud intelligo, quam pravam vaso- rum uteri laxitatem et inde provenientem humorum stagnationem, ex aborti^ endi labore ssepiusrepetito inductam." Hoffmav, Tom.Tii. p. 180. •2 c 202 has frequently performed, as we see in many diseases of the stomach and windpipe; spasmodic affections of these and other organs, being apt to return at the same hour, for a long time. With regard to the uterus, one remarkable instance is related by Schulzius, of a woman, who, in spite of every remedy, miscarried twenty-three times in the third month. In this, and similar cases, slighter causes applied at the pe- riod when abortion formerly happened, will be sufficient to induce it, than would be required at another time. We also find that an excessive or indiscriminate use of ve- ncry, either destroys the power of the organs of generation altogether, making the woman barren, or it disposes to abor- tion, by enfeebling these organs. Some slight change of structure in part of the uterus, by influencing its actions, may, if it do not prevent conception, interfere with the process of gestation, and produce prema- ture expulsion. If, however, the part affected be very small, and near the os uteri, it is possible for pregnancy to go on to the full time. Indeed, it generally does go#on, and the labour, as may be foreseen, will be very tedious; but the operation of cutting the indurated os uteri, which has been proposed, is seldom necessary. I have known one instance, in which a very considerable part of the uterus, I may say almost the whole of it, was found, after delivery, to be extremely hard, and nearly ossified: but this state could not have existed be- fore impregnation took place, for I cannot conceive that so great a proportion of the uterus should have been originally diseased, and yet that conception, and its consequent actions, should take place; but there is less difficulty in supposing, that, during the enlarging of the uterus, the vessels deposi- ted osseous or cartilaginous matter, instead of muscular fir bres. A general weakness of the system, which must affect the actions of the uterus, in common with those of other org- ans, is likewise to be considered as giving rise to abortion, though not so frequently as was at one time supposed. A focal weakness of the uterus sometimes exists when the general system is not very feeble; or when the constitution 203 is delicate, the uterus may be weaker in proportion than other organs. In this case, it cannot perform its function with the necessary activity and perfection, but is very apt, after a time, to flag. We cannot operate with medicines directly upon the womb, for the purpose of strengthening it, but must act on it by invigorating the general system, and attending to all the other functions. Sea-bathing is of great service; and after impregnation, every exciting cause of abortion must be guarded against. Women of this description are generally pale, of a weakly, flabby habit, and subject to ir- regular, often to copious, menstruation, or fluor albus. When they conceive, the cold bath, light digestible food, open bow- els, and free air, should be enjoined; and if any uneasy sen- sation be felt about the uterus or back, or the pulse throb, a little blood should be slowly taken away, and the woman keep her room for some days. Bleeding prevents the womb from being oppressed, and it is as necessary to attend to this, as it is to prevent the stomach from being loaded in a dys- petic patient. But, on the other hand, were we to bleed co- piously, we might injure the action of the uterus, and destroy the child. It has been supposed that abortion might arise from a ri- gidity of the uterus, which prevented its distention. But the uterus does not distend like a dead part, upon which pres- sure is applied, but it grows, and therefore I apprehend that an effect is here considered as a primary cause. The uterus is not only affected by the general conditions of the system, more especially with regard to sensibility, and the state of the blood vessels; but it likewise sympathises with the principal organs, and may.undergo changes in con- sequence of alterations in their state. Thus we often find that loss of tone, or diminished action of the stomach, produces amenorrhoea; and it may also on the same principle induce abortion; on the other hand, the action of the uterus may influence that of other viscera, as we see in pulmonary consumption, which is sometimes sus- pended in its progress during^pregnancy; or, if there be any disposition in an organ to disease, frequent abortion, partly 204 by sympathy betwixt the uterus and that organ, and partly by the weakness which it induces, and the general injury which it does to the system at large, may excite the irregu- lar or morbid action of the organ so disposed. As the action of the uterus is increased during pregnancy, it must require more nervous energy; but the size of the nerves of the uterus is not increased in proportion to the ac- tion; we must therefore depend for the increased supply upon the trunks, or larger portion of nervous substance, from which they arise, for we well know that the quantity of energy ex- pended in an organ, does not depend upon the size of the nerve in its substance, but on the trunk which furnishes it. Whenever action is increased in an organ, it must either perish, or the larger nerve must send the branches more en- ergy, for the branches themselves cannot form it, their extre- mities being only intended for expending it; from which it follows, that in pregnancy there must be more energy sent to the uterus, and less to some other part. This is the case with all organs whose action is increased, other parts being deprived in proportion as they are supplied, except when irritation raises general action above the natu- ral degree ; the consequence of which is, that the power is not sufficient for the action, which becomes irregular, and the system is exhausted, as we see in febrile conditions. There being increased action of the uterus in gestation, requiring an increased quantity of energy to support it, we find that the system is put pro tempore into an artificial state, and obliged either to form more energy, which cannot be so easily done, or to spend less in some other part. Thus the function of nutrition, or the action by which organic matter is deposited, in room of that which is absorbed, often yields, or is lessened, and the person becomes emaciated, or the stomach has its action diminished, or the bowels, producing costiveness and inflation. If no part give way, and no more energy than usual be formed, gestation cannot go on, or goes on imperfectly. Hence some women have abortion induced by being too vigorous; that is to say, all the organs persist in keeping up their action in perfection and complete degree. 205 A tendency to abortion also results from a contrary cause, from organs yielding too readily, allowing the uterus to act too easily. In this state it is as liable to go wrong, as the general system is when it is at the highest degree of action, compatible with health; the most trifling cause deranges it. Thus, sometimes, the intestines yield too readily, and become almost torpid, so that a stool can with difficulty be procured. Here costiveness is not a cause of abortion, though it may be blamed. In like manner, the muscular system may yield and become enfeebled; and in this instance debility is accused as the cause of abortion, although it be, indeed, only an effbet of too much energy being destined for the uterus. In this case, the woman is always weaker during menstruation and gestation than at other times. If the neighbouring parts do not accommodate themselves to the changes in the direction of energy, and act in concert with the uterus, their action becomes irregular, and conse- ' quently painful. In this case, the uterus may have its just degree of power and action; but other parts may not be able to act so well under the change of circumstances. This is chiefly the case in early gestation, for, by time, the parts come to act better. It often gives rise to unnecessary alarm, being mistaken for a tendency to abortion ; but the symp- toms are different. The pain is felt chiefly at night, a time at which weakened parts always suffer most; it returns pret- ty regularly for several weeks, but the uterus continues to enlarge, the breasts to distend, and all things are as they ought to be, if we except the presence of the pain. This may be alleviated by bleeding, and sometimes by anodynes; but can only be cured by time, and avoiding, by means of rest and care, any additional injury to parts already irregular and ticklish in the performance of their actions. If this be neglected, they will re-act on the uterus at last, and impede its function. It is therefore highly necessary, especially in those disposed to abortion, to pay attention to pains about the back, loins, or pubes; and to insist upon rest, open bowels, and detracting blood, if the state of the vascular system indi- cate evacuation. 206 Even although the different organs, both near and re- mote, may have accommodated themselves to the changes in the uterine, action, in the commencement of gestation, the proper balance may yet be lost at a subsequent period; and this is most apt to take place about the end of the third, or beginning of the fourth month, when the uterus is rising out of the pelvis: and hence a greater number of abortions take place at that time than at any other stage of pregnancy. There is from that time, to the period of quickening, a grea- ter susc eptibility in the uterus to have its action interrupted, than cither before or afterwards; which points out the neces- sity of redoubling our vigilance in watching against the ope- ration of any of the causes giving rise to abortion, from the tenth to the sixteenth week. If the action of gestation go on under restraint, as, for in- stance, by a change of position in the uterus, or by its pro- lapsing too low in the vagina, it is very apt to be accom- panied by uneasy feelings, for, whenever any action is con- strained, sensation is produced. The woman feels irregular, and pretty sharp pains in the region of the uterus, and from sympathetic irritation both the bladder and rectum may be affected, and occasionally a difficulty is felt in making water, by which a suspicion is raised that retroversion is taking place. Sometimes the cervical vessels in these circumstances yield a little blood, as if abortion were going to happen; but by keeping the patient at rest, and attending to the state of the rectum and bladder, no harm is done; and when the ute- rus rises out of the pelvis, no farther uneasiness is felt. Occa- sionally a pretty considerable discharge may take place un- der these circumstances, if the vascular system be full, or the vessels about the cervix large. But, by care, gestation will go on; for discharge alone does not indicate that abor- tion must necessarily happen. It, indeed, often causes abor- tion, and is almost always an attendant upon it; but we form our judgment, not from this symptom alone, but also from the state of the muscular fibres, and the vitality of the child. Retroversion of the uterus likewise constrains very much its action, and may give rise to abortion, though in a great- 307 cr number of instances, by care, gestation will go on, and the uterus gradually ascend. The bowels are to be kept open, and the urine regularly evacuated. Sometimes in irritable or hysterical habits, the process of gestation produces a considerable degree of disturbance in the actions of the abdominal viscera, particularly the sto- mach ; exciting frequent and distressing retching or vomit- ing, which may continue for a week or two, and sometimes is so violent, as to invert the peristaltic motion of the intes- tines near the stomach, in which case feculent matter, and, in some instances, lumbrici are vomited. This affection is often accompanied by an unsettled state of niind, which adds greatly to the distress. We sometimes. in these circumstances, have painful attempts made by the muscles to force the uterus downward, and these are occa- sionally attended by a very slight discharge of blood. We have, however, no regular uterine pain; and, if wre arc care- ful of our patient, abortion is rarely produced. The best practice is to take away a little blood at first, to keep the bowels open, to lessen the tendency to vomit, by ap- plying leeches, or an opium plaster, or a small blister, to the region of the stomach, and to allay pain by doses of hyoscy- ainus or opium, conjoined with carminatives. When the mind is much affected, or the head painful, it is proper to shave the head, and wash it frequently with cold vinegar, or apply leeches to the temples; at the same time we keep the patient very quiet, and have recourse to a soothing management. The uterus being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influ- enced by those regulating new-formed parts; with this dif- ference, however, that new-formed parts or tumours, are united firmly to the part from which they grow by all kinds of vessels, and generally by fibrous or cellular substance. whilst the ovum is connected to the uterus only by very ten- der and fragile arteries and veins. If, therefore, more blood be sent to the maternal part of the ovum, than it can easily receive and circulate and act under, rupture of the vessels will take place, and an extravasation and consequent separa 208 tion be produced; or, even when no rupture is occasioned. the action of the ovum may be so oppressed and disordered, as to unfit it for continuing the process of gestation. TMcre must, therefore, he a perfect correspondence betwixt the uterus and the ovum, not only in growth and vascularity, but in every other circumstance connected with their func- tions. Even when they do correspond, if the uterus be plethoric, the ovum must also he full of blood, and rupture is very apt to take place. This is a frequent cause of abortion, more especially in those who menstruate copiously. On the other hand, when the uterus is deficient in vascularity, which of- ten happens in those who menstruate sparingly or painfully, or who have the menses pretty abundant, but watery, the child generally dies before the seventh month, and is expel- led. The process is prematurely and imperfectly finished. The existence of plethora is to be considered as a very fre- quent cause of abortion, and requires most particular atten- tion. It more especially obtains in the young and vigorous, or in those who live luxuriously, and sleep in soft warm beds. It renders the uterus too easily supplied with blood: the in- crease is not made in the regular degree, corresponding to the gradual increase of action, and augmentation of size; but it is, if I may use the expression, forced on the uterus, which is thus made for a time to act strongly and rapidly. This action is sometimes so great, that the person feels weight in the region of the uterus, and shooting pains about the pel- vis; but, in other instances, the vessels suddenly give way, without previous warning, and the blood bursts forth at the os uteri. This cause is especially apt to operate in those who are newly married, and who are of a salacious disposition, as the action of the uterus is thus much increased, and the existence of plethora rendered doubly dangerous. In these cases, whenever the menses have become obstructed, all causes tending to increase the circulation must be avoided, and often a temporary separation from the husband is indis- pensible. Often do we find that slight exertion, within a fort- night after the menses stop, will produce a speedy and vio„- 209 lent eruption of blood, which continues until the vessels are fully unloaded, and until all that part of the process of form- ing an ovum, which has been effected, be undone. Abortion necessarily implies separation of the ovum, which may be produced mechanically, or by spontaneous rupture of the vessels, or by an affection of the muscular fibres. It una- voidably requires, for its accomplishment, contraction of those fibres which formerly were in a dormant state. A natural and necessary effect of this contraction is to develope the cervix uteri. This, when gestation goes on regularly, is accomplished gradually and slowly by the extension and for- mation of fibres. In abortion, no fibres are formed; but mus- cular action does all, except in those instances where the action of gestation goes on irregularly and too fast; in which case the cervix distends, sometimes by the third month, by the same process which distends the fundus. But much more frequently the cervix only relaxes during abortion, as the os uteri does in natural labour, and yields to the muscular action of the fundus, or distended part. The existence and growth of the foetus depend on the foe- tal portion of the ovum. The means of nourishment, and the accommodation of the foetus in respect of lodgment, depend on the uterus; and these circumstances requiring both foetal and maternal action, are intimately connected. The condi- tion of the uterus qualifying it to enlarge, to continue the existence and operation of the maternal portion of the pla- centa or ovum, and to transmit blood to the ovum, exactly in the degree correspondent to its want, constitutes the action of gestation. When the action of gestation ceases universally in the uterus, another action, namely, muscular contraction, begins, and then all hope of retaining the ovum any longer is at an end. I know that we have been told of instances where contraction, after beginning, stopped for several weeks. The os uteri may be prematurely developed; it may be open for some weeks, even without pain; but no man will say that, in this case, labour or uterine contraction has begun. We may even have partial muscular action, in a few cases, about theos uteri, which has less to do with the action of gestation % n 210 than any other part of the uterus; and this action is often attended with considerable pain or uneasiness. Sometimes it is connected with convulsive agitation of several of the ex- ternal muscles of the body. Even in this case, expulsion does not always immediately take place; for by bleeding, and rest, and opiates, the motion may sometimes be checked; but regular and universal action of the muscular fibres never yet has been stopped. It may, like other muscular actions, be suspended by anodynes or artificial treatment; but it ne- ver has, and never can be stopped, otherwise than by the expulsion of the ovum, when a new train of actions com- mence. Whenever, then, at any period of pregnancy, we have paroxysms of pain in the back*, and region of the ute- rus, more especially if these be attended with feeling of weight in that region, tenesmus, micturition, descent of the uterus in the pelvis, and opening of the os uteri, we may bo sure that expulsion, though retarded, will soon take place. This fact is not always attended to in abortion, for many think that if by anodynes they can abate the pain, they will make the woman go to the full time. This is true, with re- gard to many painful sensations, which may attend a threat- ened abortion, or which may be present, although there be no appearance of abortion; but it does not hold with regard to those regular pains proceeding from universal action of the uterine fibres; and we may save both ourselves and our pa- tients some trouble, by keeping this in remembrance. Seeing, then, that contraction is brought on by stopping the action of gestation, and that when it is brought on it can- * It may not be improper to mention, that in some febrile affections we have pain in the back and loins, occasionally remitting, or disappearing alto- gether for a short space, and then returning. Sometimes along with this we have, owing to the affection of the circulation, and in some instances to pre- vious exertion, a slight discharge from the vessels about the os uteri. This state is distinguished from uterine contraction, by our finding that the cervix is unaffected, that the pains are increased by motion or pressure, and are more irregular than those attending labour. This state may be prevented from inducing abortion, by rest, by keeping the bowels open, by anodynes preceded by venesection, if the pulse indicate it Frictions, with campho- rated spirits of wine or laudanum, give relief. Any exertion, during the re- matdtog period of gestation, will renew the pain in the back. 211 not be checked, nor the action of gestation restored, we must next inquire how this action may be stopped. I have already mentioned several circumstances affecting the uterus, and likely to injure its actions; and these I shall not repeat, but go on to notice some others, which are often more perceptible: and first I shall mention violence, such as falls, blows, and much fatigue, which may injure the child, and detach part of the ovum. If part of the ovum be detached, we have not only a discharge of blood, but also the uterus, at that part, suffers in its action, and may influence the whole organ, so as to stop the action universally. But the time required to do this is various, and opportunity is often given to prevent the mischief from spreading, and to stop any farther effusion— perhaps to accomplish a re-union. Violent exercise, as dancing, for instance, or much walk- ing, or the fatiguing dissipations of fashionable life, more es- pecially in the earlier months, by affecting the circulation, may vary the distribution of blood in the uterus, so much as to produce rupture of the vessels, or otherwise to destroy the ovum. There is also another way in which fatigue acts, namely, by subducting action and energy from the uterus: for the more energy there is expended on the muscles of the in- ferior extremities, the less can be afforded or directed to the uterus; and hence abortion may be induced at an early stage of gestation*. Even at a more advanced period, inconve- nience will be produced upon the principle formerly mention- ed; for the nerves of the loins conveying less energy, in many instances, though not always, to the muscles, they are really weaker than formerly, and are sooner wearied, pro- ducing pain, and prolonged feeling of fatigue for many days, after an exertion which may be considered as moderate. This feeling must not be confounded with a tendency to abortion, though it may sometimes be combined with it, for generally by rest the sensation goes off. Neither must we " The same effect is observable in the stomach and other organs. If a de- licate person, after a hearty meal, use exercise to the extent of fatigue, he feels that the food is not digested, the stomach having been weakened or in- jured in its actions. 212 suppose that the child is dead, from its being usually quiet ■during that period, for as soon as the uterus, which has been a little impaired in its action, recovers, it moves as strongly as ever. In the next place, I mention the death of the child, which may be produced by syphilis, or by diseases perhaps pecu- liar to itself, or by that state which produces too much liquor amnii, or by injury of the functions of the placenta, which may arise from an improper structure of the gland itself, or aneurism, or other diseases of the cord. But in whatever way it is produced, the effect is tire same in checking the action of gestation, unless there be twins, in which case it has been known, that the uterus sometimes did not suffer univer- sally, but the action went on, and the one child was born of the full size, the other small and injured*. The length of time required for producing abortion from this cause is va- rious; sometimes it is brought on in a few hours; at other times not for a fortnight, or even longer.(p) In these and similar cases, when the muscular action is commencing, the • It has even been known, that, in consequence of the death of one child, the uterus Has suffered partially, and expulsion taken place ; but the other child continuing to live, has preserved the action of gestation in that part of the uterus, which, properly speaking, belonged to it, and pregnancy has still gone on. This, however, is an extremely rare occurrence; for in almost every instance, the death of one child produces an affection of the action of gestation in the whole uterus, and the consequent expulsion of both children. (p) In one instance that fell under my notice, a lady who had suffered se, veral previous abortions, but who had also borne two healthy living children, was overturned in a carriage before the completion of the third month of gestation. She was extremely bruised, and was, in consequence, confined to her bed for several days; yet upon getting about again, she fancied, after the period of quickening, that she felt the motion of the child, with all the other symptoms of favourable and healthy pregnancy. She thus went on to the full period of utero-gestation; and on the very day she calculated, was de- livered of a foetus that certainly had lost the principle of vitality for several months, not appearing larger than an embryo of five months. The placenta was also almost exanguious, and appeared as if it might have been de- tached from the uterine parietes for some time. Indeed, the whole appeared 'ike a preparation that had been preserved in sp. vini, or sp. terebinth. The lady had a speedy recovery, and at no distant period bore a healthy living child. 213 discharge is trifling, like menstruation, until the contraction becomes greater, and more of the ovum be separated. When symptoms of abortion proceed from this cause, it is not possi- ble to prevent its completion; and it would be hurtful even if it were possible. When, therefore, after great fatigue, pro- fuse evacuations in delicate habits, violent colic, or other causes, the motion of the child ceases, the breasts become flaccid, and the signs of gestation disappear, we need not at- tempt to retard expulsion, but should direct our principal attention to conduct the woman safely through the process. Another cause is, any strong passion of the mind. The in- fluence of fear, joy, and other emotions on the muscular sys- tem, is well known; and the uterus is not exempted from their power; any sudden shock, even of the body, has much effect on this organ. The pulling of a tooth, for instance, sometimes suddenly produces abortion. Emmenagogues, or acrid substances, such as savine and other irritating drugs, more especially those which tend to excite a considerable degree of vascular action, may produce abortion. Such medicines, likewise, as exert a violent action on the Stomach or bowels will, upon the principle formerly mention- ed, frequently excite abortion; and very often are taken de- signedly for that purpose in such quantity as to produce fatal effects*; hence emetics, strong purgatives, diuretics, or a full course of mercury, must be avoided during pregnancy. • It is an old observation, that those purgatives, which produce much tenesmus, will excite abortion ; and this is certainly true, if their operation be carried to a considerable extent, and continue long violent. Hence dysen- tery is also apt to bring on a miscarriage. Those .strong purges which are sometimes taken to promote premature expulsion, not only act by exciting tenesmus, but likewise by inflaming the stomach and bowels, and thus affect the uterus in two ways. It cannot be too generally known, that when these medicines do produce abortion, the mother can seldom survive their effect. It is a mistaken notion, that abortion can be most readily excited by drastic purges, frequent and copious bleeding, &c. immediately after the woman discovers herself to be pregnant; on the contrary, the action of the uterus is then more independant of that of other organs, and therefore not so easily injured by changes in their condition. I have already shewn, that abortion 214 If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion he produced. Hence the acces- sion of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may. bring on mis- carriage, which is one cause why small-pox often excites abortion, whilst the same degree of fever, unaccompanied with eruption, would not-have had that effect. Hence also in- creased secretory action in the vagina, if to a great degree, though it may have even originally been excited in conse- quence of sympathy with the uterus, may come to incapaci- tate the uterus for going on with its actions, and therefore it ought to he moderated by means of an astringent injection. Mechanical irritation of the os uteri, or attempts to dilate it prematurely, will also be apt to bring on muscular contrac- tion. At the same time, it is worthy of remark, that the effect of such irritation is generally at first confined to the spot on which it acts, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for some time, pro- duced; and therefore slight uneasiness at the lower part of the belly, with or without a tendency in the os uteri to move or dilate, whether brought on by irritation at the upper part of the vagina or os uteri, or by affection of the neck of the bladder, &c. may be often prevented from extending far- ther, by rest, anodynes, and having immediate recourse to such means as the nature of the irritation may require for its removal*. The irritation of a prolapsus ani, or of inflamed piles, with or without much sanguineous discharge, may excite the ute- rus to contract; and if the bleeding-from the anus have been more frequently happens when the pregnancy is farther advanced, because then not only the uterus is more easily affected, but the foetus seems to suffer more readily. It is apt, either from diseases directly affecting itself, or from changes in the uterine action, to die about the middle of the third month, in which case expulsion follows within a fortnight. • Chronic inflammation of the heart is generally attended with pain at the bottom of the abdomen, which is sometimes mistaken for symptoms of cal- culus. In one case abortion seemed to proceed from this disease of the heart i # 215 profuse, and the woman weakly, it may destroy the child. The piles ought, therefore, never to be neglected. Tapping the ovum, by which the uterus collapses and its fibres receive a stimulus to action, is another cause by which abortion may be produced; and this is sometimes, with great propriety, done at a particular period, in order to avoid a greater evil. It is now the general opinion, that contraction will unavoidably follow the evacuation of the waters. But we can suppose the action of gestation to be in some cases so strong as not, at least for a very considerable time, to stop in consequence of this violence, and, if it do not stop, contraction will not take place. I do not, however, mean to say, that all discharges of watery fluid from the uterus, not followed by abortion, are discharges of the liquor amnii. On the contrary, I know, that most of these are the consequence of morbid action about the os uteri, the glands yielding a serous, instead of a gelatinous fluid, and this action may continue for many months. In all these cases, the wToinan must be confined to bed, and have an anodyne every night at bed-time, for sometime, pre- mising venesection if the pulse indicate it, and conjoining gentle laxatives. There is just so much probability of gesta- tion going on as to encourage us to use endeavours to continue it. In those instances where the discharge is small, and the oozing pretty constant, we conclude that it is yielded chiefly by the glands about the os uteri, and may derive advantage from injecting three or four times a-day a strong infusion of galls, or solution of alum. The woman ought to use no exer- tion, as the membranes are apt to give way. It is sometimes necessary to lay down rules for the man- agement of pregnant women, even although they may not have been liable to abortion. These are to be drawn from the remarks already delivered, and it is only requisite to add, that in all cases it is proper to attend to the effects of utero- gestation, or the diseases of pregnancy, which are to be miti- gated when severe by suitable remedies. The danger of abortion is to be estimated by considering the previous state of the health, by attending to the violence 21(5 of the discharge, and the difficulty of checking it; to its dura- tion, and the disposition to expulsion which accompanies it; to the effects which it has produced in weakening the system, and to its combination with hysterical or spasmodic affec- tions. In general, we say that abortion is not dangerous, yet in some cases it does prove fatal very speedily, either from loss of blood, or spasm of the stomach, or convulsions. It is satisfactory, however, to know, that this termination is rare, that these dangerous attendants are seldom present, and that a great hemorrhage may be sustained, and yet the strength soon recover. But if there be any disposition in a particular organ to disease, abortion may make it active, and thus, at a remote period, carry off the patient. Miscarriages, if fre- quently repeated, are also very apt to injure the health, and break up the constitution. When abortion is threatened, the process is very apt to go on to completion; and it is only by interposing, before the ex- pulsive efforts are begun, that we can be successful in pre- venting it; for whenever the muscular contraction is univer- sally established, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the process. As this is often the case before we are called, or, as in many instances abortion depends on the action of ges- tation being stopped by causes, whose action could not be ascertained until the effect be produced, we shall frequently fail in preventing expulsion. This is greatly owing to our not being called until abor- tion, that is to say, the expulsive process has begun; where- as, had we been applied to upon the first unusual feeling, it might have been prevented. What I wish then particularly to inculcate is, that no time be lost in giving notice of any ground of alarm, and that the most prompt measures be had recourse to in the very beginning; for, when universal ute- rine contraction has commenced, then all that we can do is to conduct the patient safely through a confinement, which the power of medicine cannot prevent. The case of threatened abortion, in which we most fre- quently succeed, is that arising from slipping of the foot, or 217 from causes exciting a temporary over-action of the vessels, producing a slight separation; because here the hemorrhage immediately gives alarm, and we are called before the action of gestation be much affected. Could we impress upon our patients the necessity of equal attention to other preceding symptoms and circumstances, we might succeed in many cases where we fail from a delay, occasioned by their not un- derstanding that an expulsion can only be prevented, by in- terfering before that process begins; for when sensible signs of contraction appear, the mischief has proceeded too far to be checked. Prompt and decided means used upon the first approach of symptoms indicating a hazardous state of the uterus, or on the earliest appearance of hemorrhage may, provided the child be still alive, be attended with success. In considering the treatment, I shall first of all notice the most likely method of preventing abortion in those who are subject to it; next, the best means of cheeking it, when it is immediately threatened; and, lastly, the proper method of conducting the woman through it, when it cannot be avoided. The means to be followed in preventing what may be call- ed habitual miscarriage, must depend on the cause supposed to give rise to it. It will, therefore, be necessary to attend to the history of former abortions; to the usual habitudes and constitution of the woman; and to her condition when she be- comes pregnant. In many instances a plethoric disposition, indicated by a pretty full habit, and copious menstruation, will be found to give rise to it. In these cases, we shall find it of advantage to restrict the patient almost entirely to a vegetable diet, and, at the same time, make her use considerable and regular ex- ercise. The sleep should be abridged in quantity, and taken, not on a bed of down, but on a firm mattress, at the same time that we prevent the accumulation of too much heat about the body. The bowels ought to be kept open, or rather loose, which may be effected by drinking Cheltenham water, or taking some other laxative. We must not, however, carry this plan too far, nor make a sudden revolution in the con- 2 E 218 &itution, as this may be productive of permanent mischief, and occasion the diseases which proceed from a broken habit. Whenever the strength is diminished, the appetite impaired, or any other bad effect is produced, we have gone too threat length. There is, in plethoric habits, a weakness of many, if not all of the functions; but this is not to be cured by tonics, but by continued and very gradually increased exercise, laxa- tives, and light diet, consisting chiefly of vegetables. This plan, however, must not be carried to an imprudent length, nor established too suddenly; but regard is to be had to the previous habits. It is a general rule, that exercise should not be carried the length of fatigue, and that it should be taken, if possible, in the country; whilst late hours, and many of the modes of fashionable life, must be departed from. Wc may also derive so considerable advantage from conjoining with this plan, the shower bath or sea-bathing, that they ought not to be omitted. There is, I believe, no remedy more powerful in preventing abortion than the cold bath, and the best time for using it is in the morning. By means of this, eonjoined with attention to the vascular system, and prudent conduct on the part of the patient, I suppose that nine-tenths of those who are subject to abortion, may go on to the full time. If the shower-bath be employed, we must begin with a Small quantity of water; and, in some instances, may at first add so much warm water as shall make it just feel cold, but not to give too great a shock. If the cold bath cause headach, this may often be prevented by premising one or two doses of physic. After conception, the exercise must be taken with circum- spection : but the diet should still be sparing, and the use of the cold bath continued. If the pulse be at any time full, or inclined to throb, or if the patient be of a vigorous habit, a little blood should be taken away at a very early period. In some cases where the action is great, we must bleed almost immediately after the suppression of the menses. It is not necessary to bleed copiously; it is much better to take away only a few ounces, and repeat the evacuation when required, 219 and we should manage so as to avoid fainting. The c;>ld bath should be conjoined, and we may derive advantage by using the digitalis*, so as slightly to affect the pulse, keeping it at or below its natural frequency, and to diminish its throbbing. But it is not requisite to be given to the degree employed in some other complaints; and, if it be pushed to an imprudent length, the child may suffer. Half a grain may be given, twice or thrice a-day. It may be continued for two days, and then omitted for a day; and in this way it may be continued till the danger is past. In those cases where the digitalis pro- duces feebleness, it is evidently improper to continue it regu- larly. Indeed, when this effect takes place, its farther exhibition is unnecessary. It is also improper where it acts powerfully on the kidneys. By attending to these cautions, it may, in cases requiring it, be continued with occasional omissions of a day or two, even for some weeks, but it is very seldom necessary to persist in it above a fortnight at most. Injecting cold water into the vagina, twice or thrice a-day, has often a good effect, at the same time that we continue the shower-bath every morning. When there is much aching pain in the back, it is of service to apply cloths to it, dipped in cold water, or gently to dash cold water on it; or employ a partial shower-bath, by means of a small watering can. In this, and all other cases of habitual abortion, we must advise, that impregnation shall not take place until we have corrected the system; and after the woman has conceived, it is requisite that she live absque marito, at least until gesta- tion be far advanced. I need scarcely add, that ^ hen con- sulted respecting habitual abortion, the strictest prudence is required on our part, and that the situation of the patient, and many of our advices, should be concealed from the most intimate friends of the patient. In other cases, we find that the cause of abortion is con- nected with sparing menstruation. This is often the case • The acetate of lead has been recommended by the ingenious and justly celebrated Dr. Rush of Philadelphia, in doses of from one to three grains, given three times a-day. Of this practice I cannot speak from my own expe- rience ; but Dr. Rush informs me, that in his hands it has been attended with great success. 220 With women whose appearance indicates good health, and who have a robust look. This is not often to be rectified by medicine, but it may by regimen, &c. Here, as in the former case, we find it useful to make the greatest part of the diet consist of vegetables; but it is not necessary to restrict the quantity. When, on the other hand, the patient has a weakly deli- cate appearance, it will be proper to give a greater propor- tion of animal food, and two or three glasses of wine, in the afternoon, with some bitter laxative, twice a-day, so as to strengthen the stomach, and at the same time keep the bowels open. We» also derive, in both cases, advantage from the daily use of the warm bath, made of a pleasant temperature; but this is to be omitted after conception; at least, for the first ten or twelve weeks: after which, if there be symptoms of irri- tation, or feeling of tension about the belly, or pain about the groins, or pubis, it may be employed, and is both safe and advantageous. But when the patient is of a phlegmatic ha- bit, or subject to profuse fluor albus, it is not indicated, and sometimes is pernicious. The internal use of the bath waters previous to conception is often of service; or where the cir- cumstances of the patient will not permit this, we may de- sire her to drink, morning and evening, a pint of tepid water, containing half a dram of sweet spirit of nitre. Throw- ing up into the vagina tepid salt-water twice or thrice a-day, seems also to have a good effect. I have already mentioned, that abortion is sometimes the consequence of too firm action, the different organs refusing to yield to the uterus, which is thus prevented from enjoy- ing the due quantity of energy and action. These women have none of the diseases of pregnancy, or they have them in a slight degree. They have good health at all times, but they either miscarry, or have labour in the seventh or eighth month, the child being dead; or, if they go to the full time, I have often observed the child to be sickly, and of a consti- tution unfitting it for living. Blood-letting is useful by ma- king the organs more irritable. The tepid bath is in general 221 of advantage, and may be employed every second evening for some time. There is another case in which all the functions are heal- thy and firm, except the circulation, which is accelerated by the uterine irritation. This is more or less the case in every pregnancy; but here it is a prominent symptom. The wo- man is very restless, and even feverish, and apt to miscarry, especially if she be of a full habit. Immediate relief is given by venesection; and afterwards we may, for some time, give every night half a grain or a grain of digitalis, with two grains of the extract of hyoscyamus. When, on the contrary, abortion arises from too easy yield- ing of some organ, we must keep down uterine action, by avoiding venery, and injecting cold water often into the va- gina, or pouring cold water every morning from a watering can, upon the loins and ilia; at the same time we must attend to the organ sympathising with the uterus. Sometimes it is the stomach which is irritable, and the per- son is often very sick, takes little food, and digests ill. A small blister, or leeches, applied to the pit of the stomach, often relieves this; a little of the compound tincture of bark, taken three or four times a-day, is serviceable; or a few drops of the tincture of muriated iron, in a tumbler glassful of aerated water. At other times, the bowels yield, and the patient is obstinately costive. This is cured by aloetic pills, or manna, with the tartarite of potash. When the muscular system yields, producing a feeling of languor and general weakness, the use of the cold bath, with a grain of opium at bed-time, will be of most service. It is evident, that it is only by attending minutely to the history of former miscarriages, that we can detect these causes; and we shall generally find, that in each individual case, it is the same organ in every pregnancy which has yielded or suffered. Previous to future conception, we may, with propriety, endeavour to render it less easily affected. General weakness is another condition giving rise to abor- tion; and upon this I have already made some remarks. I have here only to add, that the use of the cold bath, the ex- 222 hibition of the Peruvian bark, and wearing flannel next the skin, constitute the most successful practice. Syphilis is likewise a cause of abortion. When it occurs in the mother, it often unfits the uterus for going on with its ac- tions. At other times, more especially when the father la- bours under venereal hectic, or has not been completely cu- red, the child is evidently affected, and often dies before the process of gestation can be completed. In these cases, a course of mercury alone can effect a cure. But we arc not to suppose that every child, born witliout the cuticle in an early stage of pregnancy, has suffered from this cause; on the con- trary, as some of these instances depend on causes already mentioned, and which cannot be cured by mercury, I wish to caution the student against too hastily concluding that one of the parents has been diseased, because the child is born dead or putrid at an early period. It is not always easy to form a correct judgment; but we may be assisted by finding that the other causes which I have mentioned are absent; that we have appearances of ulceration on the child, and that there are some suspicious circumstances in the former history and present health of the parents. A child may be born dead, and even putrid, not only in consequence of syphilis, but also of some malformation of the foetus itself, or of its appendages; or of a general imperfection of the ovum, usually combined with an increased quantity of liquor amnii; or of original de- bility of constitution, unfiting the child for coming to maturi- ty ; or of fatal derangement of structure, or action taking place in utero, from causes often not very obvious; or from weak- ness or imperfect action of the uterus itself, or such a condi- tion of it as sometimes produces epilepsy; or it is in certain cases occasioned by a convulsion. Most of these causes are not under our controul; and indeed, with the exception of the case of syphilis we can only propose to prevent the death of the child, by the use of such general means as invigorate the constitution of the parent, or as obviate palpable predis- posing causes of injury to the uterine functions. Advancement in life, before marriage, is another cause of frequent abortion, the uterus being then somewhat imper- 223 feet in its action. In general, we cannot do much in this case, except avoiding carefully the exciting causes of abortion; and by attending minutely to the condition of other organs, during menstruation or pregnancy, we may, from the princi- ples formerly laid down, do some good. It is satisfactory to know, that although we may fail once or twice, yet, by great care, the uterus comes at last to act more perfectly, and the woman bears children at the full time. After these observations, it is only necessary to add, that in every instance of habitual abortion, whatever the condi- tion may be which gives rise to it, we find it is essential that the greatest attention be paid to the avoiding of the more evident and immediate exciting causes of miscarriage, such as fatigue, dancing, &c. In some cases, it may even be ne- cessary to confine the patient to her room, until the period at which she usually aborts is past. When abortion is threatened, we come to consider whether, and by what means it can be stopped. I have already stated my opinion, that when the action of gestation ceases, it can- not be renewed, and that general contraction of the uterine fibres is a criterion of this cessation. Still, as some of the means which may be supposed use- ful in preventing a threatened abortion, are also useful in moderating the symptoms attending its progress, we may very properly have recourse to them. Some causes giving rise to abortion, do not immediately produce it, but give warning 6f their operation, producing uneasiness in the vi- cinity of the uterus, before the action of that organ be ma- terially affected. The detraction of a little blood at this time, if the pulse be in any measure full or frequent, or, if the pa- tient be not of a habit forbidding evacuations, and the sub- sequent exhibition of an anodyne clyster, or a full dose of opium*, together with a state of absolute rest in a recum- bent posture for some days, will often be sufficient to pre- vent farther mischief, and constitute the most efficacious * Opiates are of signal benefit in this situation, and should seldom be omit- ted after venesection. 224 practice. The patient should be strictly confined to bed, sleeping with few bed-clothes, and without a fire in her apartments. Indeed, the very first thing to be done on enter- ing the room, is to order the patient to bed. The diet should, in general, be low, consisting of dry toast, biscuit and fruit; and much fluid, especially warm fluid, should be avoided. This is the time at which wc can interfere with the most certain prospect of success; and the greatest attention should be paid to the state of the rest of the system; removing un- easiness, wherever it is present, and preventing any organ from continuing in a state of undue action. It is difficult to persuade the patient to comply with that strict attention which is necessary at this period; but being persuaded that if this period be allowed to pass over with neglect, and con- traction begins, nothing can afterwards prevent abortion, I wish particularly to impress the mind of the student with a due sense of its importance; and I must add, that as after every appearance of morbid uterine action is over, the slight- est cause will renew our alarm, it is necessary great atten- tion be paid for some time to the patient. Often, instead of an uneasy feeling about the loins, or lower belly, we have, before the action of gestation stops, a discharge of blood, generally in a moderate, sometimes in a trifling degree. This is more especially the case when abortion is threatened, owing to an external cause; and, if immediately checked, we may prevent contraction from be- ginning. Even in those cases where we do not expect to ward off expulsion, it is useful to prevent, as far as we can, the loss of blood; for as I cannot see that the hemorrhage is necessary for its accomplishment, although it always attends it, I con- clude that our attempts to prevent bleeding can never do harm; if they succeed in checking abortion, we gain our object; if they fail, they do not increase, but diminish the danger. It should be carefully remembered, that the more we can save blood, the more do we serve our patient. As the mean* 225 for checking the discharge will be immediately pointed out, it is unnecessary here to enter into any detail. Sometimes the vessels about the cervix and os uteri yield, post coitum, a little blood; and this may occur either in those who have the uterus in a high state of activity, or more fre- quently where it is feeble in its functions. The same dis- charge may sometimes appear in rather greater quantity after impregnation, passing perhaps for the menses, and making the woman uncertain as to her situation ; but it is generally, though not always, irregular in its appearance, and seldom returns above once or twice. In some instances, however, it becomes greater and more frequent in proportion as the vessels increase in size. It is now apt to pass for menorrhagia. If it be allowed to continue, it tends to injure the action of the uterus, and produces expulsion, which sometimes is the first thing which shews the woman her situ- ation. The discharge is best managed by rest, and the fre- quent injection of saturated solution of the sulphate of alumine, or decoction of oak bark. When a slight discharge takes place, in consequence of a slip of the foot, or some other external cause, we may also derive advantage from the use of the injection; but if the dis- charge be considerable, it will often fail. It is better, in such a case, to trust to the formation of a eoagulum. When in a plethoric habit abortion is threatened, from a fright, or mental agitation, we have often palpitation, rapi- dity of the pulse, headach, flushed face, and pain about the back or pubis; blood-letting relieves immediately the uneasi- ness in the head, and often the pain in the back; afterwards, the patient is to be kept cool and quiet, and an anodyne ad- ministered. In those cases, where regular uterine pain precedes or ac- companies the discharge, expulsion cannot be prevented; but when the discharge precedes the pain, it sometimes may; nay, if the ehild be still alive, it frequently may. Rest is absolutely necessary, if we wish the person to go to the full time: and it is occasionally necessary to confine her to bed for several weeks, prescribe the prudent and occasional use of 3 F 226 digitalis,* and give an anodyne at bed-time, taking care also to keep the bowels in a proper state by gentle medicine. Blood ought also, unless the pulse and habit of the patient forbid it, to be detracted. Styptic injections into the vagina two or three times a-day are of great benefit. This is a very critical situation: much depends on the vi- gour and promptitude of our practice; and much, very much, upon the prudence of the patient. It is teazing to find, that sometimes, after all our care and exertions, one rash act de- stroys in a single day the effect of the whole. When we cannot prevent abortion, the next thing is to conduct the patient safely through the process, by lessening the effects of separation or detachment of the ovum, and ac- celerating the contraction. The first point which naturally claims our attention is the hemorrhage. Many practitioners, upon a general principle, bleed, in order to check this, and prevent miscarriage; but miscarriage cannot be prevented, if the uterine contraction have universally commenced; and the discharge cannot be prudently moderated by venesection, unless there be undue or strong action in the vessels, or much blood in the system; and if so, a vein may be opened with advantage. This is not always the case, and therefore, unless the vessels be at or above the natural force or strength of action, the lancet is not at this stage necessary. The ful- ness and strength of the pulse are lost much sooner in abor- tion than can be explained, by the mere loss of blood. This depends on an affection of the stomach, which has much in- fluence on the pulse; and the proper time for bleeding is be- fore this has taken place. When abortion has made so much progress before we are called, as to have rendered the pulse small and feeble; or when this is the case from the first, * I have in a preceding note, advised some caution in the use of digitalis in uterine floodings. I would here, also, recommend the same degree of cir- cumspection. When given in sufficient quantity to make any very sensible impression on the system generally, it seems, in a very peculiar manner, to relax and debilitate the vessels of the uterus, disposing them, thereby, to passive hemorrhage. When, however, it is administered with proper restric- tions, I have no doubt it may prove both a safe and a useful medicine. But. still, I would greatly prefer to bleed in the above cases. C 227 bleeding evidently can do no good. Instead of this, we may rather use the digitalis, but in ordinary cases, where the contraction is brisk, and the process quick, it is not at this stage absolutely necessary; and I shall afterwards mention that, when the stomachic affection is urgent, and the pulse much affected by it, the use of this medicine is improper. When, however, the case is tedious, and the discharge long continued, at the same time that the sickness is not consider- able, the digitalis will be of essential service, and it may be very properly combined with the sulphuric acid. Nauseating doses of emetic medicines act in the same way with the digi- talis, but are much less effectual, and more disagreeable, as well as uncertain in their operation. Internal astringents have been proposed, but they have no effect, unless they ex- cite sickness, which is a different operation from that whicb is expected from them. The application of cloths dipped in cold water to the back and external parts will have a much better effect than inter- nal astringents, and ought always to be had recourse to. If the digitalis have been exhibited, it assists that medicine in moderating the circulation. Even when trusted to alone, it lessens the action of the sanguiferous system, particularly of the uterine vessels. The introduction of a small piece of smooth ice into the vagina has been recommended, and has often a very speedy effect in retarding the hemorrhage, whilst it never, if properly managed, does any harm. A small snow-ball, wrapped in a bit of linen, will have the same ef- fect ; but neither of these must be continued so long as to pro- duce pain, or much and prolonged shivering. The heat of the surface is also to be moderated, by having few bed-clothes, and a free circulation of cool air. But the most effectual local method of stopping the hemor- rhage is by plugging the vagina. This is best done by taking a pretty large piece of soft cloth, and dipping it in oil, and then wringing it gently. It is to be introduced with the fin- ger, portion after portion, until the lower part of the vagina be well filled. The remainder is then to be pressed firmly on the orifice. This acts by giving the effused blood time to co- 228 agulate. It gives no pain; it produces no irritation; and those who condemn it, surely must either not have tried it, or have misapplied it. If we believe that abortion requires for its completion a continued flow of blood, we ought not, in those cases where the process must go on, to have recourse to cold, or other means of restraining hemorrhage. If we do not be- lieve this, then surely the most effectual method of moderating it is the best. Plugging can never retard the process, nor prevent the expulsion of the ovum; for when the uterus con- tracts, it sends it down into the clotted blood in the upper part of the vagina, and the flooding ceases. Faintness operates also in many cases, by allowing coagula to form, in consequence of the blood flowing more slowly; and, when the faintness goes off, the coagula still restrain the hemorrhage in the same way as when the plug has been used. This naturally points out the advantage of using the plug, together with the digitalis, as we thus produce coagulation at the mouths of the vessels, and also diminish the vascular ac- tion. It will likewise shew the impropriety of using injec- tions at this time; for, by washing out the coagula, we do more harm than can be compensated by any astringent effect produced on the vessels. The principal means, then, which we employ for restrain- ing the hemorrhage, are bleeding, if the pulse be full and sharp; if not, we trust to the digitalis, combined with sul- phuric acid, except in those cases already specified, as for- bidding its use, to stuffing the vagina, to the application of cold to the external parts, keeping the heat of the body in general at a low temperature, and enforcing a state of abso- lute rest, which must be continued during the whole process, however long it may, in some cases, be. The drink should be cold, and the^ food, if the patient desire any, light, and taken in small portions. Opiates have been advised, in order to abate the discharge, and are, by many, used in every case of abortion, and in every stage. But as we cannot finish the process without muscular contraction, and as they tend to suspend that, I do not s^e that their constant exhibition can be defended on ra- 229 tional principles. If given in small quantity, they do no good in the present point of view; if in larger doses, they only postpone the evil, for they cannot check abortion after con- traction has begun. But I will not argue against the use of opiates from their abuse. They arc very useful in cases of threatened abortion, more especially in accidental separa- tion of the membranes and consequent discharge. They do not directly preserve the action of gestation, but they prevent the tendency to muscular contraction, and thus do good, tn weakly or emaciated habits, opiates alone, if given upon the first appearance of mischief, are often sufficient to prevent abortion; and, in opposite conditions, when preceded by ve- nesection, they are of great service. Opiates are likewise useful for allaying those sympathetic pains about the bowels, and many of the nervous affections which precede or accom- pany abortion. They are also of much benefit in cases where we have considerable and protracted discharge, with trifling pains, as the uterus is not contracting sufficiently to expel the ovum, but^nerely to separate vessels, and excite hemorr- hagia. By suspending for a time its action, it returns after- wards with more vigour and perfection, and finishes the pro- cess. But when the process is going on regularly, opiates will only tend to interfere with it, and prolong the complaint. It was, at one time, a very frequent practice to endeavour, with the finger or small forceps, to extract the foetus and placenta, in order to stop the discharge. Puzos strongly op- posed this practice, and it is now very properly given up as a general rule. I do not wish, however, to be understood as altogether forbidding manual assistance; but I am much inclined to consider it as a useful precept, not to be hasty in attempting to extract the ovum. If the discharge be protract- ed, and the membranes entire, we may, if the situation of the patient require it, sometimes accelerate expulsion, by evacu- ating the liquor amnii. But if the pregnancy be not advanced beyond the fourth month, it will be better to trust to smart clysters, and restrain the hemorrhage by means of the plug. We thus have a greater likelihood of getting all the ovum off at once, and may excite the action by gently dilating the 230 os uteri, and moving the finger round it. If the membranes have given way, and the foetus be still retained, we may, by insinuating a finger within the uterus cautiously, hook it out; or, in many cases, it will be found partly expelled through the os uteri, and may easily be helped away. But the most tedious and troublesome case generally is that in which the foetus has been expelled, but the secundines arc still retain- ed. Now, we never can consider the patient as secure from hemorrhage until these be thrown off, and therefore she must be carefully watched, especially when gestation is consi- derably advanced. In a great majority of instances, the uterus, within a few hours, contracts and expels them. But in some cases, the hemorrhage does become profuse, and there is little disposition to separate them. By stuffing the vagina, we shall often find that the discharge is safely stop- ped, and the womb excited to act in a short time. But if vvc be disappointed, or the symptoms urgent, the finger must be introduced within the uterus*, and the remains of the ovum slowly detached by very gentle motion : and we must be very careful not to endeavour to pull away the secundines until they be fully loosened, for we thus leave part behind, which sometimes gives a great deal of trouble; and farther, if wo rashly endeavour to extract, we irritate the uterus, and arc apt to excite inflammation, or a train of hysterical, and some- times fatal symptoms. It is these two circumstances which make me cautious in advising manual assistance; and, fortu- nately, the proportion of cases requiring it is not great in abortion at an early period. When part of the ovum is left, or the whole of the secun- dines are retained, then we have another danger besides he- morrhage ; for, within a few days, putrefaction comes on, and much irritation is given to the system, until the foetid substance be expelled. Sometimes, if gestation have not been far advanced, or the piece which is left is not very large, it continues to come away in small bits for many months; and • In some instances, the half of the secundines wi!lbe found in the vagina, and the other half still in the uterus In this case, ill 'hat is necessary is gently to bring them out 231 during the whole time, the woman is languid, hysterical, and subject to irregularities of the menstrua, very often to ob- struction; but more frequently the symptoms are very acute. We have loss of appetite, prostration of strength, tumid or tender belly, frequent, small, and sharp pulse, hot and parch- ed state of the skin of the hands and feet, nocturnal sweats, and various hysterical symptoms. The discharge from the vagina is abominably foetid, and hemorrhage sometimes oc- curs to a violent degree. The treatment of this will hereafter be pointed out. From these observations we may see upon the one hand the impropriety of allowing the secundines to remain too long in the uterus; and, on the other, the danger of making rash or unnecessary attempts to extract, by which we irritate the uterus, and tear the placenta, which is almost always pro- ductive of troublesome consequences. I now return to the consideration of the usual progress of abortion. The stomach very soon suffers, and becomes debilitated, producing a gene- ral languor and feebleness, with a disposition to faint, which seems, in abortion, to depend more upon this cause than di- rectly upon loss of blood. Indeed, the hemorrhage produces both slighter and less permanent effects in abortion than at the full time, although less blood may have been lost in the latter than in the former case, for the vessels are smaller, and the discharge is not so sudden. There is still another cause for this; namely, that the action of the uterus is less in the early than in the late months. Now, we know that the ef- fect of hemorrhage from any organ is, ceteris paribus, in pro- portion to its degree of action. Hence the discharge is less dangerous than at the full time, and still less in menorrhagia than in abortion. The effect of abortion on the stomach seems to be in pro- portion to the period at which it takes place, being greater when it occurs before the fourth month than after it. The effect, though distressing, and often productive of alarm, is nevertheless beneficial, lessening the action of the vessels in the same way with digitalis, the use of which is improper when this condition is present. The strength of tire pulse is 232 mueh abated; sometimes it becomes slower; but in general it remains much as formerly in point of frequency; we are therefore not to be too anxious in removing this condition, which restrains hemorrhage; yet as it may go beyond due bounds, and produce dangerous syncope, we must check it in time. We must likewise he very attentive to the state of the discharge when this affection is considerable, for if, notwith- standing this, the hemorrhage should continue, it will pro- duce greater and more immediately hurtful effects than if this were absent. The best method of abating this sinking and feebleness, is to keep the body perfectly at rest, and the head low. If necessary, we give small quantities of stomachic cordials, such as a little tincture of cinnamon, or a few drops of ether in a glass of aerated water; or we may give a little pepper- mint water, with fifteen drops of tincture of opium. In urgent cases, Madeira wine or undiluted brandy may be given; but these are not to be frequently repeated, and are very rarely necessary. Large doses of opium are also useful. Sometimes, instead of a feeling of sinking and faintness, the fibres of the stomach are thrown into a spasmodic eon- traction, producing sudden and violent pain. This is a most alarming symptom, and may kill the patient very unexpect- edly. It is to be instantly attacked by a mixture of sulphuric ether and tincture of opium, in a full dose, whilst a sinapism is applied to the epigastric region; but if, when this pain oc- curs, there be symptoms of approaching convulsions, then bleeding should precede the anodyne, and no ether should be given. Spasms about the intestines are more frequent, and much less dangerous. They are very readily relieved by thirty drops of tincture of opium, in a desert-spoonful of aromatic tincture, or forty drops of the tincture of hyoscyamus in two tea-spoonfuls of the compound tincture of lavender. These disagreeable symptoms which I have described, for- tunately do not often attend abortion; but the process goes on safely, and without disturbance. In this case, after it is over, we only find it necessary to confine the person to bed 233 for a few days, as getting up too soon is apt to produce debili- tating discharge. Wo must also, by proper treatment, re- move any morbid symptoms which may be present, but which, depending on the peculiarities of individuals, or their previous state of health, cannot here be specified. When the patient continues weakly, the use of the cold bath, and some- times of the bark, will be of much service in restoring the strength; and, in future pregnancies, great care must be taken that abortion may not happen again at the same period. § 36. UTERINE HEMORRHAGE. Of all the incidents to which a pregnant woman is exposed, none is more alarming or troublesome than uterine hemor- rhage, when it occurs in the advanced stages of gestation, or after the delivery of the child. This, from its extent and im- petuosity, has aptly been called a flooding; and, from the frequency of its occurrence, it must be extremely interesting to every practitioner. The ovum is connected to the uterus by means of a vast multitude of delicate vessels, which pass almost at every point from the one to the other. These vessels are large where the placenta is attached; smaller where they pass in- to the decidua. As the ovum corresponds exactly to the inner surface of the uterus, and is in close and intimate contact with it, we find, that as long as this union subsists, the vessels, notwith- standing their delicacy, arc enabled to transmit blood with- out effusion. But whenever a separation of the one from the other takes place, then these vessels are either directly torn; or, e\cn supposing them to extend a little, they must be rup- tured by their own action, or by the force of the blood which they receive and circulate. AVhen this happens, an extra- vasation or discharge must be the consequence, which will be greater or smaller in proportion to the number and magnitude of the vessels which have given way, and the strength of tire action, which exists in the sanguiferous system. 2 g 234 The membranes are never so full of water as to be put upon the stretch, and therefore they cannot forcibly distend the womb, and make pressure on its inner surface. The womb again, during gestation, does not embrace the mem- branes tightly, so as to compress them. Hence it is evident, that when rupture first takes place, no resistance can, by the action of the one upon the other, be afforded to the flow of the blood. The consequence of uterine hemorrhage, when considerable, is, that the force of the circulation is diminish- ed ; faintness, or absolute syncope being induced. The blood fn this state flows more feebly; coagulation is allow ed to take place, and the paroxysm is for the present ended. This co- agulation, in slight eases, may take place even without the Intervention of faintness. Re-union, however, when the sepa- ration is extensive, and the coagulum considerable, cannot be expected to take place; and therefore, when the clot loosens, a return of the hemorrhage is in general to be looked for. One or more copious discharges of blood must injure the functions of the uterus, and ultimately destroy altogether the action of gestation. This tends to excite the muscular action of the uterine fibres; and by their contraction two effects will be produced. The uterine vessels will he diminished in their diameter or capacity, and the whole surface of the womb pressing more strongly upon the ovum, a greater resistance will be given to the flow of the blood. Thus it appears, that nature attempts to save the patient in two ways. First, by the induction of a state of faintness, or sometimes of complete syncope, which tends to check the present attack. Secondly, when the hemorrhage is so great or obstinate as to prevent any possibility of the woman going safely to the full time, such effects are produced as tend to establish muscular contraction, and accelerate exp^'sion. This double process ought, in all our reasonings, to be held in view. Uterine contraction is of two kinds, which may be called permanent and temporary. The permanent is that continued action of the individual fibres by which the uterus is render- ed tense, so that it feels hard if the hand be introduced into 235 its cavity. The temporary is that greater contraction which is excited at intervals for the expulsion of the foetus, produc- ing wdiat are called the pains of labour. In those cases where nature effects a cure by expulsion, or the production of labour, it is chiefly to the permanent or to- nic contraction that we are indebted for the stoppage of he- morrhage ; because this contraction lessens the size of the vessels, and keeps up a firm pressure of the uterine surface upon the ovum, until the pains have accomplished the expul- sion or delivery of the child. The pains alone could not do this good; for coming only at intervals, their effect would be fugacious. On the other hand, the permanent contraction would not be adequate to the purpose, without the pains, for these temporary paroxysms excite this action to a stronger degree, and, by ultimately foreing down the child, accom- plish delivery before the powers of the uterus he worn out. Such are the steps by which the patient is naturally saved. But we are not to expect that these shall, in every instance, or in a majority of instances, take place at the proper time, or in the due degree. The debility and syncope may go too far; or the clots may not form in proper time, or may come away too soon, or too easily. The action of gestation may continue, notwithstanding the violence of the hemorrhage, thus preventing the accession of muscular contraction; or before this contraction be established and the child expelled, the discharge may have been so great and constant as to render the efforts of the womb weak and inefficient, and by still con- tinuing, may destroy them altogether. These circumstances being considered, it will be evident, that although when the injury is small, and the discharge trifling, nature may permanently check it; or, in more serious cases, may preserve the woman by the expulsion of the child; yet we cannot, with prudence, place our whole reliance on her unassisted operations. There is also another circumstance relating to a particular species of flooding, which renders the accomplishment of a natural cure or escape still more doubtful. This is, that the placenta is sometimes attached to the os uteri, which neces* 236 sarily must produce a hemorrhage whenever the cervix comes to he fully developed, and the mouth to open. Tho vessels going to the placenta are much larger than those which enter the decidua; and therefore, if part of the placenta be detached, the quantity and velocity of the dis- charge must be greater, and the effects more to be dreaded, than when a part of the decidua alone is separated. If the placenta be fixed near the cervix uteri, and a part of it be detached, then the blood which is effused will separate the membranes down to the os uteri, and a profuse hemorrhage will appear. But sometimes, if it be fixed to the fundus uteri, the blood may be confined, especially if the separation have been trifling, and a coagulum will be formed exterior to the membranes, the lower part of which will still adhere to the uterus; or if the central portion of tho placenta have been detached, a collection of blood may be formed behind it, but may not extend beyond its circular margin. But if the pla- centa be placed over the os uteri, then the case is different, profuse discharge will take place, sinking the whole system, and very much enfeebling the uterus itself, so that when uterine contraction does come on, it will be weak, and inca- pable of speedily effecting expulsion; even although the con- traction should be brisk and powerful, it cannot, owing to the structure of the placenta, do the same good as in other cases of flooding; and therefore, in every instance, much blood will be lost, and in many, in very many, the patient, if we trust to this contraction alone, will perish. Contraction can only bo expected in this case to do good, when it is powerful, and the pains come on so briskly as speedily to empty the uterus, at the same time that coagula shut the mouths of the placental vessels at the unsupported part. It has been a common opinion, that flooding prooceded al- ways from the detachment of part of the placenta; but this point is not established*. In several cases of uterine hemor- * Long ago, Andrea Pasta questioned the opinion, that flooding was al- ways produced by separation of the placenta. Vide Discorso del flusso di sangue, &c. We are not, however, to suppose, that hemorrhage does not proceed from detachment of the placenta in any instance when it is placed 237 rhagc, the placenta will be found attached to the fundus ute- ri; and we cannot suppose that in all of these, the whole ex- tent of the membranes, from the placenta to the os uteri, has been separated: yet this must happen before the discharge can in these circumstances appear. We can often account for the hemorrhage, by supposing a portion of the decidua to be detached; and we know that the vessels about the cervix are sufficiently able to throw out a considerable quantity of blood, if their mouths be open. But in most cases of profuse hemorrhage, we shall find, that the placenta is attached near the os uteri, and more or less of it separated. It is possible for blood to be effused in consequence of de- tachment of part of the ovum, and yet it may not be dis- charged by the os uteri*. This detachment may be produc- ed by fatigue, falls, blows, &c. and the effusion is accompanied with dull internal pain at the spot where it takes place. This pain is something like colic, or like pain attending the ap- proach of the menses. The part of the womb where the extra- vasation takes place, swells gradually, and the uterus in a short time feels larger. If the quantity be considerable, the size increases, the uterus is firmer and tenser, as well as larger, the strength diminishes, and even faintings may come on. In course of time, weak slow pains are felt, but if the injury be great, these decline as the weakness increases. They may or may not be attended with the discharge of coagula from the os uteri. In such a case, it is evident, that nothing but delivery can save the mother. But if no bad ef- fect is produced, and the separation is not extensive, the accident may not be discerned or suspected, at least till after the child is born, when often a great quantity of blood is evacuated without affecting the pulse or strength, which it would do, did it come recently from the vessels of the uterus, high up, but only th^t it is a rare occurrence. When the stream is rapid and profuse, we have every reason to suppose that part of the placenta is sepa- rated; but if we have occasion to deliver, it will generally be found, that it is placed close by the cervix uteri, or at least not very far from it. * Vide Albinus Acad. Annot lib. I. p. 56. Recueil Periodique, torn. ii. p.- 15. and torn. iii. p. 1. 238 Let us next consider the causes giving rise to hemorrhage in various degrees; and the first which 1 shall mention is ex- ternal violence, producing a separation of part of the ovum. As the ovum and uterus correspond exactly to each otlier, and are, in the advanced stages of gestation, composed of pretty pliable materials, falls or blows will not produce lace- ration so frequently as might be supposed. In a majority of instances the effect is produced chiefly by the operation on the vessels, their action being violently and suddenly excit- ed, and rupture of their coats thus produced. When the ovum is mechanically detached, the injury must have been consi- derable, and in general the foetus is destroyed. Fatigue, or much exertion, may injure the action of the uterus, and give rise to premature expulsion, which in this case is generally attended with considerable discharge. Such exertions are likewise apt, by their effect on the circu- lation, to operate on the vessels passing to the ovum, and produce in them a greater degree of activity than they arc capable of sustaining without rupture. It is, therefore, very properly laid down as a rule of practice, to forbid pregnant women to undergo much fatigue, or exert any great muscular action; and wherever this rule has been departed from, espe- cially by a patient of an irritable or of a plethoric habit, it behoves the practitioner to attend carefully to the first ap- pearances of injury, or to the first symptoms of decay in the uterine action. Rest, and an opiate will upon general prin- ciples be indicated, and when the circulation is affected, or we apprehend increased action about the uterine vessels, ve- nesection must be premised, and the patient kept cool and tranquil. Violent straining at stool, or strong exertions of the abdo- minal muscles, made in lifting heavy bodies, or in stretching to a height, or frequent and continued stooping, may all, by compressing the womb, cause separation. For the greatest effect will be produced where the resistance is least, or the support smallest, which is at the under part of the uterus, and there rupture will be apt to take place. 239 A preternatural degree of action in the vessels going to tile placenta or decidua, must be dangerous, and likely to pro- duce rupture and extravasation. This may either be con- nected with a general state of the vascular system, marked by plethora, or by arterial irritation; or it may be more im- mediately dependent on the state of the uterus itself. When the woman is plethoric, or when the action of the vascular system is increased, it is natural to suppose, that the effect will be greatest on those parts of the womb which are in the highest state of activity. These are chiefly two; the part to which the placenta is attached, for there the ves- sels are large and numerous; and the cervix and os uteri, because there the greatest changes are going forward. At one or other of these two places, rupture is most likely to take place, and it will happen still more readily if the pla- centa be attached at or near to the cervix. It may be excit- ed either by too much blood circulating permanently in the system, or by a temporary increase of the strength and velo- city of tlie circulation produced by passion, agitation, stimu- lants, &c. A plethoric state is a frequent cause of hemorrhage ih the young, the vigorous, and the active; the decidua is separated, and a considerable quantity of blood flows; per- haps the placenta is detached, and the hemorrhage is more alarming. In some cases the rupture is preceded by spitting of blood, or bleeding at the nose, and in these cases the lancet may be of much service. We sometimes find that extravasation is produced by an increased action of the uterine vessels themselves existing as a local disease. In this case, the patient for some time before the attack, feels a weight and uneasy sensation about the hy- pogastric region, with slight darting pains about the belly or back. These precursors have generally been ascribed to a different cause; namely, rigidity of the ligaments of the womb, or of the fibres of the uterus itself. Spasmodic action about the os uteri, must produce a sepa- ration of the connecting vessels. The causes giving rise to this in the advanced period of gestation, arc not always ob- vious, neifher car* we readily determine the precise cases in 240 which this action excites flooding. We should expect that the discharge ought always to be preceded by pain, but we know that motion may take place in some instances about the os uteri without much sensation; and, on the other hand, many eases of flooding, not dependent on motion of the ute- rine fibres, are attended with uneasiness or irregular pain about the abdomen. This spasmodic action is not unfrequently produced by hanging pregnant animals. Whatever stops prematurely the action of gestation, may give rise to a greater or less degree of hemorrhage. For in this case, the developement of the cervix takes place quickly, and the ovum must be separated. The quantity of the dis- charge* will depend upon the state of the circulation—the magnitude of the vessels which are torn—the contraction of the uterus—and the care which is taken of the patient. Hence it follows as a rule in every premature labour, more especially in its first stage, that we prevent all exertion, re- frain from the use of stimulants, and confine the patient to a recumbent posture. It sometimes happens, that effective contraction docs not ■ take place speedily after the action of gestation ceases, but a discharge appears. This may stop by the induction of syn- cope, or the formation of clots. The blood which is retained about the cervix and os uteri putrefying, produces a very of- fensive smell. Milk is secreted as if delivery had taken place, and sometimes fever is excited. In this state the pa- tient may remain for some days, when the hemorrhage is re- newed, and the patient may be lost if we do not interfere. Some undue state of action about the os uteri, removing, or ceasing to form that jelly which naturally ought to be se- creted there, is another cause. This is generally productive of a discharge of watery fluid, tinged with blood; and if the patient be not careful, • In those cases where the contraction becomes universal and effective, we have little discharge, and the patient is merely said to have a premature la- bour; but if the contraction be partial, and do not soon become effective, then we have considerable discharge, and the patient is said to have a flood-, ing. 241 pure blood may be thrown out in considerable quantity. It may even happen, that the hemorrhage, under certain cir- cumstances, may prove fatal; and yet, upon dissection, no separation of the ovum be discovered, the discharge taking place from the vessels about the os uteri itself*. In some instances, where a portion of the placenta has been detached, I have observed, that near the separated part, the structure of the placenta was morbid, being hard and gristly. In these cases, I could not detect any other cause of separation, and suppose that by the accidental pres- sure of the child upon the indurated part, the uterus may have been irritated. The insertion of the placenta over the os uterif, may give rise to flooding in different ways. The uterus and placenta may remain in contact until the term of natural labour, the one adapting itself to the other; but whenever the os uteri begins to dilate, separation and consequent hemorrhage must take place. It is rare, however, for the accident to be postponed so long. In general, at an earlier period, in the eighth, or by the middle of the ninth month, we find that either the uterus and placenta no longer grow equally, in consequence of which, the fibres about the os uteri are irritated to act; or so much blood as must neces- sarily, in this situation, circulate about the cervix uteri, in- terferes with its regular actions, and induces premature contraction of its fibres, with a consequent separation of the connecting vessels. In order to ascertain whether the hemorrhage proceed from this cause, we ought, in every case to which we are •Vide a case in point, by M. Heinigke, in the first volume of Brewer'. Biblioth. Germ. t So far as I have observed, uterine hemorrhage, when pro/use, is pro- duced most frequently by this cause; at least two-thirds of those cases re - quiring delivery, proceed, I think, from the presentation of the placenta; and in the majority of the remaining third, it will be found attached near to the cervix. Most of those hemorrhages, which are cured without delivery, proceed from the detachment of the decidual alone, Qr of a very small por- tion of the placenta, which has been separated under circumstances favour^ able for firm coagulatiqn. 2 H 242 e'alled, carefully to examine our patient. The introduction of the finger is sometimes sufficient for this purpose, but fre- quently it may be necessary to carry the whole hand into the vagina. If the placenta present, wc shall feel the lower part of the uterus thicker than usual, and the child cannot be so dis- tinctly perceived to rest upon it. This is ascertained by pressing with the finger on the fore part of the cervix, be- twixt the os uteri and bladder, and also a little to cither side*. If the os uteri be a little open, then by insinuating the finger, and carrying it through the small clots, we may rea- dily ascertain whether the placenta or membranes present, by attending to the difference which exists betwixt them. But in this examination, we must recollect, that only a small portion of the edge of the placenta may present, and this may not readily be felt at first. To conclude this part of the subject, I remark in general, (hat hemorrhage from the uterus is not merely arterial, but also veinous, and the orifices of these latter vessels are ex- tremely large. Almost immediately after conception, the veins enlarge and dilate, contributing greatly to give to the uterus the doughy feel which it possesses. In the end of ges- tation, the sinuses are of immense sizey and their extremities so large, that in many places they will admit the point of the finger. Nowr, as all the veins communicate more freely than the arteries, and as they have in the uterus no valves, we can easily conceive the rapidity with which discharge will take place, and the necessity of encouraging coagula- tion, which checks veinous still more readily than arterial hemorrhage. In whatever way flooding is produced, it has a tendency lo injure or disturb gestation, and to excite expulsion; but * When a large coagulum occupies the lower part of the uterus, we may be deceived if we trust to external feeling alone, without introducing the finger within the os uteri. If the uterus have its usual feel, and the child be felt distinctly through it, then we are sure that, however near the plaoenta *a7 be to the os uteri', it is not fixed exactly over it 248 these effects may be very slowly accomplished, and in a great many instances may not take place in time to save the pa- tient or her child. Having already noticed those changes pro- duced on the womb itself by hemorrhage, and the danger of trusting to them for the recovery of the patient, I will not recapitulate, but proceed very shortly to mention the effects produced on the system at large. During the continuance of the hemorrhage, or by the re- petition of the paroxysms, if this be allowed to take place, eertain alterations highly important are taking place. There is much less blood circulating than formerly; and this blood, when the hemorrhage has been frequently renewed, is less stimulating in its properties, and less capable of affording energy to the brain and nerves. The consequence of this is, that all the actions of the system must be performed more languidly, and with less strength. The body is much more irritable than formerly, and slight impressions produce great- er effects. This gives rise to many hysterical, and sometimes even to convulsive affections. The stomach cannot so readily digest the food—the intestines become more sluggish—the heart beats more feebly—the arteries act with little force— the muscular fibre contracts weakly—the whole system de- scends in the scale of action, and must, if the expression be allowable, move in an inferior sphere. In this state, very slight additional injury will sink the system irreparably—very trifling causes will unhinge its actions, and render them irre- gular. If the debility be carried to a degree farther, no care can recruit the system—no means can renew the vigour of the uterus. We may stop the hemorrhage, but recovery will not take place. We may deliver the child, but the womb will not contract. If when the system is debilitated by hemor- rhage, some irritation be conjoined, then the vascular action becomes more or less irregular, and an approximation is made to a state of fever. The pulse is feeble, but sharp; the skin rather warm; and the tongue more or less parched. This state is dangerous, both as it exhausts still more a sys- tem already very feeble, and also as it tends to renew the hemorrhage. It will often be found to depend upon slight 244 uterine irritation, upon accumulation in the bowels, upon pulmonic affections, upon muscular pain, or upon the injudi- cious application of stimuli. Such organs as have been previously disposed to disease, or have been directly or indirectly injured during the con- tinuance of protracted flooding, may come to excite irrita- tion, and give considerable trouble. An acute attack of hemorrhage generally leaves the pati- ent in a state of simple weakness; but if the discharge be al- lowed to be frequently conjoined, and the case thus protract- ed, some irritation often comes to be renewed, which adds to the danger, and excites, if the patient be not delivered, more speedy returns. A woman seldom suffers much in a first attack of hemorr- hage. If she be stout and plethoric, she may loose a great quantity of blood, and yet to appearance not be greatly in- jured. The hemorrhage may come on in every different situa- tion; in bed she may awake suddenly from a dream, and feel herself swimming in blood; or it may attack her when walk- ing; or may be preceded by a desire to make water, and she is surprised to find the chamber-pot half filled with blood. She recovers from her consternation; perhaps in spite of every injunction, she walks about as usual, and finds no bad effect from motion; the feeling of heaviness which may have preceded the accident is gone, she is lighter and better than she was before it, and hopes all is well; but in a few days the hemorrhage is repeated, and again stops; at last, after one or two attacks, for the time is uncertain, the os uteri be- comes soft, and opens a little, perhaps without pain, or she feels dull slight pains, which, however, give her very little uneasiness. This state may take place early, and without dangerous debility; it may take place in the second or third attack; or possibly the hemorrhage may never have entirely ceased, but continued for a day or two like a flow of tho menses, and then been suddenly increased, or may flow in a torrent. But although this state may take place with- out alarming debility, it may also, and that very suddenly, be attended with the utmost danger, or may be accompanied 245 with so much hemorrhage as to prove absolutely fatal. The patient is found without a drop of blood in her face, the ex- tremities cold, the pulse almost gone, the stomach unable to retain drink. She is in the last stage of weakness, but it is not the weakness produced by fever or disease, for we find her voice good and generally the intellect clear. The he- morrhage has stopped, and a young man would suppose it still possible for her to recover. But although not a drop of blood is afterwards lost, the debility increases, the pulse is quite gone, she breathes with difficulty, and gives long sighs, wavers in her speech, and in a short time expires. We may lay it down as a general observation, that few eases of profuse hemorrhage, occurring in an advanced stage of gestation, can be cured without delivery or the expulsion of the child. For when the discharge is copious or obstinate, the placenta is generally separated, sometimes to a very con- siderable extent, and a re-union, without which the woman can never be secure against another attack, can rarely be expected. If the placenta present, the hemorrhage, although suspended, will yet to a certainty return, and few will sur- vive if the child be not delivered. But in those cases where only a portion of the decidua, or a little bit of the margin of the placenta* has been detach- ed, and the communicating vessels opened, either by a state of over-action in the vascular system, or by too much blood in the vessels, or by some mechanical exertion, if proper eare be taken, the hemorrhage may be completely and per- manently checked; or if it should return, it may be kept so much under, or may consist so much of watery discharge from the glands about the os uteri, as neither to interfere with gestation, nor injure the constitution; yet it is to be re- collected, that even these cases of flooding may sometimes proceed to a dangerous degree, requiring very active and de- cided means to be used; and in no case can the patient be considered as safe, unless the utmost care and attention be paid to her conduct. * In this case, after labour is over, we may discover the separated portion by the difference of colour; it is generally browner and softer than the rest. 24U It would thus appear, that some hemorrhagies almost in evitably end either in the delivery of the child, or the death of the parent; whilst others may be checked or moderated without an operation. A precise diagnostic line, liable to no exceptions, cannot be drawn betwixt these cases; and there- fore, whilst we believe that rapid and profuse hemorrhagies, which indicate the rupture of large vessels, can seldom be permanently checked, we still, provided the placenta do not present, are not altogether without hopes of that termina- tion, which is more desirable for the mother, and safer for the child, than premature delivery. In slighter cases, our hope is joined with some degree of confidence. A second attack, especially if it follow soon after the first, and from a slight cause, or without any apparent cause, greatly diminishes the chance of carrying the woman to a happy conclusion without manual interference. In forming our opinion respecting the immediate danger of the patient, we must consider her habit of body, and the previous state of her constitution. Wc must attend to the state of the pulse, connecting that in our mind with the quan- tity and rapidity of the discharge. A feeble pulse, with a hemorrhage, moderate in regard to quantity and velocity, will, if the patient have been previously in good health, ge- nerally be found to depend on some cause, the continuance of which is only temporary. But when the weakness of the pulse proceeds from profuse or repeated hemorrhage, then al- though it may sometimes be rendered still more feeble by op- pression, or feeling of sinking at the stomach; yet, when this is relieved, it does not become firm. It is easily compressed, and easily affected by motion; or, sometimes, even by rai- sing the head. If the paroxysm is to prove fatal, the debility increases— the pulse flutters—the whole body becomes cold and clam- my—the breathing is performed with a sigh—and syncope closes the scene. If irritation be conjoined with hemorrhage, then the pulse is sharper, and, although death be near, it is felt more dis- tinctly than when irritation is absent. 247 The termination in this case is often more audden than a person, unacquainted with the effect of pain or irritation on the pulse, would suppose. For when the pulsation is dis- tinct, and even apparently somewhat firm, a slight increase of the discharge, or sometimes an exertion without discharge, speedily stops it, the heat departs, and the patient never gets the better of the attack. We must likewise remember, that a discharge, which takes place gradually, can be better sustained than a smaller. quantity, which flows more rapidly. For the vessels in the former case come to be accustomed to the change, and are able more easily to accommodate themselves to the decreased quantity. But when blood is lost rapidly, -then very speedy and universal contraction is required in the vascular sys-" tern, in order that it may adjust itself to its contents, and this is always a debilitating process. The difference too be- twixt the former and the present condition of the body, is rapidly produced, and has the same bad effect as if we were instantly to put a free-liver upon a very low and abstemious diet. In all cases of flooding, we find, that during the paroxysm, the pulse flags, and the person becomes faint. Complete syncope may even take place, but this in many cases is more dependent on sickness or oppression at the stomach, than on direct loss of blood. In delicate and irritable habits, the num- ber of fainting fits may be great, but unless the patient be much exhausted, we generally find that the pulse returns, and the strength recruits. The prognosis here must depend greatly on the quantity and velocity of the discharge; for it may happen, that the first attack of,hemorrhage may produce a syncope, from which the patient is never to recover. When we are called to a patient recently attacked with flooding, our most obvious duty is immediately to restrain the violence of the discharge; after which we can take such measures as the nature of the case may demand, either for preserving gestation, or for hastening the expulsion of the rhiltl. 248 A state of absolute rest, in a horizontal posture, is to be enforced with great perseverance, as the first rule of prae- tice. By rest alone, without any other assistance, some he- morrhagies may be cured; but, without it, no woman can be safe. Even after the immediate alarm of the attack is over, the woman must still recollect her danger. She should be confined to bed, upon a firm mattress, for several days, and ought not to leave her apartment for a much longer period. In general, the patient has gone to bed before we arc call- ed; and, perhaps, by the time that we arrive, the bleeding has in a great measure ceased. The partial unloading of the vessels, produced by the rupture, the induction of a state ap- proaching to syneopc in consequence of the discharge, the fear of the patient, and a horizontal posture, may all have conspired to stop the hemorrhage. The immediate alarm from the flooding having subsided, the patient often expresses herself as more apprehensive of a premature labour, than of the hemorrhage, which she con- siders as over. If the attack have been accompanied with slight abdominal pain, her fears are confirmed. But we arc not to enter into these views of the case; we are to consider the discharge as the prominent symptom, as the chief source of danger. We are to look upon the present abatement as an uncertain calm; and whatever advice we may give, what- ever remedies we may employ, we are not to leave our pa- tient until we have strongly enforced on her attendants the danger of negligence, and the necessity of giving early inti- mation should the hemorrhage be renewed. There is no dis- ease to which the practitioner can be called, in which he has greater responsibility than in uterine hemorrhage. The most prompt and decided means must be used; the most patient attention must be bestowed; and, whenever he undertakes the management of a case of this kind, whatever be the situ- ation of the patient, he must watch her with constancy, and forget all consideration of gain and of trouble. His own repu- tation, his peace of mind, the life of his patient, and that of her child, are all at stake. I am doing the student the most essen- tial service, when I earnestly press upon his attention these 249 considerations. And when I intreat, implore him to weigh well the proper practice to be pursued, the necessary care to be bestowed, I am pleading for the existence of his patient, and for his own honour and happiness. Procrastination, irre- solution, or timidity, have hurried innumerable victims to the grave; whilst the rash precipitation of unfeeling men has only been less fatal, because negligence is more common than activity. I shall endeavour to point out the proper treatment in the commencement of uterine hemorrhage, and the best method of terminating the case when the patient cannot be conduct- ed with safety to the full time. After the patient is laid in bed, it is next to be considered how the hemorrhage is to be directly restrained, and whether we may be able to prevent a return. It is at all times proper to ascertain exactly the situation of the patient by examination, as we thus learn the state of the cervix and os uteri, and whether there be any tendency to labour; whether the discharge be stopped by a coagulum in the mouths of the vessels*, or by a large clot in the upper part of the vagina; whether the placenta be at- tached to os uteri, or whether the membranes present. We likewise endeavour to ascertain the quantity of blood which has been lost—the rapidity with which it flowed—-the effect which it has produced upon the mother or child—and the cause which appeared to excite the hemorrhage. The first remedy which, upon a general principle, offers itself to our attention, is blood-letting. In those cases, where the attack has been produced by over-action of the vessels, or a plethoric condition; or where it seems to be kept up by these causes, this remedy employed early, and followed by other means, may be effectual not only in checking the pre-: sent paroxysm, but also in preventing a return. By the timely and decided use of the lancet, much distress may be * We may conjecture that this is the case, if we find no clot in the vagi- na, plugging the os uteri. We are not warranted to thrust the finger forcibly within the os uteri, in this examination; or to rub away the small coagula which may be formed within it, and which may be restraining the hemor- rhage. 21 250 avoided, and both the mother and the child may be saved from danger. But we are not to apply the remedy for one state to every condition; we must have regard to the cause, and consider how far the hemorrhage is kept up by plenitude or morbid activity of the vessels. In those cases where the attack is not excited by, or connected with plethora, or undue action in the vascular system, venesection is not indicated. We have in these cases, which are, I believe, by far the most numerous, other means of safely, and powerfully mode- rating vascular action, without the detraction of blood, which in this disease it ought to be a leading principle to save as much as possible. Whatever lessens materially or suddenly the quantity of blood, must directly enfeeble, and call for a new supply, otherwise the system suffers for a long time. We shall find, that except under those particular circum- stances which I have specified, and where we have ground to believe, that the rupture of vessels has been dependent on their plenitude or over-action, the circulation may he speedi- ly moderated by other means, and especially by the applica- tion of cold. This is to be made not only by applying cloths dipped in cold water to the back and vulva, but also by sponging over the legs, arms, and even the trunk, with any cold fluid; covering the patient only very lightly with clothes, and promoting a free circulation of cold air, until the effect upon the vessels be produced. After this we shall find no ad- vantage, but rather harm from the further application of cold. All that is now necessary, is strictly and constantly to watch against the application of heat, that is, raising the temperature above the natural standard. The extent to which this cooling plan is to be carried, must depend upon circumstances. In a first attack, it is in general to be used in all its vigour; but where the discharge, either towards the end of this attack, or in a subsequent pa- roxysm, has gone so fiar as to reduce the heat much below the natural standard, the vigorous application of cold might sink the system too much. In some urgent cases it may even be necessary to depart from our general rule, and apply ^arm cloths to the hands, feet, and stomach. This is the 231 case where the discharge has been excessive, and been suf- fered to continue profuse or for a long time, and where we are afraid that the system is sinking fast, and the powers of life giving way. There are cases in which some nicety is re- quired in determining this point, and in these cireuinstances we must never leave our patient, but must watch the effects of our practice. This is a general rule in all hemorrhagies, whatever their cause may have been, or from whatever ves- sel the blood may come. A cold skin and a feeble pulse never can require the positive and vigorous application of cold; but, on the other hand, thcyr do not indicate the application of heat, unless they be increasing, and the strength declining. Then we cautiously use heat to preserve what remains, not rashly and speedily to increase action beyond the present state of power. When an artery is divided, it is now the practice to trust for a cure of the hemorrhage to compression, applied by a ligature. We cannot, however, apply pressure directly and mechanically to the uterine vessels, but we can promote coagulation, which has the same immediate effect. Rest and cold are favourable to this process, but ought only in slight cases to be trusted to alone. In this country it has been the practice to depend very much upon the application to the back or vulva, of cloths dipped in a cold fluid, generally wa- ter, or vinegar and water; but these are not always effec- tual, and sometimes, from the state of the patient, are not admissible. Plugging the vagina with a soft handkerchief,* answers every purpose which can be expected from them; and when- ever a discharge takes place to such a degree as to be called a flooding, or lasts beyond a very short time, this ought to * The insertion of a small piece of ice in the first fold of the napkin, is at- tended with great advantage, and has often a very powerful effect. Dr. Hoffman employed the introduction of lint, dipped in solution of vitriol; but this was rather as an astringent than a plug; and he does not propose it as a general practice. He considers, that he was obliged to have recourse ad anceps et extremum auxilium.—Vide Opera Omnia, t. iv. Leroux employed the plug more freely.—Vide Observations sur les Pertes, 1776. 252 be resorted to. The advantage is so great and speedy, that I am surprised that it ever should be neglected. I grant that some women may, from delicacy or other motives, be averse from it; but every consideration must yield to that of safety: and it should be impressed deeply on the mind of the patient, its well as of the practitioner, that blood is most precious, and not a drop should be spilled which can be preserved. Unless the flooding shall in the first attack be permanently checked, which, when the separated vessels are large or numerous, is rarely accomplished, we may expect one or more returns before expulsion can be accomplished. The jnore blood, then, that we allow to be lost at first, the less able will the patient be to support the course of the disease, and the more unfavourable will delivery, when it comes to be performed, prove to her and to the child. It is of consequence to shorten the paroxysm as much as possible; and, therefore, when circumstances will permit, we should make it a rule to have from the first a careful nurse, who may be instruct. ed in our absence to use the napkin without delay, should the hemorrhage return. But whilst I so highly commend, and so strongly urge the use of the plug, I do not wish to recommend it to the neglect of other means, or in every situation. In the early attacks of hemorrhage, when the os uteri is firm, and manual inter- ference is improper, I know of no method more safe or more effectual for restraining the hemorrhage and preserving the patient. But when the hemorrhage has been profuse, or fre- quently repeated, aYid the circumstances of the patient de- mand more active practice, and point out the necessity of delivery, then the use of the plug cannot be proper. If trust- ed to, it may be attended with fatal and deceitful effects. We can indeed restrain the hemorrhage from appearing out- wardly ; but there have been instances, and these instances ought to be constantly remembered, where the blood has col- lected within the uterus, which, having lost all power, has become relaxed, and been slowly enlarged with coagula; the strength has decreased—the bowels become inflated— the belly swelled beyond its size in the ninth month, a!* 253 though the patient may not have been near that period; and in these circumstances, whilst an inattentive practitioner has perhaps concluded that all was well with regard to the he- morrhage, the patient has expired, or only lived long enough to permit the child to be extracted. All practical writers warn us against internal flooding; nay, so far do some carry their apprehension, that they advise us to raise the head of the child, and observe whether blood or liquor amnii be dis- charged ;* an advice, however, to which I cannot subscribe, because in those cases where the membranes have given way, or been opened, the head cannot be thus moveable, nor these trials made, unless we have waited until a dangerous relaxation has taken place in the uterine fibres; and if, on the other hand, we have delivery in contemplation, it is our object to confine the liquor amnii as much as possible, until we turn the child. Besides using these means, it will also, especially in a first attack, and where we have it not in contemplation to deliver the woman, be proper to exhibit an opiate,(^) in order to al- lay irritation; and this is often attended with a very happy effect, Such are the most effectual methods of speedily or imme- diately stopping the violence of the hemorrhage. The next points for consideration are, whether we can expect to carry the patient safely to the full time, and by what means we are to prevent a renewal of the discharge. It may, I believe, be laid down as a general rule, that when a considerable portion of the decidua has in the seventh month, or later, been separated, the hemorrhage, although it may be checked, is apt to return. When a part of the pla- centa has been detached, and more especially if that organ • Vide Dr. Johnson's System of Midwifery, p. 157; and Dr. Leak's Dis. eases of Women, vol. ii. p. 280. (?) In the exhibition of opiates in uterine hemorrhages generally, we would advise their combination with ipecacuanha, in the proportion of half a grain of the latter to about two grains of opium; to be repeated more or less frequently, according to the circumstances of the case. Vide Barton's Edit. of Cullen's Mat. Med. Vol. ii. p- 334, and Chapman's Edit, of Burns. Sal be fixed over the os uteri, gestation cannot continue long; for either such injury is done to the uterus as produces ex- pulsion and a natural cure, or the woman bleeds to death, or we must deliver, in order to prevent that dreadful termina- tion. If the discharge be in small quantity, and have not flowed with much rapidity—if it stop soon or easily—if no large clots are formed in the vagina*—if the under part of the uterus has its usual feel, shewing that the placenta is not attached there, and that no large coagula are retained within the os uteri— if the child be still alive—if there be no indication of the accession of labour—and if the slight discharge which is still coming away be chiefly watery, we may in these circuin- stanccsconcludc that the vessels which have given way are not very large, and have some reason to expect, that by care and prudent conduct, the full period of gestation may be ac- complished. It is difficult to say, whether in this event the uterus forms new vessels to supply the place of those whicb have been torn, and whether re-union be effected by the in- corporation of these with corresponding vessels from the cho- rion. In a case of abortion, we know that re-union takes place; but when, in the advanced period of pregnancy, the decidua has become very thin, soft, and almost gelatinous, it is not established that the circulation may be renewed. At all events, we know that the power of recovery or reparation is very limited, and can only be exerted when the injury is not extensive. The means for promoting re-union of the ute- rus and decidua, are the same with those which we employ for preventing a return of the hemorrhage; and these we ad- vise, even when we have little hope of effecting re-union, and making the patient go to the full time, because it is our object to prevent as much as possible the loss of blood. When the placenta is partly separated, all the facts of which we are in possession are against the opinion that re- union can take place. If the spot be very trifling, and the vessels not large, we may have no return of the bleeding; a small coagulum may permanently restrain it; but if the sepa- ration be greater, and the placenta attached low down, or %h over the os uteri, the patient cannot go to the full time, unless that be very near its completion. We judge of the case by the profusion and violence of the discharge; for all great he- morrhagies proceed from the separation of the placenta; and by the feel of the lower part of the uterus,—by the quantity of clots, and the obstinacy of the discharge, which may per- haps require even actual syncope to stop the paroxysm; a circumstance indicating great danger. The best way by which we can prevent a return, is to moderate the circulation, and keep down the actions of the system to a proper level with the power. The propriety of attending to this rule will appear, if we consider, among- other circumstances, that when a patient has had an attack of flooding, a surprise, or any agitation which can give a temporary acceleration to the circulation, will often renew the discharge. The action of the arteries depends very much upon that of the heart; and the action of this organ again is dependant on the blood. When much blood is lost, the heart is feebly excited to contraction, and in some cases it beats with no more force than \% harely sufficient to empty itself. This evidently lessens the risk of a renewal of the bleeding; and in several cases, as, for example, in hemoptysis, we, by suddenly detracting a quantity of blood, speedily excite this state of the heart. Whatever tends to rouse the action of the heart, tends to renew hemorrhage ; and if the proposition be established, that the rapidity with which the strength and action of the vessels are diminished is much iiifluenced by the rapidity with which a stimulus is withdrawn, the converse is also true, and wre should find, were it practicable to restore the quantity of blood as quickly as it has been taken away, that the same effect would be produced on the action of the heart, as if a person had taken a liberal dose of wine. It has been the practice to give, nourishing diet to restore the quan- tity of blood; but until the ruptured vessels he closed, or the tendency to hemorrhage stopped, this must be hurtful. It is our anxious wish to prevent the loss of blood; but it does not thence, follow, that,, when it is lost, we should wish rapidly to restore it. This is against every principle of sound pathology; 256. but it is supported by the prejudices of those who do not re- flect, or who are ignorant of the matter. When a person is reduced by flooding, even to a slight degree, taking much food into the stomach gives considerable irritation; and if much blood be made, vascular action must be increased. What is it which stops the flow of blood, or prevents for a time its repetition? Is it not diminished force of the circula- tion which cannot overcome the resistance given by the co- agula? Does not motion displace these coagula, and renew the bleeding? Does not wine increase for a time the force of the circulation, and again excite hemorrhage ? Is it not con-s formable to every just reasoning, and to the experience of ages, that full diet is dangerous when vessels are opened? Do we not prohibit nourishing food and much speaking in hemorrhage from the lungs? and can nourishing diet and mo- tion be proper in hemorrhage from the uterus? If it were possible to restore in one hour the blood which has been lost in a paroxysm of flooding, it is evident, that unless the local condition of the parts were altered, the flooding would at the end of that hour be renewed. The diet should be light, mild, given in small quantity at a time, so as to produce little irritation*, and much fluid, which would soon fill the vessels, should be avoided. We shall do more good by avoiding every thing which can stimulate and raise actionf, than by replenishing the system rapidly, and throwing rich nutriment into the stomach. * Such as animal jellies, sago, toasted bread, hard biscuit, See. These arti- cles, given at proper intervals, are sufficient to support the system without raising the action too much. f The system, with its power of action, may, for illustration, be compar- ed to a man with his income. He who had formerly two hundred pounds per annum, but has now only one, must, in order to avoid bankruptcy,spend only one half of what he did before; and if he do so, although he has been obliged to live lower, yet his accounts will be square at the end of the year. The same applies to the system. When its power is reduced, the degree of its action must also be reduced; and, by carefully proportioning the one to the other, we may often conduct a patient through a very grea,t and conti- nued degree of feebleness. At the same time, it must be observed, that as there is an income so small, as not to be sufficient to procure the necessaries of life, so also may the vital energy be so much reduced as to be inadequate 257 It is, however, by no means my intention to say, that we must, during the whole remaining course of gestation, (pro- vided that that go on, the attack having been permanently cured) keep down the quantity of blood. A only mean that we are not rapidly to increase it. Even where the strength has been much impaired by the profusion of the discharge, or the previous state of the system, it is rather by giving food so as to prevent farther sinking, than by cramming the patient, that wc promote recovery; and I beg it to be remem- bered, that although I talk of the management of those who are much reduced, yet I am not to be understood as in any degree encouraging the practice of delay, and allowing the patient to come into this situation of debility; but when we find her already in this state, it is not by pouring cordials and nutriment profusely into the stomach, that we are to save her; it is by preventing farther loss and farther weak- ness; it is by giving mild food, so as gradually to restore the quantity of blood and the strength ; it is by avoiding the sti- mulating plan on the one hand, and the starving system on the other, that we are to carry her safely through the danger. Some medicines possess a great power over the blood ves- sels, and enable us in hemorrhage to cure our patient with less expence of blood than we could otherwise do. The digi- talis is of this class, and may often be given with much ad- vantage in flooding, where the pulse indicates increased vas- cular action, and when we do not mean to proceed directly to delivery. But when the discharge lias been trifling, and the pulse is slow, and perhaps feeble, the digitalis is unne- cessary even from the first; and if, in the progress of the disease, the stomach have become affected, and the patient is sick, inclined to vomit, or faintish, or the pulse feeble and small, it is likewise improper. In those cases which demand it, when the pulse is sharp, and throbbing, and frequent, it may be given either in the to the performance'of those actions which are essential to our existence, and death is the result. But surely he who should attempt to prevent this by stimulating the system, would only hasten the fatal termination: Does not heat overpower and destroy those parts which have been frost-bit,.' 2 K 258 form of powder or of tincture; half a grain of the dried leaves may be given every two hours, until the pulse be af- fected, and afterwards at longer intervals, so as to keep the circulation modf^'ate. The tincture may also be employed with the same advantage. Two drams may be added to a four-ounce mixture, and a table spoonful given every two hours, watching the effect, and diminishing the dose when necessary. The addition of a little well-prepared hepatiscd ammonia sometimes makes the effect be more speedily pro- * duced, but not more than five drops should be added to each dose.(r) At the same time that we thus endeavour to diminish the action of the vascular system, we must also be careful to re- move as far as we can every irritation. I have already said all that is necessary with regard to heat, motion, and diet. The intestinal canal must also be attended to, and accumu- lation within it should be carefully prevented by the regular exhibition of laxatives. A costive state is generally attended with a slow circulation in the veins belonging to the hepatic system, and of these the uterine sinuses form a part. If the arterial system be not proportionally checked, this sluggish (r) Our author has here omitted to mention, the powerful effects of the acetate of lead in restraining uterine hemorrhage. The dose must depend upon the circumstances of the case, and the judg. ment of the practitioner. In a general way we may say, that two or three grains may be given at a time, and repeated more or less frequently, accord- ing to the urgency of the symptoms. It should be combined with a portion of opium. Professor Barton, who has called the attention of American practitioners to this powerful article of the materia medica, in restraining internal he- morrhage, recommends the combining with it a portion of ipecacuanha. For his opinion on this subject, we must refer the student to the Professor's edition of Cullen's Materia Medica, vol. ii. p. 20, 21, and 334. Other prac- titioners, among whom is Dr. Chapman, in these cases place considerable confidence in a combination of opium and ipecacuanha, in the proportion of two grains of the former to half a grain of the latter, to be repeated every two hours. From my own experience, I should be induced to decide in favour of tho acetate of lead, when combined as above directed. 259 motion is apt, by retarding the free transmission along the meseraic veins, to excite the hemorrhage again. Uneasiness about the bladder or rectum, or even in more distant parts, should be immediately checked; for, in many cases, hemorrhage is renewed by these irritations. In those cases, or where the patient is troubled with cough, or affect- ed with palpitation, or an hysterical state, much advantage may be derived from the exhibition of opiates. In many in- stances where an attack of flooding is brought on by some irritation affecting the lower part of the uterus in particular, or the system in general, or where the bowels are pained, and the pulse not full nor strong, rest, cool air, and an ade- quate dose of tincture of opium will terminate the paroxysm, and perhaps prevent a return. This is especially the case, if only a part of the decidua have been separated, and the dis- charge have not been profuse. When the vascular system is full, venesection is necessary before the anodyne be admi- nistered, and the digitalis may either succeed the opiate, or be omitted, according to the state of the pulse and of the stomach. But although anodynes be in many instances, and especi- ally in first attacks, of great benefit, yet they are not to be indiscriminately employed nor exhibited when the circum- stances of the patient require delivery, unless the strength be much impaired; and then, a full dose is to be given as a. cordial, previous to delivery. It may happen that we have not been called early in a first attack, and that some urgent symptom has appeared. The most frequent of these, is a feeling of faintness or com- plete syncope. This feeling often arises rather from an af- fection of the stomach than from absolute loss of blood; and in this case it is less alarming than when it follows copious hemorrhage. In either case, however, we must not be too hasty in exhibiting cordials. When the faintishnesa depends chiefly upon sickness at the stomach, or feeling of failure, circumstances which may accompany even a small discharge, it will be sufficient to give a few drops of hartshorn in cold water, and sprinkle the face "with cold water. When it is 260 more dependant on absolute loss of blood, we may find it n«- ecssary to give small quantities of wine warmed with aro- matics; but our cordials even in this case must not be given with a liberal hand, nor too frequently repeated*. It is scarcely necessary for me to add, that we arc also to take immediate stfcps by the use of the plug, &c. for restraining -the discharge. This I may observe once for all.(s) Complete, syncope is extremely alarming to the bye- standers; and, if there have been a great loss of blood, it is indeed a most dangerous symptom. It must at all times be relieved, for although faintness be a natural mean of chee' - ing hemorrhage, yet absolute and prolonged syncope is hazardous. But we arc not to exhibit large doses of cordials for its removal. We must keep the patient at perfect rest, in a horizontal posture, with the head low, open the windows, sprinkle the face smartly with cold vinegar, apply volatile salts to the nostrils, and give some hartshorn, or a spoonful of warm wine internally. Universal coldness is also a symptom which must not be allowed to go beyond a certain degree, and this degree must be greatly determined by the strength of the patient and the quantity and rapidity of the discharge. When the strength is not previously much reduced, a moderate degree of cold- ness is, if the hemorrhage threaten to continue, of service: but when there has been a great loss of blood, then universal coldness, with pale lips, sunk eyes, and an approaching dc- * As syncope and loss of blood have both the effect of relaxing the mus- cular fibre, as is well known to surgeons, it may be supposed that they should increase the flooding by diminishing the contraction of the uterus, if that have already taken place. But the contrary is the case, for by allowing co- agula to form, syncope restrains hemorrhage, and therefore ought not to be too rapidly removed. * (s) In restraining uterine hemorrhage, We should not forget that injections thrown up the vagina, and if possible into the uterus, may have a consider- able effect in repressing the discharge. In this way I have known solutions of the acetate of lead, of the sulphate of alumine, and a strong decoction or infusion of galls, produce salutary effects. A solution of the acetate of lead in cold water combined with laudanum may be also thrown up by enema, as recommended by Dr. Dewees 261 liquium, may too often be considered as a forerunner of death. When we judge it necessary to interfere, we should apply warm cloths to the hands and feet, a bladder half filled with tepid water to the stomach, and give some hot wine and water internally. Vomiting is another syrmptom which sometimes appears. It proceeds very generally from the attendants having given more nourishment or fluid than the stomach could bear, or from a gush of blood taking place soon after the patient has had a drink. It in this case is commonly preceded by sick- ness and oppression, which are most distressing, and threat- en syncope until relief is obtained by vomiting. Sometimes it is rather connected with an hysterical state, or with ute- rine irritation. If frequently repeated, it is a debilitating operation, and by displacing clots may renew hemorrhage; but sometimes it seems fortunately to excite the contraction of the uterus, and gives it a disposition to empty itself. For abating vomiting, we may apply a cloth dipped in laudanum, and camphorated spirits of wine, to the whole epigastric re- gion ; or give two grains of solid opium, or even more, if the weakness be great. Sometimes a little infusion of capsicum is of service. It should just be gently pungent. In flooding it is of importance to pay much attention to the state of the stomach, and prevent it from being loaded; on the other hand, we must not let it remain too empty, nor allow its ac- tion to sink. Small quantities of pleasant nourishment should be given frequently. We thus prevent it from losing its tone, without oppressing it, or filling the system too fast. Hysterical affections often accompany protracted floodings, such as globus, pain in the head, feeling of suffocation, pal- pitation*, retching, in which nothing but wind is got up, &c. These are best relieved by some foetid or carminative sub- stance conjoined with opium. The- retching sometimes rc- " The quantity of blood lost is sometimes so great as to do irreparable in- jury to the heart, and ever after to impede its action. One well marked in- stance of this is related by Van Swieten, in his commentary on Aph. 1304, where, & r twelve years the woman after a severe flooding1, could not sit up in bed without yio'ent palpitation and anxiety. 262 quires an anodyne clyster, or the application of a campho- rated plaster*, to the region of the stomach. After having made these observations on the management of flooding, and the best means of moderating its violence, of preventing a return, and of relieving those dangerous symptoms which sometimes attend it; I next proceed to speak of the method of delivering the patient when that is necessary. I have separated the detail of the medical treat- ment of a paroxysm from the consideration of the manual assistance, which may be required; because, however inti- mately connected the different parts of our plan may be in actual practice, it is useful in a work of this kind, in order to avoid confusion, that I lay them down apart. As some peculiarities of practice arise from the implanta- tion of the placenta, over the os uteri, I shall confmc my present remarks to those cases in which the membranes are found at the mouth of the womb, desiring it to be remem- bered, however, that this circumstance does not necessarily indicate that the hemorrhage does not proceed from separa- tion of the placenta, which may be fixed very near the cer- vix, although it cannot be felt. The operation of delivering the child is not difficult to de- scribe or to perform. The hand, previously lubricated, is to be slowly and gently introduced completely into the vagina. The finger is to be introduced into the os uteri, and cautious- ly moved so as to dilate it; or if it has already dilated a lit- tle more, two fingers may be inserted, and very slow and gentle attempts made at short intervals to distend it; and the practitioner will do well to remember, that he will suc- ceed best when he rather acts so as to stimulate the uterus, and make it dilate its mouth, than directly to distend it. On the part of the operator is demanded much tenderness, cau- tion, firmness, and composure; on the part of the patient is to be desired patience and resolution. The operator is to keep in mind, that painful dilatation is dangerous, it irritates • This may be made by melting a little adhesive plaster, and then adding to it a large proportion of camphor, previously made into a thick liniment by rubbing it with olive oil. 263 and inflames the parts, and that the woman should Complain rather of the uterine pains which are excited, than of the fingers of the practitioner. More or less time will be requi- red fully to dilate the os uteri, according to the state in which the uterus was when the operation was begun. If the os ute- ri is soft and pliable, and has already by slight pains been in part distended, a quarter of an hour, or perhaps only a few minutes will often be sufficient for this purpose; but if it has scarcely been affected before by pains, and is pretty firm, though not unyielding, then half an hour may be required. I speak in general terms, for no rule can be given applicable to every case. Not unfrequently, although the patient have felt scarcely any pains, and certainly no regular pains; the os uteri will be found as large as a penny-piece, and its mar- gin soft and thin. The os uteri being sufficiently dilated, the membranes are to be ruptured, the hand introduced, the child slowly turned and delivered, as in footling cases; en- deavouring rather to have the child expelled by uterine con- traction than brought away by the hand. Hasty extraction is dangerous, for the uterus will not contract after it. And, therefore, if when we are turning, we do not feel the uterus acting, we must move the hand a little, and not begin to de- liver until we perceive that the wromb is contracting. The delivery must be but slow until the breech is passing, then we must be careful that the cord be not too long compressed before the rest of the child be born. The child being remov- ed, and the belly properly supported, and gently pressed on by an assistant, the hand should again be cautiously introdu- ced into the womb, and the two knuckles placed on the sur- face of the placenta, so as to press it a little, and excite the uterus to separate it. The hand may also be gently moved in a little time, and the motion repeated at intervals, so as to excite the uterus to expel its contents; but upon no ac- count arc we to separate the placenta and extract it. This must be done by the uterus; for we have no other sign that the contraction will be sufficient to save the woman from fu- ture hemorrhage. The whole process, from first to last, must be slow and deliberate, and we are never to lose sight of our 264 object, which is to excite the expulsive power of the uterus. It is not merely to empty the uterus—it is not merely to de- liver the child, that we introduce our hand: all this we may do, and leave the woman worse than if we had done nothing: The fibres must contract and press upon the vessels; and as nothing else can save the patient, it is essential that the practitioner have clear ideas of his object, and be convinced on what the security of the patient depends. But to teach the method of delivery, and say nothing of the circumstances under which it is to be performed, would be a most dangerous error. I have in the beginning of this sec- tion, pointed out the effect of hemorrhage, both on the consti- tution and on the uterus; and I have stated, that the action of gestation is always impaired by a certain loss of blood, and a tendency to expulsion brought on. But before the uterine contraction can be fully excited, or become effective, the wo- man may perish, or the uterus be so enfeebled as to render expulsion impossible. Whilst then we look upon the one hand to the induction of contraction, we must not on the other de- lay too long. We must not witness many and repeated attacks of hemorrhage; sinking the strength; bleaching the lips and tongue, producing repeated fainting fits, and bringing life itself into immediate danger. Such delay is most inexcusable and dangerous; it may end in the sudden loss of mother and child; it may enfeeble the uterus, and render it unable after- wards to contract; or it may so ruin the constitution, as to bring the patient, after a long train of sufferings, to the grave. Are we then uniformly to deliver upon the first attack of .flooding, and forcibly open the os uteri? By no means; safety is not to be found either in rashness or procrastination. The treatment which I have pointed out, will always se- cure the patient until the delivery can be safely accomplish- ed. As long as the os uteri is firm and unyielding—as long as there is no tendency to open, no attempt to establish con- traction, it is perfectly safe to trust to the plug, rest, and cold. But I must particularly state to the reader, that the os uteri may dilate without regular pains; and in almost every instance it does, whether there be or be not pains, be- 265 come dilatable. Did I not know the danger of establishing positive rules, I would say, that as.long as the os uteri i* firm, and has no disposition to open, the patient can be in lit- tle risk if we understand the use of the plug; we may even plug the os uteri itself, which will excite contraction. But if the patient be neglected, then I grant that long before a ten- dency to labour or contraction be introduced, she may perish. I am not, however, considering what may happen in tlie hands of a negligent practitioner; for, of this, there would he no end, but what ought to be the result of diligence and care. It is evident, that when the uterus has a disposition to contract, and the os uteri to open, delivery must be much safer and easier than when it is still inert, and the os uteri hard. We may with confidence trust to the plug, until these de- sirable effects be produced; and, in some instances, we shall find, that by the plug alone we may secure the patient: the contraction may become brisk, if we have prevented much loss of blood, and expulsion may naturally take place. Who would, in those circumstances, propose to turn the child, and deliver it? Who would not prefer the operation of nature to that of the accoucheur? To determine in any individual case whether this shall take place, or whether delivery must be resorted to, will require deliberation on the part of the prac- titioner. If he have used the plug early and effectually, and the pains have become brisk, he has good reason to expect natural expulsion; and the labour must be conducted on the general principles of midwifery. But if the uterus have been enfeebled by loss of blood—if the pains are indefinite—if they have done little more than just open the os uteri, and have no disposition to increase, then he is not justified in expect- ing that expulsion shall be naturally and safely accomplish- ed, and he ought to deliver. When he dilates the os uteri, he excites the uterine action, and feels the membranes become tense. But he must not trust to this: he must finish what he has begun. Thus it appears, that by the earjy and effective use of the plug, by filling the vagina with a soft napkin, or with tow, 31 266 wc may safely and readily restrain hemorrhage, until such changes have taken place on the os uteri as to render deli- very easy; and then we either interfere or trust to natural expulsion, according to the briskness and force of the con- traction, and state of the patient. By this treatment, we obtain all the advantage that can be derived from the operations of nature, and, where these fail, are enabled to look with confidence to the aid of artifi- cial delivery. But it may happen that we have not had an opportunity of restraining the hemorrhage early; we may not have seen the patient until she has suffered much from the bleeding.* In this case, we shall generally be obliged to deliver, and must upon no account delay too long; yet, if the os uteri be very firm, and without disposition to open, we shall generally find that the sinking is temporary; wc may still trust for some time to the plug. Hemorrhage is naturally restrained by faintness. A repe- tition is checked in the same way; and faintness takes place sooner than formerly. In one or two attacks, the uterus suf- fers, and the os uteri becomes dilatable. Slight pains come on, or are readily excited by attempts to distend.the os uteri. Syncope then will, in general, even when the plug has not been used, and the patient has been neglected, restrain he- morrhage, and prevent it from proving fatal until the os uteri has relaxed; but a little delay beyond that period will destroy the patient; and it is possible, by giving wine, and, otherwise treating her injudiciously, to make hemorrhage prove fatal, even before this takes place. But although I have considered it as a general rule, that where the os uteri is firm and unyielding, wre may, notwithstanding present alarm* trust some time to the plug. Yet I beg it to be remem- bered, that there may be exceptions to this rule; for the Constitution may be so delicate, and the hemorrhage so sud- den, or so much increased by stimulants, as to induce a pcr- • We are not to confine our attention to the quantity which has been lost, but to the effect it has produced , and this will cxteris paribus be great in proportion as the hemorrhage has been sudden. 267 manent effect, and make it highly desirable that delivery should be accomplished: but such instances are rare; and although I have spoken of the effects of syncope in restrain- ing hemorrhage, I hope it will not be imagined by the stu- dent that I wish to make him familiar with this symptom. It is very seldom safe, when we have our choice, £o wait till syncope be induced; and if it have occurred, it is not usually prudent to run the risk of a second attack. The old practitioners, not aware of the value of the plug, nor acquainted with the sound principles of physiology, had no fixed rule relating to delivery, but endeavoured to empty the uterus early; but it was uniformly a remark, that those women died who had the os uteri firm and hard.* What is this but to declare, that the rash and premature operation is fatal ? It is an axiom which should be deeply engraved on the memory of the accoucheur, and which should constantly in- fluence his conduct. Pain and suffering are the immediate consequence of the practice; whilst a repetition of the flood- ing after delivery, or the accession of inflammation, are the messengers of death. It was the fatal consequence of this blind practice that; suggested to M. Puzos the propriety of puncturing the mem- branes, and thus endeavouring to excite labour. His reason- ing was ingenious: his proposal was a material improvement on the practice which then prevailed. The ease of the opera- tion, and its occasional success, recommend it to our notice; but experience has now determined that it cannot be relied on, and that it may be dispensed with. If we use it early, and on the first attack, we do not know when the contraction may be established; for, even in a healthy uterus, when we use it on account of a deformed pelvis, it is sometimes several days before labour be produced. We cannot say what may take place in the interval. The uterus being slacker, the he- morrhage is more apt to return, and we may be obliged after all to have recourse to other means, particularly to the plug. Now we know that the plug will, without any other opera*- * Vide the works of Mauriceau, Peu> &c. 268 tion, safely restrain hemorrhage, until the os nterLbe in a proper state for delivery.* The proposal of M. Puzos then is, I apprehend, inadmissible before this time. If after this there be occasion to interfere, it is evident that we must de- sire some interference which can be depended on, both with respect to4ime and degree. This method can be relied on in neither; for we know not how long it may be of exciting con- traction, nor whether it may be able to excite effective con- traction after any lapse of time. If it fail, we render deli very more painful, and consequently more dangerous to the mo- ther, and bring the child into hazard. It has been observed, in objection to this, by Dr. Denmanf, that if turning be dif- ficult, the flooding will be stopped by the contraction of the womb. But we know that the uterus, emptied of its water, may embrace the child so closely as to render turning, if not difficult, at least painful, and yet not be acting so briskly as to restrain flooding: nothing but brisk contraction can save a patient in flooding, if the vessels be large or numerous. The only case then which remains to be considered, is that in which pains come on, and expulsion is going forward. Now, in this case, the flooding is stopped cither by the con- traction or by the plug, and the membranes burst in the na- tural course of labour; after which it is speedily concluded. Here, then, interference is not required; but if, after going on in a brisk way for some time, the pains abate a little, which often happens even in a natural labour, it will be proper to rupture the membranes, if we have reason to think that a slight stimulus to the uterus would renew its action: and, in determining this, the practitioner must be influenced by the • The ingenious M. Alphonse Le Roy seems much inclined to trust almost' entirely to the plug, and supposes that the blood will act as a foreign body, and excite contraction; but this, as a general doctrine, must be greatly quali- fied. Respecting the proposal of M. Puzos, he observes, " Puzos, en con- seillant assez hardiment de percer Ies eaux, n'avoit d'autres vues que la con- traction de la matrice, qui est la suite de cette operation et la cessation de la perte, et il la conseilla mime dans les cas des pertes qui arrivent avant terme Mais un grand nombre de femmes sont peries par l'effect de cette meme pratique." Lecons sUr les pertes de sang, p. 45. t Introduction to the practice of Midwifery, vol. ii. p. 310. 269 previous discharge; for if the uterus have been much reduced by it in its vigour, it will be less under the influence of a sti- mulus; and if, upon the present diminution of the pains, the flooding is disposed to return, I should think that we surely ought to trust rather to the hand, which can stimulate in the necessary degree, and finish the process with safety, than to a method which is much more uncertain and less under our command*. The proposal of M. Puzos then will, if this reasoning be just, be very limited in its utility. Its simplicity gave me at first a strong partiality in its favour-; and if I now have changed my opinion, I have given my reasons. But there still remains a most important question to be answered. In those cases where the patient has been allowed to lose a great deal of blood frequently and suddenly, when the strength is gone, the pulse scarcely to be felt, the extre- mities cold, the lips and tongue without blood, and the eye ghastly, shall we venture to deliver the woman? Shall we, by plugging, endeavour to prevent farther loss, and by nourish- ment and care recruit the strength; or empty the uterus, and then endeavour to restore the loss? We have only a choice of two dangers. The situation of the patient is most perilous, and I have in practice weighed the argument with that at- tention which the awful circumstances of the case required. I think myself justified in saying, that we give both the mo- ther and the ehild the best chance of surviving by a cautious delivery. For in these cases the uterus is almost torpid, it possesses no tonic contraction!; the very continuance of the ovum within it is more than it can bear, and on the most . In those cases where the placenta presents, few practitioners would think of trusting to the evacuation of the .liquor amnii; they would deliver. If then delivery be considered as safe and proper in one spec.es of flooding, it cannot be dangerous in the other; and whenever interference in the way of operation is necessary, the security afforded by the introduction of the hand will much more than compensate for any additional pain. But even ,n this respect, the two operations are little different, if properly P**"^ t The use of the plug cannot here certainly prevent farther loss of blood, for the uterus affords no resistance, the hemorrhage continues, and after death large coagula will be found within the womb. 270 favourable supposition, it will require many days before it could be brought into a state capable of contracting. The general system is completely exhausted, and cannot support its condition long. I have never known a woman live twenty- four hours in these circumstances. On the other hand, I grant, that it is possible the woman may die in the act of delivery, or very soon after it; hut if she can be supported for two days, we may have hopes of re- covery. By a very slowr and cautious delivery, and by endea- vouring to excite the action of the uterus, so as to prevent discharge afterwards, we not only remove the irritation of the distended womb, but we likewise take away a receptacle of blood. During the contraction of the uterus, the blood in its sinuses will be thrown into the system, and tend to sup- port it. Part, no doubt, will escape; but by keeping the hand in the uterus, by supporting the abdomen with a compress, and exciting the uterine action by cold applications to the belly, we may prevent a great loss. When to these consid- erations wc add the additional chance which the child has for life, our practice, I apprehend, will, in this very hazard- ous case, be decided. When the pulse becomes firmer and fuller upon the contraction of the uterus, the risk from de- bility is diminished. A full dose of laudanum ought to be given previous to delivery. The remarks upon the subsequent management of the pa- tient, I shall reserve until I come to consider the treatment of flooding, after delivery. At one time it was supposed, that the placenta was, in every instance, attached originally to the fundus uteri, and that it could only be found presenting in consequence of having been loosened and falling down. This accident was supposed to retard the birth of the child, by stopping up the passage, and also was considered as dangerous on account of the flooding which attended it. On this account Deventer en- deavoured to accelerate the delivery by tearing the placenta, or rupturing the membranes when they could be found. This was a dangerous practice, and very few survived when it 271 wTas employed. Mr Giffard and M. Levret* were among the first who established it as a rule that the placenta did not fall down, but was from the first implanted over the os uteri: and the latter gentleman published a very concise and accu- rate view of the treatment to be pursued. We know, that during the eighth month of gestation, very considerable changes take place about the cervix uteri. It is completely developed and expanded; and, in the ninth month, very little distance intervenes betwixt the ovum and the lips of the os uteri. These changes cannot easily take place with- out a rupture of some of the connecting vessels, for either the placenta does not adapt itself to the changes in the shape of the cervix; or, which happens more frequently, some slight mechanical cause, or action of the fibres about the os uteri, produces a rupture. This rupture may doubtless take place at any period of pregnancyf, but it is much more frequent in the end of the eighth and beginning of the ninth month, than at any other time. But whether the separation happens in the seventh, eighth, or ninth month, the consequent hemorrhage is always profuse, and the effects most alarming. The quantity, but especially the rapidity of the discharge, very frequently pro- duces a tendency to faint, or even complete syncope; during which the hemorrhage ceases, and the woman may continue for several days without experiencing a renewal of it. In some instances she is able to sustain many and repeated at- tacks, which may take place daily for some weeks. These, however, it is evident, cannot be very severe, and the strength • Je m'engage a prouver 1° que le placenta a'topla^e1 quelquefois sur la circonference de I'orifice interne de la matrice * e'est-a-dire, sur celui qui du col va joindre I'interieur de ce viscere, & non sur celui qui regarde le vagin. 2°. Qu'en ce cas la perte de sang est inevitable dans les dernier terns de la grossesse. Et 3°. Qu'il n'y a pas de voye plus sore pour remSdier a cet accident urJ gent que de faire I'accouchement force"—L'art des Accouchemens, p. 343. f In some cases, hemorrhage has taken place so early as the third month. By proper means this has been stopped, and the patient has continued well for some months, when the flooding has returned, and the placenta been dis- covered to present must originally have been great. In other instances, the woman never gets the better of the first attack. It indeed diminishes, but does not altogether leave her, and a slight ex- ertion renews it in its former violence. But whether the pa- tient suffer much or little in the first attack—whether she be feeble or robust, the practice must be prompt, and the most solemn call is made upon the practitioner for activity. The moment that a discharge of blood takes place, he ought to ascertain by careful examination the precise nature of the case, and must take instant steps for checking it, if nature have not already accomplished that event. If the os uteri be firm and close in a first attack, we ought to use the plug, which will restrain the hemorrhage, and in- sure the present safety of the patient. If this practice have been immediately followed, she will in general soon recover, and the length of time for which she will remain free from a second attack, will depend very much upon the care which is taken of her; but sooner or later the attack must and will return. If the uterus have been injured in its action by the first attack, this will generally be attended with very slight dull pains, and we shall feel the os uteri more open and lax- er than usual; but if the first and second discharges have been promptly checked, it may be later before those effects he perceived ; but the moment that they are produced, wc ought to deliver, and it should even be a rule, that where they are not likely soon to take place, and the discharge has been profuse and rapid, and produced those effects on the system which I have already pointed out, as the consequence of dangerous hemorrhage, we must not delay until pains be- gin to open the os uteri. Fortunately, we are not often oblig- ed to interfere thus early; for by careful management, and the use of the plug, we can secure our patient. Although I have said that we may wait safely until the os uteri begins to open, and asserted, that no woman can die from mere hemorrhage, before the state of the os uteri ad- mit of delivery, I must yet add, on this important subject, that this state does not consist merely in dilatation, for it 27S may be very little dilated; but in dilatability,(t) we may safely deliver whenever the hand can be introduced without much force. A forcible introduction of the hand on the first attack of hemorrhage, would, in many cases, be attended with the greatest danger, and in almost every case is improper and unnecessary. I have never yet seen an instance, where delivery was required during the first paroxysm, if the pro- per treatment was followed. Whether it may be required in a second or third attack, or even later, must depend upon the quantity and rapidity of the discharge, its effects and the strength of the woman. But whenever we find the os uteri soften, and in any degree more open than in its usual state, and it admits the finger to be introduced easily with- in it, we may deliver safely; and if the hemorrhage be con- tinuing, ought not to delay. This state will generally be found accompanied with obscure pains; but we attend less to the state of pains, than of discharge, in determining on delivery. The pains gradually increase for a certain period, and then go off. During their continuance, the os uteri dilates more; but if the hemorrhage have been, or continues to be consider- able, we must not wait until the os uteri be much dilated, as we thus reduce the woman to great danger, and diminish the chance of her recovery. A prudent practitioner will not, on the one hand, violently open the os uteri at an early period, but will use the plug; until the os uteri becomes soft and dilatable ; and if the hemorrhage be not considerable, he will (t) Rigby, a respectable surgeon of Norwiclwn England, is entitled,-as we believe, to the credit of first promulgating this distinction, which is of great importance to be attended to in practice ; his words are, "We should be as much influenced (as respects the period of introducing the hand) by the os uteri being in a state capable of dilatation without violence, as by its being really open ; when this is the case, therefore, ifLthe woman's situation demand speedy assistance, we should not hesitate to attempt delivery. His Essay on this subject, was published in the year \777, and is in every respect a valua- ble work, rendered more so by the number of interesting cases appended to it. Ithasbeenrepublishpdin this city, and is highly worthy of the perusal of every Student and Practitioner of Midwifery. Its title is "An Essay on the Uterine Hemorrhage, which precedes the delivery of the full grown Foetus : illustrated with cases by Edward Rigby, member of the Corporation of Surgeons in London." 2 M 874 even, if the state of the patient allow him, wait until slight pains have appeared, or the os uteri begun sensibly to open without them; for he will recollect, that the more violence that is done to the os uteri, the greater is the risk of bad symptoms supervening. It is an error into which some have fallen, who look upon debility from discharge, as the only barrier to recovery. Violent delivery may produce inflamma- tion, or a very troublesome fever. On the other hand, he will not allow his patient to lose much blood, or have many attacks; he will deliver her immediately, for he knows that whenever this is necessary it is easy, the os uteri yielding to his cautious endeavours. But very frequently we arc not called until the patient has had one or two attacks, and been reduced to great dan- ger. We find her with feeble pulse, ghastly countenance, frequently vomiting, and occasionally complaining of slight grinding pains. On examination, the vagina is so filled with clotted blood, which adheres so firmly by the lymph to the uterus, that at first we find some difficulty in discover- ing the os uteri. We cannot here hesitate a moment what course to follow. If the patient Is to be saved, it is by delive- ry. The os uteri will be in part dilated ; it will easily be fully opened, We perhaps find an edge of the placenta pro- jecting into the vagina, perhaps the centre of the placenta presenting or protruding like a cup into the vagina; but in ihose cases the rule is the same. We pass by the placenta to the membranes, rupture them*, and turn the child, de- livering according to the directions which I have already given. It may be supposed, that as the treatment is so nearly the same, it is not material that we distinguish whether the pla- centa or membranes present. But it is convenient to make a distinction, because in those cases where the placenta does not present, it is possible, in certain circumstances, to cure the flooding, and carry the patient to the full time; and in ' • This is much safer for the child than pushing the hand through the pla- centa; and it is equally advantageous for the mother, and easy to the opera- tor. 275 those cases, which are indeed the most numerous, where this cannot be done, we always look to uterine contraction as a very great assistance, and expect that where that is great- est, the danger will be least. But when the placenta pre- sents, we have no hope of conducting the woman safely to the full time. We have no ground to look to contraction or labour-pains as a mean of safety; for, on the contrary, every effort to dilate the os uteri separates still more the placenta, and increases the hemorrhage*. The very circumstance which in some other cases would save the patient, will here in general increase the danger. I say in general, for there are doubtless examples where the patient has by labour been safely and without assistance delivered of the child, when part of the placenta has presented. Nay, there have been instances where the placenta has been expelled first, and the child after it.| These examples are to be met with in collections of cases by practical writers; and some solitary instances are likewise to be found in different journals. It would be much to be lamented if these should ever appeal- without having at the same time a most solemn warning sent along with them to the accoucheur, to pay no attention to them in his practice.^ I am convinced that they may do in- expressible mischief by affording argument for delay, and excusing the practitioner to himself for procrastination. There is scarcely any malady so very dreadful as not to af- ford some examples of a cure effected by the powers of na- ture alone; but ought we thence to tamper with the safety of those whose lives are committed to our charge? Ought we to neglect the early and vigorous use of an approved remedy, because the patient has not in every instance perished from • The greatest number of profuse or alarming hemorrhagies proceed from the presentation of the placenta, or the impUntation of its margin over the os uteri; and, consequently, the greatest number of cases requiring delivery are of this kind. f Even in those cases where the placenta is expelled first, the flooding may recur, and the woman die, if she be not assisted. Vide La Motte. Obs. cexxxviii. & cexxxix. $ Most of those who have met with such cases do not seem to count mutn upon them- 276 the negligence of the attendant ? It is highly proper to pub- lish the case of a patient who, from hernia, has had an anus formed at his groin, because it adds to our stock of know- ledge : But what should wc think of a surgeon who should put such a case into the hands of a young man, without, at the same time, saying, " Sir, if such a case ever happen in •♦ your practice, either you or your patient will be very much '«to blame." I do not mean from this to say, that we are to blame, in every instance, the accoucheur who has attended a case where the placenta has presented, and the patient been delivered by nature ; far from it, for by the use of the plug, he may have restrained the hemorrhage, pains may have come on, and the child, descending, may have car- ried the plug before it: or, when he was called to his pa- tient, he may have found her already in labour, and the pro- cess going on so well and so safely, that all interference would have been injudicious. But these instances are not to be converted into general rules, nor allowed to furnish any pretext for procrastination. They happen very seldom, and never ought to be related to a young man witliout an express intimation that he is not to neglect delivery, when it is re- quired, upon any pretence whatsoever. § 37. FALSE PAINS. Many women arc subject, in the end of gestation, to pains about the back or bowels, somewhat resembling those of la- bour, but which, in reality, are not connected with it. These, therefore, are called false pains. They sometimes only pre- cede labour a few hours; but in many cases, they come on several days, or even some weeks, before the end of preg- nancy, and may be very frequently repeated, especially dur- ing the night, depriving the woman of sleep. They are often confined altogether to the belly, shifting their place, and being very irregular both in their attacks and conti- nuance. In some cases they affect the side, particularly the right side, in the region of the liver, and are exceedingly se- 377 vere, especially in the evening; they are accompanied with acidity or water-brash, or reaching, and generally the child is at that time very restless. These pains may doubtless oc- cur in any habit, but they chiefly harass those who are ad- dicted to the use of cordials. On other occasions, the false pains occupy chiefly the back or hips, or upper part of the thighs. They even sometimes resemble still more nearly par- turient pains, in being attended with an involuntary effort on the part of the abdominal muscles, to press down, so as to make the woman suppose that she is about to be delivered; and this is occasionally accompanied with tenesmus, or with protrusion of the bladder from the vagina, very like the membranes of the ovum. In other cases, they are attended with a discharge of watery fluid from the vagina. False pains may be occasioned by many causes: the most frequent are flatulence; a spasmodic state of the bowels, resembling slight cholic; or irritation, connected with costiveness or di- arrhoea; or nephritic affections, often accompanied with strangury. A sudden motion of the back, or unusual degree of fatigue, may cause a remitting pain in the back and loins; or getting suddenly out of bed when warm, and placing the feet on the cold floor, may have the same effect. A slight de- gree of lumbago may also resemble the parturient pains. Agitation of mind, or a febrile state of the body, or some irritation in the neighbourhood of the uterus, Or some unu- sual motion of the child, may produce an uneasy sensation in the uterus; and sometimes this is accompanied by a discharge of watery fluid from the vagina. False pains may often be distinguished by their situation; as for instance, when they affect the bowels or kidneys; by their shifting their situation; by their duration; by their ir- regularities ; and by the symptoms with which they are at- tended. But the best criterion is, that they seldom affect the os uteri, that part not being dilated during their continuance. It is necessary however to observe, that a dilated state of the os uteri does not always prove that the pains are those of la- bour; for it may be found prematurely dilated for a week or 278 two before the proper term of labour, without any pain.* In this case, if the pains proceed from affections of the bowtds, no effect is produced during the pain, in rendering the os uteri tense, or making it larger. On the other hand, it some- times happens, that the fibres about the os uteri are prema- turely irritated; and this state may be accompanied with pain, and with a perceptible change on the os uteri during a pain. This is a very ambiguous case; but we may be assisted in our judgment, by discovering, that the term of utero-gesta- tion is not completed, that the os uteri is hard or thick, and the pains irregular. In all such cases, it is best to proceed on the supposition, that the woman is not actually in labour; for by letting her alone, she most likely will have a conti- nuance of pain, terminating, it is true, in labour, but the process will be tedious and fatiguing; whereas, by suspend- ing the action by an opiate, and if necessary by venesection, the woman may go on for some time longer, and will at all events have an easier delivery. When the false pains are accompanied with afebrile state, or are very distressing during the night, it will be proper to detract blood, and afterwards give an anodyne. In all other cases, it is generally sufficient to keep the woman in a state of rest, prescribe an opiate, and if necessary, open the bowels by means of a clyster. Rubbing with anodyne balsam is also useful. Shivering and tremor occur in some cases, in the end of pregnancy; and as they also occasionally precede labour, they often give rise to an unfounded expectation, that deli- very is approaching. They appeal* to be connected sometimes with the state of the stomach, or alimentary canal; in other instances with some change in the os uteri itself, which, even without pain, may be so far opened or relaxed as to allow the * In some cases the os tincx would seem to possess the power of dilata- tion and contraction. I recently attended a woman who, for more than two weeks, continued to have uterine pains occasionally so strong as to induce me, under the suspicion of her being in labour, to make repeated examina- tions. To my surprise, I found the os tincae sometimes quite contracted, and at other times dilated to more than an inch in diameter. C 279 finger very easily to touch the child's head through the mem- branes. It is usually in, the evening, or through the night, that the shivering is felt; and it is occasionally pretty severe, and may be several times repeated. Nothing, however, is re- quired, except a little warm gruel, or a moderate dose of laudanum, which is always effectual. BOOK II. Of Parturition. »:»: CHAP. I. Of the Classification of Labours. Labour may be defined to be the expulsive effort made by the uterus for the birth of the child, after it has acquired such a degree of maturity, as to give it a chance of living, independently of its uterine appendages. I propose to divide labours into seven classes; but I do not consider the classification to be of great importance, nor one mode of arrangement much better than another, for the pur- poses of practice, provided proper definitions be given, and plain rules delivered, applicable to the different cases. The classes which I propose to explain are, Class I. Natural Labour; which I define to be labour taking place at the end of the ninth month of pregnancy; the child presenting the vertex, and the forehead being di- rected at first toward the saero-iliac symphysis; a due proportion existing betwixt the size of the head, and the capacity of the pelvis; the pains being regular and effective; the process not continuing beyond twenty- four hours, seldom above twelve, and very often not for six. No morbid affection supervening, capable of pre- venting delivery, or endangering the life of the woman. This comprehends only one order.(u) («) Our author might, perhaps with propriety, have divided this class in. to two orders, viz. Order 1. The posterior fontanelle of the child presenting towards the left acetabulum, and the anterior fontanelle, or forehead, towards the right saero-iliac symphysis. This is by far the most common presentation. 281 Class II. Premature labour, or labour taking place consider- ably before the completion of the usual period of utero- gestation, but yet not so early as necessarily to prevent the child from surviving. This comprehends only one order. Order 2. The posterior fontanelle presenting towards the right aceta- bulum, and the anterior fontanelle, or forehead, towards the left sacro- iliac symphysis. This position or presentation, according to Baude- , locque, occurs but in the proportion of 1 to 7 or 8 of the first. In an accurate register kept by Baudelocque, it appears, that of 12,183 presentations of the head, 10,003 were of the first position, or with the pos- terior fontanelle towards the left acetabulum, and 2,113 in the second posi- tion, or with the posterior fontanelle towards the right acetabulum. Classification and systematic arrangements generally, are most frequently purely artificial and arbitrary ; and that of our author's as laid down above, is not such as we can cordially approve, but as his division of the subject in the following sections is founded upon it, we have not deemed it proper to propose any essential alteration. The great and deserved celebrity of Bau- delocque as a practical writer, seems, notwithstanding, to demand that we should here briefly state his division of the presentations of the vertex, which he considers as natural. There are then, according to him, six positions in which the vertex pre- sents at the superior strait, viz. 1. The posterior fontanelle is situated behind the left acetabulum, and the anterior before the right saero-iliac symphysis. 2. The posterior/bntane/Ze is situated behind the right acetabulum, and the anterior before the left saero-iliac symphysis. 3. The posterior fontanelle answers to the symphysis of the pubis, the ante- rior to the sacrum. 4. The anterior fontanelle answers to the left acetabulum, and the posterior to the right saero-iliac symphysis. 5. The anterior fontanelle is situated behind the right acetabulum, and the posterior before the left saero-iliac symphysis. 6. The anterior^ntane/Ze is behind the symphysis of the pubis, and the pos- terior before the sacrum. The more frequent occurrence of the 1st and 2d than of the 4th and 5th is calculated to be in the proportion of 80 or 100 to 1. The 3d and 6th presen- tations are extremely rare, and indeed may be almost considered as preter- natural, or pre-supposing some deformity of the pelvis or foetal head. It will be observed, that in the arrangement of our author, the first and second positions of the vertex only, are admitted into the class of natural la- bour, whilst the third, fourth, fifth and sixth positions of Baudelocque, ar« thrown into the class of preternatural labours under order 5. Malposition of the head. 2 justed, it is next to be inquired, how the retention is to be prevented, and, if not prevented, how the placenta is to be extracted. With regard to the first question, it may be an- swered, that the placenta will be less apt to be retained, if the expulsion of the child he conducted slowly, and the uterus made to contract fully upon it. As to the mode of extracting the placenta, we can be at no loss, if we recollect that the expulsion is accomplished by the contraction of the uterus. Our object, then, is to excite this when the placenta is re- tained, in consequence of the womb not acting strongly. The hand is to be slid slowly and cautiously into the uterus, which is often sufficient to make it contract; but if it do not, the hand is to be moved a little, or pressed gently on the pla- centa, at the same time that we pull very slightly by the cord, or lay hold of the detached placenta with our hand, and with caution extract it slowly. This requires no exertion, for the uterus is pressing it down, and, if any force be used, we do harm. Attempts to bring away the placenta, by pulling strongly at the cord, whether the hand be introduced into the uterus or not, are always improper. If persisted in, they * Or separation of the funis- 312 generally end, either in the laceration of the cord, or the in- version of the uterus. There arc two circumstances, however, under which the placenta may be retained, which require some modification of the practice. The first is, when the placenta is retained by spasm. In this case, when the hand is conducted along the cord through the os uteri, the placenta is not perceived, but it is led by the cord to a stricture, like a second, but contract- ed os uteri, beyond which the placenta is lodged. This con- traction must he overcome before the placenta can be brought away, which may be accomplished by gradual and continued attempts to introduce one, two, or more fingers through it; and these, if cautiously made, arc perfectly safe. It will, however, be observed, that the uterus at short intervals con- tracts, which is accompanied with pain; but this contraction is confined to the stricture alone, the cavity of the womb not being lessened by it, and during this state all attempts to di- late the aperture are hurtful. We must he satisfied with keeping the fingers in their place, to preserve the ground we have gained. Opiates have been proposed to remove this spasm, and render the introduction of the hand unnecessary; they seldom, however, succeed alone, but given in a full dose may make the manual attempt more easy. Sometimes the sudden application of a cloth, dipped in cold water, to the belly, has the same effect. The second circumstance to which I alluded is, adhesion of the placenta, which usually is only partial. This may occur with or without a change of struc- ture, but in general the structure is more or less altered, the adhering part being denser than usual, and sometimes almost like cartilage. The separation of the adhering portion should not be attempted hastily, nor by insinuating the finger be- tween it and the uterine surface. It is better to press on the surface of the placenta, so as thus to excite the uterine fibres to contract more briskly at the spot; or by gently rub- bing, or, as it were, pinching up the placenta between the fingers and thumb, it may be separated. If, however, the adhesion of the part of the placenta be very intimate, we must not, in order to destroy it, scrape and irritate the sur- 313 face of the uterus, but ought rather to remove all that does not adhere intimately, leaving the rest to be separated by nature1. But in taking this step, we are not to proceed with impatience, nor to attempt to bring away the non-adhering portion, until a considerable time has elapsed, and cautious efforts have been made to remove the entire placenta; thus satisfying ourselves of the existence of an obstinate and inti- mate union. Cases, where this conduct is necessary, are very rare, and when they do occur, there is usually an indu- ration of the adhering part. It is generally thrown off in a putrid state in forty eight hours. Sometimes the placenta ad- heres when it is unusually tender and soft, and then we must, with peculiar care, avoid hasty efforts, by which the placenta would be lacerated, and part left behind, which would be hurtful afterwards; whereas by a little more patience, and gentle pressure on the surface of the placenta, the uterus might have been excited to throw the whole off. CHAP. III. Of Premature Labour. When a woman bears, a child in any of the three last months of pregnancy, she is said to have a premature labour; and this process forms a medium between abortion and na- tural labour. In some cases, the uterus is fully developed before the usual term of gestation, and then contraction commences; but, in a great majority of instances, premature labour pro- ceeds from accidental causes, exciting the expulsive action of the uterus, before the cervix and os uteri have gone through their regular changes. The cervix must, therefore, be expanded by muscular action, before the os uteri can be properly dilated; and this preparatory stage is generally marked by irregular pains, and not unfrequently by a fever- ish state, preceded by shivering. A feeling of slackness about the belly, with different anomalous sensations, often accom- pany this stage of premature labour. When the cervix is ex* % s JH panded, then the os uteri begins to dilate, and this part of the process is often more tedious than the same period of na- tural labour, and generally as painful. It is also frequently attended with a bearing-down sensation. The second stage of labour is usually expeditious, owing to the small size of the child. The decidua being thicker than at the full time, the protrusion of the membranes is attended with more san- guineous discharge; and if the woman move much, or exert herself, considerable hemorrhage may take place. The third stage is likewise slow, for the placenta is not soon thrown off. In the last place, spasmodic contraction of the uterus is more apt to take place in all the stages of premature than of natu- ral labour. A variety of causes may excite the action of the uterus prematurely, such as distention from too much water; or the death of the child, which is indicated by shivering, subsidence of the breasts, cessation of motion, and of the symptoms of pregnancy; or the artificial evacuation of the liquor amnii; or violent muscular exertion; or drugs acting strongly on the stomach and bowels; or passions of the mind; or acute diseases; or rigidity of the uterine fibres. Certain general conditions of the system render the operation of these causes more easy, such as plethora, debility, and great irri- tability. A tendency to premature labour is to be prevented by the means pointed out when treating of abortion. I have only to add, that when the abdomen is tense and hard, or painful, in- dicating a rigidity of the uterine fibres, or of the abdominal muscles, tepid fomentations, gentle laxatives, and repeated small bleedings, are useful. When a woman is threatened with premature labour, we ought, unless there be very decided marks of the death of the child, to endeavour to check the process, which is done by exhibiting an opiate, keeping the patient cool and tranquil, and removing any irritation which may exist. If she be ple- thoric, or the pulse be throbbing, blood is to be detracted. When labour is established, it is to be conducted much in the same way with parturition at the full time; but the fol- lowing observations will not be improper. The patient must 315 avoid much motion, lest hemorrhage be excited. Frequent examination and every irritation are hurtful, by retarding the process, and tending to produce spasmodic contraction. If this contraction take place, marked by paroxysms of pain referred to the belly or pubis, little or no effect being pro- duced on the os uteri, a full dose of tincture of opium should be given, after the administration of a clyster. Severe pains, with premature efforts to bear down, and a rigid state of the os uteri, require venesection, and afterwards an opiate. The delivery of the child is to be retarded, rather than accelerat- ed in the last stage, that the uterus may contract on the pla- centa. This is farther assisted, by rubbing gently the uterine region after delivery. If the placenta be long retained, or he- morrhage come on, the hand is to be gently introduced into the uterus, and pressed on the placenta, to excite the fibres to throw it off. We should not rashly attempt to remove it, for we are apt to tear it; neither arc we to pull the cord, for it is easily broken. In those cases where premature labour is connected with redundance of liquor amnii, I think it useful to introduce the hand immediately on the delivery of the child, for I have observed, that the placenta is apt to be re- tained by irregular contraction. We do not instantly extract the placenta, but it is desirable to get the hand in contact with it before the circular fibres contract. CHAP. IV. Of Preternatural Labour. Various signs have been enumerated, by which it was supposed, that malposition of the child might be discovered antecedent to labour. An unusual shape of the abdomen; some peculiar feeling, of which the mother is conscious, and which she has not felt in any former pregnancy; greater pain or numbness in one leg than in the other; a sensation of the child rising suddenly towards the stomach; have all been mentioned as indicating this, but are all, even when taken collectively, uncertain tokens. We cannot determine the pre- 316 mentation, until labour has begun. In a great majority of in- stances, the head, during the end of gestation, may be felt resting on the cervix uteri, but, in repeated instances, I have not been able to distinguish it in a pregnancy which ended in natural labour. Sometimes, in consequence of a fall, or other causes, the head seems to recede, but afterwards re- turns to its proper position. When labour begins, wc may generally distinguish the head by its proper character; but, if it lie high, and especially if the pelvis be deformed; wo may not find it always easy to ascertain tho presentation at a very early period. In such cases, it is of great consequence to preserve the membranes entire. When the head does not present, the presentation is generally more distant, and lon- ger of being distinctly ascertained*, the lower part of the uterus is more conical, and the tumor formed by the cranium cannot be felt through the membranes or cervix uteri: when the finger touches the part through the membranes, it very easily recedes, or seems to rise up. If the child lie more or less across the uterus, the os uteri is generally long of being fully dilated, the membranes protrude like a gut, and some- times, during the pains, the woman complains of a remark- able pushing against the sides. The pains are severe, but in cross presentations, she is sensible that they are not advanc- ing the labour, It is a fact well ascertained, that although the head have been felt distinctly in the commencement of labour, yet, when the membranes break, it may be exchanged for the shoulderf, or some other part. On this account, as well as for other reasons, it is always proper to examine immedi- ately after the membranes have given way, * When the presentation is long of being felt, we have been advised to examine the woman in a kneeling posture, or even to introduce the hand in- to the vagina, and rupture the membranes. The last advice is sometimes useful, as it enables us, if the presentation require it, to turn the child at a time when it can be easily done. But this is not to be hastily practised, nor adopted till the os uteri be well dilated. 11 have been informed of a case, where the shoulder was exchanged for the head, and Joerg seems to have met with the same circumstance. Hist, Partus, p. 90. 317 ORDER 1. PRESENTATION OF THE BREECH. The breech is distinguished by its size and fleshy feel, by the tuberosity of the ischia, the shape of the ilium, the sul- cus between the thighs, the parts of generation, and by the discharge of meconium, which very often takes place in the progress of labour*. After the breech has descended some way into the pelvis, the integuments may become tense or swelled, so as to make it resemble the head. Before the mem- branes burst, the presentation is very mobile, and bounds up readily from the finger. Many have advised, that when the breech presented, the feet should be brought down first; but the established prac- tice now is, when the pelvis is Veil formed, and other circum- stances do not require speedy delivery, to allow the breech to be expelled without any interference, until it has passed the external parts. The breech, and consequently the body of the child, may vary in its position with regard to the mother ;(&) but there are chiefly two situations requiring our attention, because • A discharge of liquor amnii, apparently coloured with meconium is no proof that the breech presents, neither is it a sign that the child is dead. (6) Baudelocque has divided the presentations of the breech into four posi- tions. In the 1st. The child's back is towards the mother's left side, and a little forward. But in proportion as it descends, its greatest breadth becomes parallel to the antero-posterior diameter of the inferior strait; the left hip placing itself un- der the pubes and the right before the sacrum. 2nd. The child's back is towards the right side of the uterus, and a little forward; the right hip placing itself under the arch of the pubes, the left.be- ing turned towards the sacrum. 3rd. The spine of the child's back is turned directly towards the umbilicus of the mother. Although it is allowed seldom to descend in this position. 4th. The spine of the child is towards the sacrum of the mother, and its, abdomen towards the anterior and middle part of the uterus of the mother. As it descends, the breadth from one hip to the other becomes parallel to one, of the oblique diameters of the pelvis. These may, by many, be considered as in a great measure, divisions with- out a difference; but as the authority from whence they originate is so re- spectable, we thought it best to give them a place. 318 the rest arc ultimately reduced to these. First, where the thighs of the child arc directed to the saero-iliac junction of the pelvis; and secondly, where they are directed to the ace- tabulum. In either of these cases, delivery goes on with equal ease, until the head comes to pass. Then, if the thighs have been directed to the fore part of the pelvis, the face will also be turned toward the pubis, and cannot clear its arch so easily as the vertex. When the thighs are directed to the back part of the pel- vis, we find that the process of delivery is as follows: The breech generally descends obliquely, one tuberosity being lower than the other. The lowest one follows the same turns as the vertex does in natural labour, and observes the same relation to the axis of the brim and outlet of tire pelvis. The breech is expelled with one side to the symphysis of the pu- bis, and the other to the coccyx; and after the presenting tu- berosity protrudes under the arch of the pubis, the other clears the perinseum, like the face, in natural labour. Whilst the breech is protruding, it gradually turns a little round, so that the shoulders of the child come to pass the brim dia- gonally, the diameter from the acetabulum to the saero-iliac junction being the greatest. The breech being delivered, a continuance of the pains pushes it gradually away, in the di- rection of the axis of the outlet, until the legs come so low as to clear the vagina. When this takes place, the head is gene- rally passing the brim obliquely, the face being turned toward the saero-iliac junction; and most frequently the arms pass along with it, being laid over the ears. They then slip down into the vagina, by the action of the uterus, and the head alone enters the cavity of the pelvis. The face turns into the hollow of the sacrum, and the chin tends toward the breast of the child. Then it clears the perinseum, which slips over the face, and the vertex comes last of all from under the pu- bis. If, however, the chin be folded down on the breast be- fore the head has descended into the pelvis, then, from the unfavourable way in which it enters the brim, there may be some difficulty to the passage, for it in some respects resem- bles a presentation of the face. The hand should be intro- 319 duced, and the face pressed up. In one case, Dr. Smellie found so much difficulty, that he applied the crotchet on the clavicle. Now the management of this labour is very simple. Whilst the breech is coming forth, the perinseum is to be supported, and nothing more is to be done till the knees are so low as to be on a line with the fourchette. If they do not naturally bend, and the feet slip out, the finger of one hand is to be employed to bend the leg gently, and bring down the foot; the knee, in this process, pressing obliquely on the abdomen of the child. But whether the legs be expelled naturally, or be brought down, we must carefully protect the perinseum, lest it should be torn by a sudden stroke of the leg in passing. Next, the cord is to be pulled gently down a little, to make the circulation more free. Thirdly, we attend to the arms; if these do not descend by the natural efforts, we introduce a" finger, and gently bring down first one, and then the other, using no force, lest the bone should break. The perinseum is also to be guarded, to prevent a slap of the arm from injuring it. Fourthly, if the head do not directly turn down, the fin- ger is to be carried up, and placed upon the chin or in the mouth, in order gently to depress it toward the breast, and this is generally sufficient. To guard the perinseum, the hand must be applied on it, and the body of the child moved near the thighs of the mother, that the vertex may more readily rise behind the pubis, whilst the face is passing. If the body be, on the contrary, removed farther from the mother, and nearer the operator, the head can neither pass so easily into the pelvis, nor out from the vagina. In a natural labour, after the head is expelled, the whole body should be allowed to he slowly born by the efforts of the womb alone. But in breech cases, should the process, after the breech is expelled, be slow, the delivery of the body and head must by the means I have related, be accelerated, lest the umbilical cord suffer fatal compression. The first symptom of danger is a convul- sive jerk of the body, and, if the head be not speedily brought down, the child will be lost. Should delay inevitably arise, we must try to bring the cord to the widest part of the pelvis. 320 But even although all pressure could be removed, the child cannot live long, if it be not delivered, as the function of the placenta is soon destroyed, that organ being often entirely de- tached from the womb, following the head whenever it is born. When the thighs, in breech cases, are directed to the pu- bis or acetabulum, then the face cannot turn in to the hollow of the sacrum. It rests for some time on the pubis, and it comes out with difficulty upon the arch; for in breech and footling cases, the face is generally born before the vertex. In order to prevent this difficulty, it will, as soon as the breech is expelled and the feet are delivered, be proper to grasp the breech, and slowly endeavour to turn the body round; but, should this not succeed, or not have been at- tempted till the shoulders have come down, and the head is about to pass the brim, the practice is dangerous, and the neck may be materially injured. It is, in this case, better to introduce a finger, and press with it on the head itself, en- deavouring thus to turn the chin, from the acetabulum to the saero-iliac junction of the same side. If the position be not rectified, then we assist the descent by depressing the chin, and gently bringing it under the pubis; and this may be fa- cilitated by pressing the vertex upward and backward, mak- ing it turn up on the curve of the sacrum, to favour the descent of the face. We must be careful of the perinseum. When the pelvis is contracted or deformed, it will be pru- dent, at an early stage of the labour, to bring down the feet. But if this have been neglected, then should the difficulty of delivery, or the length of time to which the labour is protract- ed, require it, we must insinuate a blunt hook, or a soft rib- band, over one of the groins, and thus extract the breech; or the forceps may with much advantage be applied. When the resistance is slight, the insinuation of the fingers over the groin, may sometimes enable us to use such extracting force, as at least excites the uterus more briskly to expel. Should the head not easily follow the body, we must not at- tempt to extract it by pulling forcibly at the shoulders, as 331 we may thus tear the neck, and leave the head in utero** The cord is, first of all, to be freed as much as possible from compression; then we gently depress the shoulders, in the direction of the axis of the brim, at the same time that we with a finger act upon the chin. Should this not succeed, we must apply the lever over the head, and depress in the pro- per direction. If this fail, the only resource is to open the cranium above or behind the ear, and fix a hook in the aper- ture ; but this is not to be done until we have fully tried other means, and by that time the child will be dead. When the breech presents, and parturition is tedious, the parts of generation are often swelled and livid. When the parts are merely turgid a little, and purple from congestion of venous blood, nothing is necessary to be done. But when inflammation takes place, it is more troublesome, for being of the low kind, it is apt to end in gangrene. Fomentations arc useful, but often spirituous applications succeed best. ORDER 2. OF THE INFERIOR EXTREMITIES. Presentation of the feet is known, by there being no round- ed tumour formed by the lower part of the uterus.(c) The • La Motte, Chapman, Smellie, and Perfect, give examples of the head being left in utero without the body, and the body without the head. There are ehiefly two sources of danger, the first and most immediate, is uterine hemorrhage ; the second is the consequence of putrefaction, which produces sickness, nausea, fever, and great debility. The head may be extracted, by fixing a finger in the mouth, or by the crotchet, with or without perforation, (c) Baudelocque distinguishes four principal positions of the feet, to which he considers all the rest may be referred. Of these four positions he consti- tutes as many species of labour. In the 1st Position, the heels answer to the left side of the pelvis, and a little forward; the toes to the right side, and backward, nearly opposite the sacro- iliac symphysis. Above that symphysis are placed the breast and face: while the back is situated under the anterior and left lateral part of the uterus. In the 2nd position, the heels are towards the right side of the/*/«/*. and the toes to the left and a little backward. The trunk and head are so situated, that the breast and face answer to that part of the uterus which is over the left saero-iliac symphysis, and the back to the anterior and right lateral part of that vucu). as 323 membranes also protrude in a more elongated form than when the head or breech present. The presenting part, when touched during the remission of the pain, is felt to be small, and affords no resistance to the finger. When the membranes break, we may discover the shape of the toes and heel, and the articulation at the ankle. Sometimes both the feet and the breech present. Two circumstances contribute to an easy delivery: first, that the toes be turned toward the sa- ero-iliac junction of the mother; and secondly, that both feet come down together. The best practice is, to avoid rupturing the membranes till the os uteri be sufficiently dilated; then we grasp both feet, and bring them into the vagina; or, if both present together at the os uteri, we may allow them to come down unassisted". In either case, we do not accelerate the delivery till the cord is in a situation to suffer from pres- sure, that is, till the knees are fully protruded, and the thick part of the thighs, near the breech, can be felt; then, if the face be towards the belly of the mother, we grasp the thighs, and gently turn the body round. The management is the same as in breech cases. There is little danger of the feet of two different children being brought down together, as twins are included in separate membranes. But as the case is possible, it is proper to attend that the feet be right and left. Sometimes a knee and foot, or the knees alone, present ;(ssa, while the side and the hip are over the right; so that the back is placed transversely under the anterior part of the uterus when it is the right shoulder, and on the posterior part of that viscus, when it is the left The child is also placed transversely in the fourth position of the shoulder, butthehead lies in the right iliac fossa, and the lower part of the trunk over the left; the breast is under the anterior part of the utcru* when it is the right shoulder, and over the sacrum when it is the left 3*4 the tuberosity of the ischium, and the general shape of the back parts of the pelvis, contribute with certainty to ascer- tain the nature of the case. The hand and arm may present under different circum- stances. The original presentation may have been that of the shoulder, but the arm may have, in the course of the la- bour been expelled; or the hand may rest on the os uteri, before the membranes have broken; or the fore arm may, for a length of time, lie across the os uteri, the hand not be- ing protruded for some hours. Sometimes both hands arc felt at the os uteri, and even both arms may be expelled into the vagina; but in most cases this does not happen, unless an improper conduct be pursued. In some rare instances, the hands of twins have been found presenting together, both sets of membranes having given way: it is more common to find both the hands and feet of the same child presenting; and this, next to the presentation of the feet alone, is the easiest case to manage*. It is not uncommon, in this case, to find the cord presenting at the same time, and then, by delay, the child may be lost. In most cases where the superior extremities present, the feet of the child are found in the fore part of the uterus, to- ward the navel of the mother. But their situation may be known, by examining the presentation. If we feel the shoul- der, we know, that if the scapula be felt toward the sacrum, the feet will be found toward the belly. If the arm be pro- truded into the vagina, the palm of the hand is found in pro- nation, directed toward the side where the feet lie. It is easy to know which hand presents. If we examine with the right hand, we shall find, that if the palm of the child's hand be taken into ours in a state of pronation, the thumb of the right hand, or the little finger of the left hand, will correspond to our thumb. In these preternatural presentations, the ancients were acquainted with the practice of turning, and delivering the * If the uterus be firmly contracted, the liquor amnii having been all eva- cuated, it may sometimes be necessary to carry the hand up to the knees, to change the situation. 325 child by the feet. But their remarks on this subject formed no general rule of conduct; on the contrary, practitioners were almost invariably in the habit of endeavouring to re- move the presentation, and to bring the head to the os uteri. Par.; was among the first who advised turning as a general practice; but even his pupil Guillimeau disregarded the rule, and left it to Mauriceau to enforce it, both by reasoning and practice*. We should be careful not to rupture the membranes pre- maturely; and more effectually to preserve them entire, we must prevent exertion, or much motion on the part of the mo- ther. As soon as the os uteri is soft, and easily dilatable, the hand should be introduced slowly into the vagina, the os uteri gently dilated, and the membranes ruptured. The hand is then to be immediately carried into the uterus, and upwards until the feet are found. Both(/) feet arc to bo grasped betwixt our fingers, ami brought down into the va- gina, taking care that the toes are turned to the back of the mother. The remaining steps have been already described. This operation is not very painful to the mother; it is easily accomplished by the accoueheur, and it is not more hazard- ous to the child than an original presentation of the feet. But it is necessary, in order to render this assertion correct, that the operation be undertaken before the liquor amnii be evacuated; and it is of importance to fix upon a proper time. We are not to attempt the introduction of the hand whilst the os uteri is hard and undilated; this is an axiom in prac- tice ; on the other hand, we are not to delay until the os uteri be dilated so much, as to be apparently sufficient for the pas- * Mauriceau justly observes, that although, after much fatigue, the head can be brought to the os uteri, the woman may not have strength to finish the*delivery.—In a case mentioned by Dr. Smellie, the patient died of flood- ing.—Joerg still admits the propriety of bringing the head, when it is nearer than the feet, to the os uteri, or the foetus is so placed, that the feet cannot without difficulty and danger be brought down. (/) It is not absolutely necessary that both feet should be found and grasped, in the first instance ; it will be sufficient to find and bring down one, if both cannot be easily reached, the second foot, with proper man« agement, (to be hereafter directed) will soon follow. 326 sage of a bulky body. In the cases now under consideration, the os uteri does not dilate so regularly, and to so great a degree, before the membranes break, as when the head pre- sents. If we wait in this expectation, the membranes will give way before we are aware. If the os uteri be dilated to the size of half a crown, thin and lax, the delivery ought not to be delayed, for every pain endangers the rupture of the membranes. If they do give way, we are immediately to in- troduce the hand, and will still find the operation easy, for the whole of the water is not discharged at once, nor does the uterus immediately embrace the child closely. If the liquor amnii have been discharged in considerable quantity previous to labour, or if the membranes have burst at the commence- ment of it, when the os uteri is firm and small, we must by a recumbent posture, try still to preserve a portion of the waters, till the orifice will permit delivery- The introduc- tion of the hand into the vagina and os uteri may be render- ed easier, and less painful, by previously dipping it in oil or lintseed tea, or any other lubricating substance. But if the water has been long evacuated, then the fibres of the uterus contract strongly on the child, the presentation is forced firmly down, and the whole body is compressed so much, that the circulation in the cord frequently is impeded, and, if the labour be protracted, the child may be killed. This is a very troublesome case, and requires great caution. If the pains be frequent, and the contraction strong, then all attempts to introduce the hand, and turn the child, must not only produce great agony, but, if obstinately persisted in, may tear the uterus from the vagina, or lacerate its cervix or body. After a delay of some hours, however, the uterus may be less violent in its action, or by medical aid, the pains may be suspended. Copious blood-letting, certainly, has a power in many cases of rendering turning easy, but it im- pairs the strength, and often retards the recovery. If the patient be restless and feverish, it may, to a certain extent, be necessary and proper; but if not, we shall generally suc- ceed, by giving a powerful dose of tincture of opium, not less than sixty or eighty drops. Previous to this, the bladder is 387 to be emptied, lest it should be ruptured during the opera- tion ; and, if necessary, a clyster is to be administered. The patient is then to be left, if possible, to rest. Sometimes in half an hour, but almost always within two hours after the anodyne has been taken, the pains become so far suspended, as to render the operation safe, and perhaps easy. Our first object is, to get the hand into the uterus; and for this pur- pose, we must raise up the shoulder a little, working the fin- gers past it, by slowT, cautious, but steady efforts. The cervix often contracts spasmodically round the presentation, and is the chief obstacle to the delivery, but the opiate generally allays this*. Sometimes our efforts renew the pains, which, although they may not prevent the operation, make it more painful, and cramp and benumb the hand. Having passed the hand beyond the cervix, we carry it on betwixt the body of the child and the surface of the uterus, which is felt hard and smooth, from the tonic or permanent action of the fibres, until we reach the feet, both of which, if possible, we seize and bring down; but if we cannot easily find both, one is to be brought down into the vagina, and retained there.(g) The child will be born, with the other folded up on the belly. In bringing down the feet, as well as in carrying up the hand, we must not act during a pain, but should keep the hand flat on the child; a contrary practice is very apt to lacerate the uterus. Before introducing the hand, we must ascertain, by examining the presentation, which way the feet lie, that we may proceed directly to the proper place. We must also con- sider, whether we shall succeed best with the right or the left hand. If the right shoulder or arm present, some have made it a rule to deliver with the left hand, others with the right; but much must depend on the dexterity of the opera- tor, and the position of the woman. The most common posi- tion is the same as in natural labour. Sometimes we may find it useful to make the woman lie forward on the side of • The spasm may yield rather suddenly to the hand, as if rupture of the fibres had taken place. I was informed of one case of this kind, but the womb was entire, and no bad symptoms came on. (g) By means of a noose applied round the ankle. 328 the bed, with her feet on the ground, and to place ourselves behind her. When the hand and arm have been protruded, and the shoulder forced down in the vagina, it has been the practice with many, before attempting to turn, to return the arm again within the uterus; and when this was impracticable, it has been torn(A) or cut off, especially if the child was supposed to be dead. Others advise, that we should not attempt to re- duce the arm; nay, even that we should, in difficult cases. facilitate the operation, by bringing down the other arm, in order to change, to a certain degree, the position of the child. So far from it being necessary to replace the arm, we shall sometimes find advantage from taking hold of it with one hand, whilst we introduce the other along it; as the parts are thus a little stretched, and it serves as a director by which we slip into the uterus. By the means pointed out, and by a steady, patient con- duct, we may, in almost every instance, succeed in delivering the child. But it must be acknowledged, that in some cases. from neglect or mismanagement, the woman is brought into great danger, or may even be allowed to die undelivered. This catastrophe proceeds sometimes from mere exhaustion. or from inflammation, but oftener, I apprehend, from rupture of the uterus; or in a neglected case, so much irritation may be given to the system, as well as to the parts concerned in parturition, that although the delivery be easily accomplish- ed, the woman does not recover, but dies, either from pul- monic or abdominal inflammation, or fever, or flooding. More- over, such tedious cases generally end unfavourably for the child. When turning has not been practicable, if the child was supposed to be alive, the os uteri has been cut, or the csesa- (o) We would strenuously dissuade from unnecessarily mutilating the foetus, even under the supposition of its death. We have known the child born with symptoms of life, even after the head has been opened, and the greatest portion of the brain evacuated, and born alive, after its death had been considered as certainly ascertained. It can seldom, if ever, be neces- sary to take off the arm to facilitate the operation of turning. 329 rian operation has been proposed and practised*. If dead, it has been extracted, by pulling down the breech with a crotchet-} 5 and sometimes, in order to assist delivery, the body has been mutilated}, or the head opened with the per- forator. When the child has been small or premature, it has hap- pened that the arm and shoulder have been forced out of the vagina, and then, by pulling the arm, the delivery has been accomplished^. In a greater number of instances, a sponta- neous turning of the child has taken place, and the breech has been expelled first. The action of the uterus is exerted in the direction of its long axis, and therefore tends to push its contents through the os uteri. The child forms an ellipse ? and either in natural labour, or presentation of the breech, the long axis of the ellipse corresponds to the long axis of the uterus. But in a shoulder presentation, the axis of the ellipse lies obliquely with regard to that of the uterus, or to the di- rection of the force; and therefore the continued action of the uterus may tend, by operating on the side of the ellipse, to depress the upper end, and in the same proportion elevate the shoulder, the child moving like the beam of a pair of scales. Dr. J. Hamilton justly observes, that the evolution can only take place when the action of the uterus cannot be exerted on the presenting part, or where that part is so shaped that it cannot be wedged in the pelvis. This occur- rence was first of all noticed, I believe, by Schoenheider**; * Vide Memoir by M. Baudelocque, in Recueil Period. Tome V. table I. cases 5 and 15. t Peu, in one case where both arms were protruded, applied a fillet over the breech to bring it down. Pratique, p. 412.—Smellie, in 1722 brought down the breech with the crotchet. Col. 35. case 3.—Giffard did the same in 1725. Case 3. } Vide Perfect, Vol. I. p. 351.—Dr. J. Hamilton's Cases, p. 104. He found ?t necessary to separate three of the vertebr*.—Dr. Clarke twisted off the arm, and perforated the thorax freely. At the end of 36 hours the fetus was expelled double. Med. and Phys. Jour. Vol. VII. p. 394. f Giffard, case ill; and Baudelocque l'Art, &. 1530, in a note.—In Mr. Gardiner's case, the head followed the shoulders. Med. Comment. V. 307- •* Acta. Hj*n. Tom. JI. art. xxiii. 2 T 330 but Dr. Deinnan* was the first who, in this country, call- ed the attention of practitioners to it. He collected no less than thirty cases, but in these only one child was born alive. It does not appear that the child being large, is an obstacle to the deli very f. A knowledge of this fact does not exonerate us from making attempts to turn; for although a consider- able number of cases are recorded where it has taken place, yet these are few in proportion to the number of presenta- tions of the shoulder. In this city, whicb contains not less than 90,000 inhabitants, I cannot learn that more than one case of spontaneous evolution has taken place, though some women have either died undelivered, or have not been deli- vered until it was too late to save them4 Sometimes the arm presents along with the head, and this can only render delivery tedious or difficult, by encroaching on the dimensions of the pelvis. This case does not require turning; but if we can, we should return the arm beyond the head; if wc cannot, we may succeed in bringing it to a place where it will not interfere much with the passage of the head. Sometimes the head is placed pretty high, being re- tained by a spasmodic contraction of a band of fibres round it, and the arm is the only presentation which can be felt, until the hand be introduced. Opiates, in this ease, may be of service. Wc must never attempt by force to destroy the * Lond. Med. Jour. Vol. V. p. 64.—See also case by Mr. Outnwait, in New Lond. Med. Jour. Vol. II. p. 172.—Mr. Simmons Med. Facts and Obs. Vol., I. p. 76.—-Perfect's cases, 11.367—Med. and Phys. Journ. Vol. III. p. 5. f Mr. Hey's case, in Lond. Med. Jour. Vol. V. p. 305. \ Delivery by spontaneous evolution is a very rare occurrence. But that it occasionally happens is proved beyond suspicion by the cases recorded by Dr. Denman and other respectable practitioners. Considering the difficulty and even danger often incident to turning, it is certainly important to know how to distinguish those particular cases in which this curious resource of nature will probably be successfully exerted* To warrant such an expectation, it must clearly appear that the uterine action, instead of operating on the presenting part, fixing it more closely in the pelvis, has the contrary effect of displacing it, and gradually bringing it out of the pelvis. But, if we are con- vinced after a careful examination that there is no tendency to spontaneous evolution, we should proceed to turn the child, as in proportion to the delay of fhe operation is commonly the haeaijd attending it. C 331 stricture, in order either to return the armor bringdown the head. Occasionally both a hand and the feet have been found presenting with the head, or the feet and head present. In such cases, wc can, if necessary, bring down the feet alto- gether, and this is in general proper. Besides these presentations, we may meet with the back part of the neck, and the upper part of the shoulder; or the nape of the neck alone; or the throat.(i) These, which are very rare, require turning. They arc recognised by their relation to the head and shoulders. OROER 4. OF THE TRUNK. The hips, hack, belly, breast, or sides, may, though very rarely, present, the child lying more or less transversely.(fc) The hip is sometimes, taken for the head*, but is to be dis- tinguished by the shape and relations of the ilium. In all the other cases, the presentation remains long high; but when the finger can reach it, the precise part may be ascertained, by one who is accustomed to feel the body of a child. If the child lie transversely, it may remain long in the same posi- tion, and the woman may die if it be not turned. But if, as is more frequently the case, it be placed more or less obliquely, then, if the pains continue effective and regular, either the breech or the shoulder will be brought to the os uteri, accord- ing as the original position favoured the descent of one or other end of the ellipse formed by the child. In these presenr tations, the hand should be introduced, to find the feet, by which the child is to be delivered. But, this rule is not abso- lute with regard to the presentation of the hip, which only renders labour tedious. (/) Of each of these, Baudelocque has constituted four varieties of present tations, for a synopsis of which we must refer to the table, which the reader will find at the end of this volume. (£) Of each of these presentations there are also, according to Baude- locque, four varieties; for an enumeration of which, the reader is referred to the close of this volume. • La Motte was of opinion, that no part resembled the head more than the hip. Vide obs. 283 and 284. 332 0RHER 5. OF THE FACE, &C. The child may present the head, and yet it may be impro- perly situated, and give rise to painful and tedious labour. 1st, The forehead, instead of the vertex, may be turned to the acetabulum.(J) In this case, the presentation is felt in the first stage high up, smooth and flatter than the vertex. In a little longer, we tdiscover the anterior fontanelle, and the situation of the sutures. By degrees, the head enters the cavity of the pelvis, the vertex being turned into the hollow of the sacrum; and by a continuance of the pains, the fore- head either turns up within the pubis, and the vertex passes Out over the perinseum; or the face gradually descends, and the chin clears the arch of the pubis, the vertex turning up within the perinseum toward the sacrum, till the face is born. The first is the usual process in this presentation; all the steps of the labour are tedious, and often, for a considerable period, the pains seem to prodqee no effect whatever. In the last stage, the perinseum is considerably distended, and it re- quires care and patience to prevent laceration. This presen- tation is difficult to be ascertained at an early stage, before the membranes burst; and sometimes the duration of the la* hour is attributed to weakness of the uterine action, and not to the position of tb ent did not know that I was doing more than making an ordi- nary examination. Some have advised, that we should keep up the forehead during a pain, to make the vertex descend; or that we should, with the finger, depress the occiput. The fontanelle, or crown of the head, may also present, although the face be turned to the saero-iliac junction. In this case it is felt early, and, by tracing the coronal suture, we may ascertain whether the frontal bones lie before or be- hind. It is a much more uncommon presentation than that noticed above. The labour is, at first, a little slower than in a natural presentation, but, by degrees, the head becomes more oblique, the vertex descending; and this maybe assist- ed, by supporting the forehead with the finger during a pain. Should any untoward accident require the delivery to be ac- celerated, wc have been advised to turn the child, and in do- ing so to use the left hand, if the occiput lie to the left aceta- bulum, and vice versa. But this operation can seldom be requisite. The crown of the head may also present with the face to the pubis or the sacrum, but these positions are extremely rare.(w) In time, the head will generally become more dia- gonal, and descend obliquely, but we ought not to trust to this. Wc should rectify the position, for it is by no means dif- recommended; it has often proved successful in his own practice. It will be found that this mode of proceeding was first inculcated by Baudelocque, from observing that nature herself sometimes obviated difficulties, and ac- celerated the termination of the labour, by converting the fourth position into the second, and the fifth into the first; or, in bringing the posterior fon- tanelle from the right or left saero-iliac symphysis, to the right or left aceta- bulum. Vide Art deg Accouchemens. (n) These constitute the third and the sixth positions of the vertex, ac- cording to Baudelocque. The comparative infrequency of their occurrency is illustrated in the table, appended to the chapter on the Classification of Labours. 334 fieult to move the head with the finger, if we attempt it early. We may even carry the forehead from the pubis to the socro-iliac junction. The process is still more simple when the occiput is turned to the pubis, if we perform it early. If, however, we neglect it, we find that in a few instances the head does not turn at all, but enters the pelvis in the origi- nal direction, and becomes wedged,(o) requiring the use of instruments. This is oftcnest the case when the occiput is turned to the pubis; for the forehead being broad, does not by a continuance of labour slip to the side of the promontory of the sacrum, so readily as the occiput would do. 2d, The side of the head may present. In this case, the presentation is long of being felt, but it is recognised by the car. If, however, it has been long pressed in the pelvis, it is extremely difficult to determine the case. It is very rare, and has even been deemed to be impossible. In some instan- ces the child has been turned, but it is most common to rec- tify the position of the head by introducing the hand. 3d, The occiput may present, the triangular part of the bone being felt at the os uteri. It is known by its shape, by the lambdoidal suture, and its vicinity to the neck. The fore- v head rests on some part of one of the psose muscles, and from this oblique position of the head, the labour is tedious. It has been proposed, in this case, to turn; but it is better, if we do any thing, to rectify the position of the head with the hand. Nature is, however, adequate to the delivery, even If not assisted,. Some advise, that the woman should, by a change of position, endeavour to remedy the obliquity, making the child incline, so as to affect the situation of the head, but this has not much power in altering the position of the presentation, at least after the water has been evacua- ted. 4th, The face may present, with the chin to one of the acetabula, or to the saero-iliac junction, or to the pubis or sacrum. The two first are the best, the second is more trou- (o) This by the Frensh writers is termed enclavement, and by the English, the locked head. 335 hlesoine, and the last is worst of all. When the faee presents, the labour is generally tedious ami painful, for it is little compressible, and affords a broad surface, not well calcu- lated to take the proper turns in the pelvis. The head, also, being thrown back on the neck, a larger body must pass, than when the chin is placed on the breast. By a continuance of the pains, the face becomes swelled; and although at first it was recognisable by the mouth and features, yet now it is indistinct, and has been taken either for a natural presenta- tion or the breech. By rude treatment, the skin may be torn; and even under the best management, the face, when born, is very unseemly, and sometimes quite black and elon- gated, so that it has been known to measure nearly seven inclies. This is especially the case when the chin is directed to the sacrum, and some children die from obstructed circu- lation, owing to the continued pressure on the jugular veins. Face presentations have been attributed sometimes to con- vulsive vomiting, cough, or frequent examination, but gene- rally no evident cause can be assigned ; and in the beginning of labour, the face itself does not present, but only the fore- head : hence La Motte tells us, that although at first he found the head present properly, yet, when the membranes broke, the face came down. Some have advised, that the child should be turned; others, that the chin should be raised up, to make the upper part of the face come down; or that if the head be advanced, a finger should be inserted into the mouth, to bring down the jaw un- der the pubis. Others leave the whole process to nature; but many endeavour with the hand to rectify the position. If the presentation be discovered early, tlie^re can be little doubt as to the propriety of rectifying the position, but if the labour be advanced, this is difficult; and then it only remains that we should endeavour, if the labour be severe and tedi- ous, to make the face descend obliquely, by cautiously but firmly supporting with a finger, during the pains, the chin or end which is highest, in order to favour the descent of the lowrer end. When the chin has advanced so far* as to come near the arch of the pubis, we way follow a different mv~ 336 thod, and gently depress it, which assists the delivery, for generally the chin is first evolved. If, however, the process go on regularly, and tolerably easy, we need not make these attempts. As the perinseum is much stretched, we must sup- port it, and avoid all hurry in the exit of the head. When the chin is directed to the sacrum, the labour is sometimes so tedious as to require the application of instru- ments . ORDER 6. OF THE UMBILICAL CORD. Sometimes the cord descends before, or along with the pre senting part of the child. This has no influence on the pro- cess of delivery, but it may have a fatal effect on the child; for, if the cord be strongly compressed, or compressed for a length of time, the child will die, as certainly as if respira- tion were interrupted after birth. If the cord be discovered presenting before the membranes burst, or if the os uteri be properly dilated when they burst, the best practice is to turn the child. It has indeed been proposed, to push the cord be- yond the presenting part, or hook it upon one of the limbs ; but if the hand is to be Introduced so far, it is better at once to turn the child. If the os uteri be not sufficiently relaxed, we must not use force to expand it; and little can be done, except by rest, to prevent as much as possible, the evacuation of the water. As soon as the os uteri will admit the introduction of the hand, the child should be turned if it can be easily done. But if the presentation be advanced before we are called, and turning he difficult, then we must endeavour to keep the cord slack, or remove it to that part of the pelvis where it is least apt to be compressed; or it will be still better, to endea- vour with two fingers to push the cord slowly past the head, and prevent it for two or three pains from coming down again.(p) This is less violent, and safer, than attempts to turn (/>)Mauriceau, in these cases, recommends returning the funis, and pushing a piece of soft linen after it, the end of which may remain hanging without. Dr. Mackenzie, a celebrated accoucheur of London, in a case where the funis presented, pulled down as much as he could, which he inclosed in a leathern 337 in an advanced stage of labour. Should this not be prac- ticable, and the pulsation suffer, or the circulation be endan- gered, we must accelerate labour by the lever or forceps. If the pulsation be stopped, and the child dead, when we ex- amine, then labour may be allowed to go on, without paying any attention to the cord. The sum of the practice then Is, that when the os uteri is not dilated, so as to permit of turning, we must not attempt it; when turning is prac- ticable, it is to be performed. When the head has descended into the pelvis, the cord is to be replaced, or secured as much as possible from pressure; but if the circulation be impeded, the woman must be encouraged to accelerate the labour by bearing down, or instruments must be employed. When the presentation is preternatural, these directions are likewise to be attended to, and the practice is also to be re- gulated by the general rules applicable to such labours. ORDER 7. PLURALITY OF CHILDREN AND MONSTERS. Various signs have been mentioned, whereby the pre- sence of a plurality of children in utero might be discovered, previous to their delivery. These are, an unusual size, or an unequal distension of the abdomen, an uncommon motion within the uterus, a very slow labour, or a second discharge of liquor amnii during parturition. These signs, however, are so completely fallacious, that no reliance can be placed upon them, nor can we generally determine the existence of twins, until the first child be born. Then by placing the hand on the abdomen, the uterus will be found large*, if it contain another child; and, by examination per vaginam, the second set of membranes, or some part of the child, will be found purse; and thus returned it, pushing them up together into the uterus; in this case the child was born alive. He afterwards pursued the same practice, and sometimes succeeded; and others have since followed his example. • In a case related by Mr. Aitken, the uterus was felt, after delivery, large and hard, as if it contained another child, but none was discovered. In the course of a fortnight the tumor gradually disappeared. Med-Comment. Vol. II. p. 300. 2 C 338 to present. This mode of inquiry is proper after every de- livery. Soon after the first child is born, pains usually come on, like those which throw off the placenta, hut more severe; and they have not the effect of expelling it, for it is generally retained till after the delivery of the second child. No inti- mation of the existence of another child is to be given to the mother, but the practitioner is quietly to make his examina- tion, rupture the membranes, if they have not given way, and ascertain the presentation. If it be such as require no alte- ration, he is to allow the labour to proceed according to the rules of art, and usually the expulsion is very speedily ac- complished. If the first child present the head, the second generally presents the breech or feet, and rice versa; but sometimes the first presents the arm, and, in that case, when we turn, we must be careful that the feet of the same child he brought down. This one being delivered, the hand is to be again introduced, to search for the feet of the second child, which arc to be brought into the vagina, but the delivery is not to be hurried. : It sometimes happens, that after the first child is born, the pains become suspended, and the second is not horn for se- veral hours. Now this is an unpleasant state, both for the patient and practitioner. She must discover that there i> something unusual about her, and he must be conscious that hemorrhage, or some other dangerous symptom, may super- vene. The first rule to be observed is, that the accoucheur is upon no account to leave his patient till she be delivered. The second regards the time for delivering. Some have ad- vised that the case be entirely left to the efforts of nature, whilst others recommend a speedy delivery. The safest prac- tice, perhaps, will lie between the two opinions. If effective pains do not come on in an hour, the child ought to be de- livered by turning. The forceps can seldom be required; for if the head have come so low as to admit of their application, the delivery most likely will be accomplished without assist- ance. 339 If, however, the position of the second child be such as to require turning, we arc to lose no time, but introduce the hand for that purpose, before the liquor amnii be evacuated, • or the uterus begin to act strongly on the child. Turning, in such circumstances, is generally easy. When the child presents the breech or feet, the directions formerly given, respecting these presentations, are to he attended to. In the event of hemorrhage, convulsions, or other danger- ous symptoms, supervening between the birth of the first and second child, the delivery must be accelerated, and man- aged upon general principles. When there are more children than two, the woman sel- dom goes to the full time, and the children survive only a short time. There is nothing peculiar in the management of such labours. It still remains to observe, that we ought to be peculiarly careful in conducting the expulsion of the placentse of twins. Owing to the distension of the uterus, and its continued ac- tion in expelling two children, there is a greater than usual risk of uterine hemorrhage taking place. The patient must be kept very quiet and cool, gentle pressure should be made with the hand externally on the womb, and no forcible at- tempts are to be permitted, for the extraction of the placen- tse, by pulling the cords. If hemorrhage come on, then the hand is to be introduced to excite the uterine action, and the two placentse are to he extracted together. The application of the bandage, and other subsequent arrangements must be conducted with caution, lest hemorrhage be excited. The placentse are often connected, and therefore they are naturally expelled together, but this adds nothing to the difficulty of the process. Sometimes they are separate, and the one is thrown off before the other; or it may even hap- pen, that the placenta of the first child is expelled before the second child be born, but this is very rare, and Is not de- sirable. Women, who have born a plurality of children, are more disposed than others to puerperal diseases, and must there- 340 fore be carefully watched. It rarely happens, that they are able to nurse both children without injury. It is possible for two children to adhere, or for one ehild to have some additional organ belonging to a second, as, for example, an arm or an head. Such cases of monstrosity may produce considerable difficulty in the delivery; and the ge- neral principle of conduct must be, that when the impedi- ment is very great, and does not yield to such force as can be safely exerted, by pulling that part which is protruded, a separation must be made, generally of that part which is protruded, and the child afterwards turned, if necessary. Unless the pelvis be greatly deformed, it will be practicable to deliver, even a double child, by means of perforation of the cavities, or such separation as may be expedient, and the use of the hand, forceps, or crotchets, according to circum- stances. A great degree of deformity may render the cesa- rean operation necessary. With respect to children who are monstrous from defici- ency of parts, I may take the present opportunity of obser- ving, that no difficulty can arise, during the delivery, except in ascertaining the presentation, if the malformation be to a great extent, as, for instance, in acephalous children. Ji TJLBLE of the various Presentations at the period of Parturition which indispensably require that the Child be turned and delivered by the Feet. [According to BAtiDEiocauu. o .-§ S IS °<~ ° t; oj « go ■ eels w -+j .s ° £3 to IV J positions, viz. Of which there are IV positions, viz. fist. J 2d. i 3d. , l4th. fist. J 2d. 13d. , Jjlth. fist. J 2d. i 3d. . 14th. fist. I 2d. I 3d. 4th. £ 0} «= O-O j= presenting at the Os Uteri. fcJG .S O OJ

, - The Neck and Head resting on the left Ilium; and the Abdomen on the right Ilium. The Neck and Head resting on the right Ilium; the Abdomen on the left. - - The Breast above the Pubes; the inferior Extremities above the Sacrum. The Breast above the Sacrum; the inferior Extremities above the Pubes. - The Breast resting on the left Ilium; the Thighs and Knees on the right Ilium. The Breast resting on the right Ilium; the Thighs and Knees on the left. The Knees above, or on one side of the projection of the Sacrum; the Abdomen above the Pubes; the Breast and Face to the anterior portion of the Uterus. The Knees over the anterior brim of the Pelvis; the .Breast and Face to the posterior portion of the? Uterus. $ The Knees to the concavity of the right Ilium; the Breast to the left Ilium. The Knees to the concavity of the left Ilium; the Breast to the right Ilium. The Occiput over the margin of the Pubes; the Back above the Sacrum. - - The Occiput on one side of the projection of the Sacrum; the Back above the Pubes. - The Occiput to the left Ilium; the Back to the right Ilium. - - - The Occiput to the right Ilium; the Back to the left Ilium. - - - - - - The back of the Neck over the margin of the Pubes; the Lumbar Region above the Sacrum. The Lumbar Region over the Pubes; the back of the Neck over the posterior margin of the Pelvis. The Occiput on the left Ilium; the Lumbar Region on the right Ilium. - - - - The Occiput on the right Ilium; the Lumbar Region on the left Ilium. <- - The Back above the Pubes; the Thighs above the Sacrum. The Thighs and Feet above the Pubes; the Back and Head towards the Sacrum. - The Back, on the left Ilium; the Thighs and Feet on the right Ilium. - « - The Back on the right Ilium; the Thighs and Feet on the left Ilium. - . - The Ear and angle of the lower Jaw to the Pubes; the Shoulder towards the Sacrum. The Face towards > the left side of the mother when the right side of the Neck presents, and vice versa. 5 The Ear and angle of the lower Jaw towards the Sacrum; the Shoulder towards the Pubes. The Face? towards the right side of the mother when the right side of the Neck presents, and vice versa. $ 4th. 1st. Of which there are IV < positions, viz Of which there are IV positions, viz. Of which there are IV positions, viz 2d. 3d. 4th. 1st. 2d. 1 3d. 4th. 1st. 2d. 3d. 4th. The side of the Head upon the left Ilium, and the Shoulder on the right Ilium. The Face towards the Sacrum when the right side of the Neck presents ; towards the Pubes when the Heft. } The side of the Head upon the right Ilium, and the Shoulder on the left Ilium. The Face towards the ? Pubes when the right side of the Neck presents; towards the Sacrum when the left. } The side of- the Neck on the Pubes, and the Side over the Sacrum. The Breast towards the left Ilium,") when the right Shoulder or Arm presents, and towards the right Ilium whjen the left Shoulder or t Arm presents. '! • J The side of the Neck over the Sacrum, and the Side over the Pubes. The Breast!towards the right Ilium when the right Shoulder presents, and vice versa. The Neck and Head on the left Ilium; the Side and Hip on the right Ilium. The Back to the fore part of the Uterus when the right Shoulder presents, and to the back part when the left presents. $ The Nefk and Head on the right Ilium; the Side and Hip on the left Ilium. The Breast to the fore parO of the Uterus when the right Shoulder and Arm presents, and vice versa. $ The Axilla over the Pubes; the Hip over the Sacrum. The Breast towards the left Ilium when the right > Side presents, and vice versa. $ The Axijla over the Sacrum; the Hip over the Pubes. The Breast towards the right Ilium when the right? Side presents, and vice versa. $ The Axilla on the left Ilium; the Hip on the right Ilium. The Breast towards the back part of the Uterus 5 when jthe right Side presents, and vice versa. ) The Axilla on the right Ilium; the Hip on the left Ilium. The Breast towards the fore part of the Uterus \ whenihe right Side presents, and vice versa. ) The Thikhs towards the Sacrum; the Spine of the Ilium towards the Pubes. ThejBreast towards the left ? side of the Uterus when the right Hip presents, and vice versa. , $ The Thighs towards the Pubes; the Spine of the Ilium towards the Sacrum. The Breast towards the right ? side of the Uterus when the right Hip presents, and vice versa. The ThiUs towards the right side; the Spine of the Ilium towards the left side. posterior part of the Uterus when the right Hip presents, and vice versa. The Thighs towards the left side; the Spine of the Ilium towards the right side anteriTr part of the Uterus when the right Hip presents, and vice versa. The Breast towards the ? The Breast towards the \ Either the right or left hand of the practitioner, indifferently, to be introduced to turn the Child. The right hand to be introduced when the Face is on the right side of the vertebral column, and vice versa. The left hand to be introduced to reach the Feet and turn the Child, &c. The right hand to be introduced, &c. &c. Either the right or left hand, indifferently, to be introduced. The right hand to be introduced when the face is on the right side of the vertebral column, and vice versa. The left hand to be introduced, &c. &c. The right hand to be introduced, &c. &c. The right or left hand may be introduced, indifferently, &c. The right or left hand, indifferently, may be introduced. The left hand to be introduced towards the right side of the Uterus. The right hand to be introduced towards the left side of the Uterus. The right or left hand, indifferently, may be introduced. The right or left hand, indifferently, may be introduced. The left hand to be introduced towards the right side of the Uterus. The right hand to be introduced towards the left side of the Uterus. Either the right or left hand, indifferently, to be introduced, &c. Either the right or left hand, indifferently, to be introduced. The light hand to be introduced towards the left side of the Uterus. The left hand to be introduced towards the right side of the Uterus. The right hand to be introduced towards the left side of the Uterus. The right hand, &c. &c. The right or left hand, indifferently, &c. &c. The right or left hand, indifferently, &c. &c. | The right hand to be introduced, &c. &c. The right hand, &c. &c. The left hand to be introduced towards the right Ilium. The right hand to be introduced towards the left Ilium. The right hand to be introduced when the right side of the Neck presents; the left hand when the left side, &c. The left hand to be introduced when the right side of the Neck presents; the right hand when the left side. The right hand to be introduced when the right side of the Neck presents, &c. The left hand to be introduced, &c. The right hand to be introduced when the right Shoulder; the left when the left Shoulder presents. \ The left hand to be introduced when the right Shoulder presents; the right hand when the left Shoulder, &c. The right hand to be introduced when the right Shoulder presents; the left hand when the left Shoulder., &c. The right hand to be introduced when the right Shoulder presents; the left hand when the left Shoulder, &c. The right hand to be introduced if the right S ide presents; the left hand if the left Side presents. The left hand to be introduced if the right Site presents; the right hand if the left Side presents. The right hand to be introduced if the right Side presents; the left hand if the left Side presents. The right hand—if right Side----the left hanjd if left Side. < § The right hand to be'introduced when the rigl|t Hip presents; the left hand when the left Hip, &c. The left hand to be introduced when the right Hip presents; the right hand when the left Hip, &c. The left hand to be introduced in both varieties of the position. The right hand to be introduced in both varieties of the position. JVote.—It is to be observed that Baudeloque, and the French practitioners generally, in preternatm-al Labours, or where the operation of Turning, or the application of the Forceps becomes necessary, place the Woman in a Supine Position, \fith the Breech brought to the Edge or Foot of the Bed, SO that the Ooccix and Perinseum may be free, the Thighs and Legs half extended, thk Feet resting on Two Chairs placed properly, or supported by Assistants. j j The Child tt'esenting different parts of its anterior Sur- face to the Orifice of the Uterus. __________:________A_____________________, S3 3 £3- NOTES- BOOK i. CHAP. II. NOTE 1, Page 12.—Dr. Denman mentions an instance, where the pa- tient, in three succeeding pregnancies, was progressively worse, and did not, until the lapse of eight years, recover from the lameness produced by the third delivery. Introd. Vol. I. p. 16. NOTE 2, p. 12.—In one case, where the symphysis was divided, the pa- tient was able to walk on the 15th day.—In Dr. Smollet's case, although in the 8th month of gestation, the bones were found to rise above each other, yet the woman recovered in two months after delivery. Smellie, Vol. II. coll- 1. n. i. c. 2. NOTE 3, p. 13.—As an illustration of this disease, I shall relate the out- lines of a case mentioned by Louis, in the Memoirs of the Royal Academy of Surgery. A woman in the 2d month of her pregnancy, after pressing in a drawer with her foot, felt a considerable pain at the lower part of the bel- ly, greatly increased by every change of posture ; and along with this she complained of strangury. She was bled, and purged, and kept at rest, by which means, especially by the last, she grew better. But in the two latter months of pregnancy, the symptoms were renewed, so that presently she could neither walk, nor even turn in bed, without great pain ; but her great- est suffering was caused by raising the legs to pull on her stockings, as then the bones were more powerfully acted on. A slight degree of hectic fever now appeared. Her delivery was accomplished easily ; but on the evening of the 3rd day, when straining at stool, after having received a clyster, the" pain, which had troubled her little since her labour, returned with as much severity as ever. On the 5th day the pulso.was very weak and frequent, she sweated profusely, and had a wildness in her countenance, with symptoms of approaching delirium. In the afternoon the pulse became full and tense, with vertigo and throbbing of the arteries of the head. The pain at the sym- physis was excruciating, and although she was fomented and bled seven times, she obtained no relief. On the 8th day the pain abated, but diffused itself over the rest of the pelvis, particularly affecting the left hip and the sacrum. On the 11th day she died. On opening the body, there was found a separation of the bones at the pubis, but the capsule was entire, and much distended. It contained about an ounce and a half of matter. Whether the timeous evacuation of this matter might have saved the patient) is a question 344 worth our consideration. I am disposed to answer it in the affirmative, from observing, that wherever the patient has recovered in such circumstances, it has uniformly happened, that a discharge of matter has taken place. NOTE 4, p. 13.—Dr. Laurence shewed Dr. Smellie a pelvis, where all the bones were separated to the extent of an inch. NOTE 5, p. 13.—In a case related by De la Malle, the pain did not ap- pear till the 14th day after delivery, and was felt first in the groin. The pa- tient was unable to move the leg, and had acute fever, which proved fa,tal. The sacrum was found separated, three lines from the ilium. In the operation of dividing the pubis in a parturient woman, it was foUnd that one side yielded more than the other, and consequently that side would suffer most at the sacrum. Baudelocque L'Art, &c. section 2063. NOTE 6, p. 13.—Dr. Smellie relates an instance, where, during labour, the woman felt violent pain at the right saero-iliac symphysis. On the 5th day this pain was extremely severe, and attended with acute fever ; but the symptoms were abated by blood-letting, and a clyster, and fomentations, which produced a copious perspiration. She was not able to walk for five or six months without crutches, but was restored to the use of the limb, by means of the cold bath. Coll. 1. n. i. c. 1. When uneasiness is felt at the pubis, or about the pelvis, during gestation, and there is an apprehension that the bones may separate, it will be proper to bleed the patient occasionally, which may prevent the accident. CHAP. VI. NOTE 1, p. 28.—It is not necessary to give examples of every degree of deformity ; but it will be useful to select some specimens of the different kinds. The slighter degrees do not require to be particularized. I shall first of all give the dimensions of a dried pelvis, so contracted, as to prevent a child at the full time from passing without assistance. From the pubis to the sacrum, it measures three inches; from the acetabulum to the sacrum, on the right side, two and an half inches ; on the left, two inches and seven eighths; from the brim above the foramen thyroideum, to the opposite saero-iliac junction, five inches ; from the same part of the brim on one side, to the same on the opposite, three inches and an half; transverse diameter, four inches and seven eighths; from the arch of the pubis to the hollow of the sucrum, five inches ; from one tuberosity of the ischium to the other, four inches and an half; from one spine to another, four inches and an half; the arch of the pubis is natural. The distance from the face of the third lumbar vertebrae, to the spine of the ilium on both sides, is six inches. These dimensions may be compared with those of the well formed pelvis. The symphysis pubis has the cartilage in the inside, projecting like a spine, which, added to the smallness of the pelvis when recent. The linea ilio-pec- tinea also, on the left side, is for the length of two inches as sharp as a knife; and from tfcsse two causes, the cervix uteri and bladder were torn in labour. 345 NOTE 2, p. 29.—In a pelvis of this kind, which I shall describe, the vei. tebrx and sacrum lean much to the left side. The line from the promontory of the sacrum to the part of the pubis opposite it, is barely an inch and an half; but an oblique line drawn to the symphysis, which is to the right of the promontory, is near two inches. From the promontory to the side of the brim at the ilium on the left side, is two inches and three tenths; on the right side, three inches and four tenths. On the left side, from the lateral part of the sacrum to the acetabulum, is nine tenths of an inch; on the right side, fully two inches. Now in this pelvis, when the soft parts are added, we shall find that an oval body may pass on the right side, whose long diameter is three inches and an half, and whose short diameter is bare- ly two inches. In a pelvis with a semicircular brim, whose short diameter, at the middle and each side, is one inch and an half, an oval could pass when the soft parts are added, whose long diameter is about two inches and a quarter; and the short one about one inch and a quarter- NOTE 3, p. 30.—In a well formed pelvis, a line drawn transversely along the brim, and in contact with the sacrum, either touches at its two extremi- ties, the saero-iliac junctions or the linea ilio-pectinea, about half an inch before them; but in a very deformed pelvis, such a line will touch the brim, at, or even before the acetabula. In a well formed pelvis, a line drawn from the middle of the linea ilio-pectinea on one side, to the same spot on the opposite side, is about an inch, or an inch and an half distant from the sa- crum. But in a deformed pelvis, this line would either pass through the sa- crum, or altogether behind it. NOTE 4, p. 30.—The following are the dimensions of a pelvis of this kind, which 1 select as a specimen. From the spinous process of the ilium on one side to the other, is eight inches and three fourths. From the lumbar vertebrae to the spinous process of the ilium on the right side, six inches; on the left side, one inch and seven eighths. From the spinous process of the ilium back to its ridge, two inches and an half. From the symphysis pu- bis to the sacrum, one inch and three fourths. From the right acetabulum to the sacrum, six tenths of an inch ; from the left, seven eighths of an inch. From the brim above the foramen thyroideum to the same point on the op- posite side, seven eighths of an inch. From the same part 6f the brim to the opposite saero-iliac junction, three inches and an half on both sides. From the tuberosity of on« ischium to that of the other, two inches and an half. From the tuberosity to the coccyx, three- inches. From the spine of one is- chium to that of the other, three inches and an half. From the lower part of the symphysis pubis to the hollow of the sacrum, four inches; distance of the rami of the pubis, five eighths of an inch. This pelvis has a triangular brim; for it will be. observed, that the brim above the foramen thyroideum measures nearly an inch across, and there- fore there is a considerable space betwixt the two ossa pubis, gradually, however, becoming narrower toward the junction of the bones; but little advantage in delivery can be gained from this. When wo examine it with' a 34(3 view to determine what bulk may be brought through the brim, we find that it is by its shape virtually divided into two cavities one on the right, and the other on the left side, and the short diameter of the one is six tenths of an inch and that of the other seven eighths of an inch; therefore no art can bring a child at the full time through it. In this pelvis, the sacrum has fallen so forward at the top, that in a stand- ing posture the face of that bone is almost horizontal, and its under part with the coccyx is bent forward like a hook. The vertebrae are much dis- torted. NOTE 5, p. 30—This is the case in a pelvis where the distance from the part of the brim above the foramen thyroideum on one side, across to the same part on the opposite side, is only five eighths of an inch. From the right acetabulum to the sacrum is an inch and three eighths. From the left is one inch. This pelvis at the brim is externally triangular, but it is, from the near approximation of the bones, virtually semicircular, the space be- twixt the two ossa pubis being so trifling as not to merit consideration; and the diameter of the brim here is one inch, exclusive of the small slit betwixt the bones. The sacrum in this pelvis is very much curved, and the outlet is small. NOTE 6, p. 31.—Dr. Denman mentions a fatal case of this kind, to which Dr. Hunter was called. The child was delivered by the crotchet, but the patient died on the fourth day. A firm fatty excrescence, springing from one side of the sacrum, was found to have occasioned the difficulty. Vide In- trod. Vol. II. p. 72.—Baudelocque, in the 5th vol. of Recueil Periodique, re- lates a case, where, in consequence of a scirrhous tumour adhering to the pelvis, the crotchet was necessary. In a subsequent labour, the exsarean operation was performed, and proved fatal to the mother.—Dr. Drew re- cords an instance where the tumour adhered to the sacro-sciatic ligament, and was successfully extirpated during labour. Vide Edin. Journal, Vol. I. p. 23. NOTE 7, p. 31.—A fatal case of this kind occurred to Dr. Ford, and is noticed by Dr. Denman. Vol. II. p. 75.—Another fatal instance is recorded by M. Baudelocque, 1'Art. section 1964. NOTE 8, p. 31.—Several cases of this kind have been met with, and in one related by M. Brand, and noticed by Dr. Sandifort in his Obs. Anat. Path, the woman died undelivered. CHAP. VII. NOTE 1, p. 33.—The following are the dimensions of a very large pelvis which I possess. The conjugate diameter is four inches and three fourths; the lateral five inches and five eighths; the diagonal five inches and an half- From the symphysis pubis to the saero-iliac junction, five inches. From the top of the arch of the pubis to the sacrum, is five inches and three eighths. From one tuberosity of the ischium to the other, is five inches and an half; 847 and the arch is very wide. Depth of the pelvis at the sacrum without the coccyx, five inches. Breadth of the sacrum at the top, four inches and seven eighths. Depth of the pelvis at the sides, four inches. chap. ix. NOTE 1, p. 43.—In birds, we find that the ovaria contain a great number of yolks of different sizes. Those which are nearest the wide canal called the oviduct, which leads to the cloaca, are largest, whilst those remote from it are very minute. The full grown yolk is detached from the ovarium, and in its passage down is furnished both with the albumen and the necessary membranes and shell. In viviparous fishes, as the skate, ray, &c. the same structure obtains. These animals have two ovaria, containing eggs of differ- ent sizes ; the smaller are white, the larger yellowish, and they pass down to an oviduct, which contains a glandular body that furnishes the covering of the egg. Each ovary has a separate oviduct, which forms a vast sac, that termi«ates in the sides of the cloaca, by orifices that have a duplicature like a valve. The cloaca itself forms an ample reservoir, that seems more like a continuation of the oviduct than the termination of the rectum. In oviparous fishes, the ovaria are known under the name of roes, and all the visible eggs. are of the same size, and so numerous, that some contain above 200,00d. Med. Gall. an. 3, p. 73, relates a similar case, but the hydatids were expelled in the fourth month without hemorrhage. Other cases of hy- datids are to be found in Tulpius, lib. III. c 32. Shenkius, p. 685. Mercatus de Mulier. affect, lib. III. c. 8. Christ, a Veiga Art Med. lib. III. J 10, c. 13, relates an instance of 60 hydatids, as large as chesnuts. being expelled. Stalpart Vander Wiel, Tom. I. p. 301, mentions a woman, who in the ninth month, after enduring pains for three days, expelled many hydatids, and the process was followed by lochia Lossius, Obs. Med. lib. IV. ob. 1(3, mentions a widow who for several years had a tumid belly; after death, hyda- tids were found in utero. See also Mauriceau's Observations, obs. 367. Ruysch,.Obs. Anat. Chir. p. 25. Albinus Anat. Acad. lib. p. 69. and tab. III. tfg. 1, describes in an abortion, the commencement of this change. The vesicles are not larger than the heads of pins. Wrisberg describes a more advanced stage in Nov. Comment. Gotting. Tom. IV. p. 73; and Sandifort, in his Obs. Ar.at. Path. lib. II c. 3. tab VI. fig. 5, has a case extremely dis- tinct See also Haller, Opusc. Path. ob. 48. Vigarous. Malad. &c Tom. I. p. 385, proposes mercury to kill the hyda- tids. He knew an instance where the woman discharged hydatids always when she went a la garde-robe. Mr. Mills relates a case, where the woman betwixt the second and third month, had symptoms of abortion, and after- wards, in the fifth or sixth, expelled above three pints of hydatids. Vide Med. and Phys. Journal, Vol. II. p. 447- When the mass is expelled, it is found either to consist entirely of small vesicles, or partly of vesicles, and partly of more solid remains of the ovum, or coagulum of blood. NOTE 60, p. 89.—Hildanus relates a case of this kind in his own wife, dulcissima et charissima conjux mea. Hydatids may also be combined with pregnancy. The same author tells us of a woman, who, in the fifth month, was delivered of a mola aquosa, or vesicles containing ten pounds of water; she did not miscarry, but went to the full time. NOTE 61, p. 89.—Kirkringius, p. 28, considers dropsy of the uterus as impossible, and says, that every case of collection of water depends on a large hydatid. Dr. Denman seems to be much of the same opinion. But we find instances where water is accumulated and repeatedly discharged, appa- rently from the removal of a temporary obstruction. Fernelius relates a case where the woman always before menstruation discharged much water. Path. lib. VI. c. 15. And M. Geoffroy describes a case of repeated discharge. Vide Fourcxoy la Med. Eclaree, Tom. II. p. 287- A case is related by Tur- ner, where the external membrane of the uterus was said to be distended with water. The menses were suppressed, and a secretion of whitish fluid took place from the breasts. Phil. Trans. No.20?V 355 NOTE 62, p. 92.—Sometimes the situation of the abdominal viscera is very much altered. In Mr. White's case, the liver was found to descend to the lower part of the belly, and the diaphragm was lengthened so as to al- low the stomach to reach the umbilical region. Vide Med. Obs. and Inq. Vol. III. p. 1. In a complicated case, related by Schlincker, the pylorus hung down to the pubis. Haller, Disp. Med. IV. 419. NOTE 63, p. 92.—This point is very well considered by Verdier, in his paper on Hernia of the Urinary Bladder, in the first Vol. of Mem. de l'Acad. de Chir. See also a paper by M. Tenon, in Mem. de l'Institut, Tom. VI. p. 614 —Mr. Paget relates a very interesting case of prolapsus uteri, in which the bladder became retroverted, lying above the uterus. It could not descend before it, or along with it, being filled with a calculus, weighing 27 ounces, and others of a small size. Some parts of the bladder were an inch thick; a catheter could not be introduced. Med. and Phys. Journal, Vol. VI. p. 391. NOTE 64, p. 92.—Ruysch, feeling some hard bodies in the tumour, form- ed by the protruded parts, cut out 42 calculi from the bladder. M. Tolet extracted fifty, and afterwards cured the woman with a pessary. Duverney met with large calculus in the bladder, with procidentia uteri; and Mr Whyte relates a similar fact- Med. Obs. and Inq. Vol. III. p. 1. See also Deschamps Traite de la Taille, Tom. IV. p. 158. NOTE 65, p 92.—Kerkringius says, nemo vidit nemo sensit decepti omnes imagine falsa, alios decipiunt; laxitas qu&dam colli quae extra pudendum prominet bote nobis fecit ludibrio. Opera, p. 48. Vide also Job a Meckren, Observ. Chir. c. 51. Barbette Chirurg. c. 8. Roonhuysen, Obs. Chir. part. I. ob. 2. NOTE 66, p. 93.—Dr. Monro mentions a procedentia uteri, in a very young girl. It was preceded by bloody discharge. Works, p. 535. Another case is related by Saviajrd, Obs. 15, in which the prolapsed uterus was mis- taken for the male penis; and as Goldsmith's soldier believed they would allow him to be born in no parish, so this girl was in danger of being deter- mined to have no sex. NOTE 67, p. 94—Morand relates the case of a woman who had fectid discharge from the vagina, accompanied with pain. On examination, fun- gous excrescences were discovered in the vagina, and amongst these a hard substance, which being extracted, was found to be part of a silver pessary. The vagina contracted at this spot, and thus, though in a disagreeable way, prevented a return of the prolapsus. Pessaries have also ulcerated through to the rectum; and Mr. Blair mentions a woman in the Lock Hospital, who had introduced a quadrangular piece of wood into the vagina as a pessary, and which ulcerated thus into the rectum, producing great irritation. Med. and Phys. Journal, Vol. X. p. 491. It is likewise necessary, if the pessary have an opening in it, to observe that the cervix uteri do not get into the opening, and become strangulated. NOTE 68, p. 95.—See Rossuet, Plater, and Platner, Inst. Chir. section 1447. Wedelius de Procip. Uteri, c. 4. Volkamer, in Miscel. Cur. an. 2. ob. oj(3 jiJo Anotner case may be seen in Journal de Med. Tom. LXV'llI. p. 195. Pare oeuvres, p. 970.—Carpus extirpated it with success. Vide I.ongii Episf. Med. lib. II. epist. 39.—Slcvogtius relates a distinct case, where the womb was found in the vagina, as if in a purse. Dissert. 12.—Benevenius says, he saw a woman whose uterus sloughed off. De Mirand. Morb. Causis, cap. 12.—Dr. Elmer supposes he has met with a similar case. Med. Phys. Jour- nal, Vol XVIII. p. 344.—The latest case is related by Laumonier. The patient was long subject to prolapsus uteri, but at last the womb, with the vagina, was forced out so violently, that she thought all her bowels had come out. At the upper part of the tumour there was a strong pulsation It was extirpated chiefly by ligature. The woman died some years after this, and the womb was found wanting. La Med.Eclaree par Fourcroy, Tom. IV. p. 33. M. Baudelocque, however, says, that the uterus was only parti- ally extirpated. Vide Recueil Period. Tom. V. p. 332. NOTE 69, p. 95.—Harvey relates a case, where the tumour was as large as a man's head, ulcerated, and discharged sanies. It was proposed to ex- tirpate the prolapsed uterus, but the following night a foetus was expelled, spithamx longitudine. Opera, p. 558. See also a case by Mr. Antrobus, in, Med. Museum, Vol. I. p. 227. NOTE 70, p. 95.—Dr. Burton had a patient, who in the fourth month of pregnancy fell, and was thereafter seized with suppression of urine. The os uteri was found almost at the orifice of the vagina. He drew off about three quarts of urine, raised up the womb, and introduced a pessary. Sys- tem, p. 156. NOTE 71, p. 95.—Mr. Dray mentions a case where, in the fourth month of pregnancy, the woman was seized with pains, like those indicating abor- tion, accompanied with suppression of urine. The os uteri was very near the orifice of the vagina. This disease proving fatal, the bladder was found to be thickened, enlarged, and in part mortified. Vide Med. and Phys. Jour- nal, Vol. III. p. 456. NOTE 72. p. 96.—Reink mentions a woman who was pregnant of twins. In the fourth month the womb prolapsed, and caused a fatal suppression of urine. The vagina, at the upper part, was corrugated and inverted. Haller, Disp. Chir. Tom. III. p. 585. NOTE 73, p. 97.—Sampson, in the Phil. Trans. No. 140, describes an ovarium filled with hydatids, containing 112 pounds of fluid.—Willi men- tions a tailor's wife, whose ovarium weighed above 100 pounds, and con- tained partly hydatids, partly gelatinous fluid. Haller, Disp. Med. Tom. IV. p. 447. NOTE 74, p. 98.—In a case detailed by Vater, the patient had symptoms of pregnancy, secreted milk, and even thought she felt motion. The belly continued swelled, and she had bad health for three years and a half, when she died. The abdomen contained much water, and the right ovarium was found to be as large as a man's head, containing capsules, filled with puru- f-M looking matter. The uterus was healthy, but prolapsed, and the ureter 357 was distended from pressufle. Haller, Disp. Med. Tom. IV. p. 401. This was not a case of extra-uterine gestation, for the ovarium was divided into cells, and had no appearance of foetus. NOTE 75, p. 98.—In some cases it does not ascend out of the pelvis, or if it do, the inferior part of the tumour sinks again into it. Morgagni relates an instance where the ovarium weighed 24 pounds; and the lower part of it filled the pelvis so well, that when it was drawn out, it made a noise like a cupping glass when pulled away from the skin. Epist. 39, art. 39. NOTE 76, p. 98.—It may be combined with effusion of water in the ab- dominal cavity. Dr. Bosch's patient had 16 pints of water in the abdomen, and both ovaria were enlarged so as to weigh 102 pounds. This patient complained of great pain and weight in the lower belly, and over the right hip. She was much emaciated, but the menses were regular- When she was tapped, not above two tea cupfuls of fluid were discharged. Med. and Phys. Journal. Vol. VIII. p. 444.—Mr. French met with a case of ascites and dropsy of the ovarium. The ovarium extended from the pubis to the diaphragm. This patient had voracious appetite. Mem. of Medical Sofiety, Vol. I. p. 234. NOTE 77, p. 98.—If only one of the ovaria be enlarged, or if both be af- fected, but only one much increased, the uterus is often not raised, because the ovarium turns on its axis, and the uterus lies below it. In a case with which I was favoured by Dr. Cleghorn, both ovaria were greatly tumified, and could be felt on each side of the navel, whilst immediately beneath that, they seemed to be united by a flat hard substance; and when the urine was long retained, a fluctuation could be perceived before that part. Upon dis- section, a firm thick substance was found, extending from the pubis to the navel, betwixt the ovaria. This was the uterus and vagina. The uterus it- self was lengthened, the cervix was three inches long, and all appearance of os tincae was destroyed. Her complaints began after being suddenly terri- fied : first she felt severe pain in the right groin, with weakness of the thigh, and soon afterwards perceived a tumour in the belly, and presently another appeared in the left side. She was tapped 16 times. NOTE 78. p. 99.—In a case noticed by Dr. Denman, the labour was ob- structed until the ovarium was emptied, by piercing it from the vagina.' The woman died six months afterwards. Introd. Vol. II. p. 74. In Dr. Ford's case, related by Dr. Denman, the crotchet was employed. See also a case by M. Baudelocque, l'Art des Accouch. § 1964. NOTE 79, p. 100.—Dr. Denman justly observes, that diuretics have no effect, Vol. I. p. 122. And Dr. Hunter remarks, that " the dropsy of the •« ovarium is an incurable disease, and that the patient will have the best «« chance for living longest under it, who does the least to get rid of it. The «< trocar is almost the only palliative." Med. Obs. and Inqu. Vol. II. p. 41. Willi, however, relates a case of 14 years standing, which was cured by diuretics; and it was calculated that the tumour contained 100 pounds of fluid. Haller, Disp. Med. Tom. IV. p. 451. 358 NOTE 80, p. 101.—Dr. Denman advises the operation to be deferred as long as possible, and I believe he is right; for every operation is followed by re-accumulation, which is a debilitating process ; yet it is astonishing how much may in the course of time be secreted, without destroying the patient, Mr. Ford tapped his patient 49 times, and drew off 2786 pints. The secre- tion was at last so rapid, that three pints and three ounces were accumulated daily. Med. Comrhun. Vol. II. p. 123.—Mr. Martineau tapped his patient 80 times, and drew off 6631 pints, or 13 hogsheads; at one time he drew off no less than 108 pints. Phil. Trans. Vol. LXXIV. p. 471. NOTE 81, p. 101.—Le Dran relates two cases in the Mem. de l'Acad. de Chir. Tom. III. In the first, the cyst was opened, and the woman cured of the dropsy, but a fistulous opening remained, p. 431. In the second, he made a pretty large incision, and introduced a canula into the sac. The operation was followed by fever, delirium, and vomiting; the woman re- tained nothing but a little Spanish wine for three weeks. She discharged daily 8 or 10 ounces of red fluid. At length, all of a sudden, 15 ounces of white pus were evacuated, and then the symptoms abated ; but a fistula re-. mained for two years, when it healed, p. 442. Dr. Houston relates the case of a woman in his neighbourhood, in whom he made an incision 2 inches long into the ovarium, and then with a fir splint turned out a great quantity of gelatinous matter and hydatids. He kept the wound open, with a tent, and succeeded in curing the patient. The disease was attributed to rash extraction of the placenta, and had existed for 13 years. It was attended with violent pains. Phil. Trans. XXXIII.p. 5. M. Voison relates a case, which was palliated by tapping, and keeping a fistula open. Recueil Periodique, Tom. XVII. p. 381. And Portal gives an instance, where, by keeping the canula in the wound for a short time, a ra- dical cure was obtained, and the person afterwards had children. Cours d'Anat. Tom. V. p. 554. NOTE 82, p. 102.—De La Porte tapped a woman who had a large tu- mour in the belly, bat nothing came through the canula. He made an inci- sion of considerable length, and, in the course of two hours and an half, ex- tracted 351b. of jelly. The lips of the wounds were then brought together. Next day 151b. of jelly were evacuated, but presently vomiting and fever took place ; and she died on the thirtieth day, having discharged altogether 671b. of fluid. This disease was of sixteen months standing, and was attri- buted to hemorrhage. Mem. de l'Acad. de Chir. Tom. III. p. 452. Dr. Denman notices the case of a patient, who died the sixth day after in- jecting the ovarium. Vol. I. p. 122. NOTE 83, p. 102.—Dr. Monro, in Med. Essays, Vol. V. p. 773, details the history of a patient who had a diseased ovarium, and in whom the tu- mour pointed about four inches below the navel.'It was opened, but nothing but air came out, followed next day by faeces : on the fifth day some pus was discharged. She gradually improved in health, and the tumour of the belly subsided; but in two years after the suppuration was renewed, and she died. In this case, the colon had probably adhered to the ovarium. 3pp NOTE. 84. p. 102.—Dr. Denman relates the case of a patent, who, having for some time suffered from pain and tenderness about the sacrum and uterus, and uterine hemorrhage, was suddenly seized with vomiting, syncope, pains in the belly, and costiveness; presently a tumour was felt in the right side, and this soon occupied the whole abdomen. This patient was cored, after purging a ge- latinous fluid. Med. and Phys. Jour. Vol. II. p. 20. NOTE 85. p. 102-—Dr. Monro relates a case of supposed pregnancy, in the tenth month of which, the tumour was removed by an aqueous discharge from the vagina. In a future attack, however, violent bearing-down pains were ex- cited, and the woman died exhausted. The left ovarium was found greatly en- larged with vesicles. Med. Essays, Vol. V. p. 770. NOTE 86. p. 102.—See Dr. Baillie's Morbid Anatomy, chap. 20. Dr. J. Cleghorn mentions a woman who died ten days after being tapped. The right ovarium was found greatly enlarged, and had many cells, some containing hair, cretaceous matter, fragments of bone and teeth, other gelatinous fluid. Trans. of Royal Irish Acad. Vol. I. p. 80. In Essays Phys. and Literary, Vol. II. p. 300, a case is mentioned, in which the one ovarium contained many vesicles; the other contained a mass, like brain, with bones and teeth. In the Museum attached to the hospital at Vienna, there is a large ovarium, the inner surface of which is covered with hair. Horstius met with an ovarium, containing hair. purulent looking and oily matter. Opera, p. 249. Scheakius met with fat and hair, p. 556. and Schacher relates a similar case in Haller's Disp. Med. Tom. IV. p. 477. Ruysch, in his Adversaria, says he met with bones and hair, and Le Rich, in the Hist, de l'Acad. de Sciences, 1743, mtt with hair and oil, in Mils, together with bones and teeth. See alsoRecnil Period. Tom.XVII. p. 462. NOTE 87.p. 102-__Duverney saw a tumour extirpated from the scrotum, con- taining fleshy matter and bones. CEuvres, Tom. II. p. 562. And M- Dupuytren presented a report to the Medical School at Paris, relating the h.story of a tu- mour found in the abdomen of a boy, containing a mass of hair, and a fcetus nearly ossified. It was supposed, that at conception, one germ had got within another. See Edin. Med. Jour. Vol. I. p. 376. From the respectable evidence of Baudelocque* Le Roy, &c. this cannot be placed on a footing with Halley's case of a greyhound dog, who voided by the anus a living whelp! Phil. Trans. Vol, XIX p. 316. I believe that bones, hair, &o. have been found in a gelding. NOTE 88 p 102. Schlencker mentions a woman, who, soon after delivery. felt obtuse pa'i v in the left side, and presently a swelling appeared in the belly. She had bad appetite, swelled feet, prolapsed uterus, and suppression of urine and feces. The left ovarium was hard and stony, and weighed 3 ounces. Hal- L Disp Med. Tom. IV. p. 419- In this case the tumefacuon of the belly could not be caused by the presence of the ovarium,, but rather by the pressure CnNSTEe89nri02.-Vide case by Fontaine, in Haller, Disp. Med. Tom. IV- p 485. The patient had tumour of the abdomen, withi lancing pains in the left Le. extending to the thigh. The left ovarium weighed 10 pounds the r.ght vas as large as the fist, and both consisted of fatty matter. Portal hkew.se re- ates a case of this disease, where the right ovarium was as large as a man s 360 luead, very hard, and rilled with steatomatous matter, weighing altogether 35 pounds. The uterus and bladder were turned to the left side. No water was effu- sed, but the person was cut off by hectic and diarrhoea. Some steatomatous con* cretions were found in the lungs. Cours d'Anatomie, Tom. V- p. 549. CHAP. XII. NOTE 1. $ 1. p. 115.—(to follow the close of J 1 ) Although hysteria be not a diseased state of menstruation, yet, as it is a very general attendant upon devi- ations of that action, and a very frequent and distressing complaint, to which women are subject, it will be proper to notice it briefly at this time. In the well marked hysteric paroxysm, a sense of pain or fulness is felt in some part of the abdomen, most frequently about the umbilical region, or in the left side, betwixt that and the stomach. This gradually spreads, and the sensa- tion of a ball is felt passing along It mounts upwards, and by degrees reaches the throat, and impedes respiration, so as to give the feeling of a globe in the oesophagus, obstructing the passage of the air, and, as Van Swieten observes, the throat appears sometimes really to be distended. The patient now falls down convulsed, and apparently much distressed in breathing, uttering occasion. ally shrieks, something like the crowing of a cock, or sobbing violently, or otherwise indicating a spasm of the muscles of respiration. She is generally pale, and frequently insensible, at least during part of the fit, and seems to be in a faint; but when she recovers, she is ctnscious not only of having been ill, but of many things which passed in a state of apparent insensibility. After re- maining for some time in a state of considerable agitation of the muscular or- gans, the affection abates, and the patient remains languid and feeble, but grad- ually recovers, and presently is restored to her usual health. This restoration is accompanied with eructation, which indeed often takes place during the parox- ysm ; and also by the discharge of limpid urine, which, by Sydenham, is consid- ered as a pathognomonic symptom of hysteria. Headach is also apt to follow a fit. Besides producing these regular paroxysms, hysteria still more frequently oc- casions many distressing sensations, which are so various, as not to admit of description. Of this kind are violent headach, affecting only a small part of the head, sudden spasms of the bowels, dyspnoea, with or without an appearance ef croup, and sometimes attended with a barking cough, irregular chills, and sudden flushings of heat, spasmodic pains, palpitation, syncope, &c. These, if se- vere, or frequently repeated, are generally attended with a timid or desponding state of mind. During an hysteric fit, the patient is to be laid in an easy posture, a free ad- mission of cool air is to be procured, the face is to be sprinkled with cold vine- gar or Hungary water, volatile salts are to be held to the nostrils, and if she can swallow, 30 drops of tincture of opium are to be administered, with the same or a greater quantity of ether, in some carminative water; or should there be a tendency to syncope, a dram of the spiritus ammoniae aromaticus may be conjoined. 361 A similar'combination of opium is the most powerful remedy in the different hysterical affections above enumerated. But it is further useful to remark, 1st, that local pain is frequently removed by sinapisms, with or without the inter- nal use of opium ; 2nd, that severe affections of the organs of respiration some- times yield more speedily toemetics than to antispasmodics, or may even require the use of the lancet, but this mode of evacuation is to be avoided as much as possible, as it increases a disposition to the disease ; 3rd, that irregular action of the heart, besides requiring powerful antispasmodics, demands, more than any other symptom, during the attack, a state of rest, and the removal of every thing which can agitate the mind ; 4th, continued insensibility, or coma, is a very dangerous symptom, as it may end fatally ; the lancet ought to be early, but not largely used, the bowels should be emptied, and the head covered with a blister. The prevention of regular hysteric fits, or of individual symptoms, is to be attempted by a tonic plan, especially by the use of the cold bath, moderate ex- ercise, preserving a correct state of the bowels, or even giving pretty powerful purges, and the administration of preparations of steel: the mind ought also to be cailed as much as possible from brooding over the disease; for in hysteria, the patient is frequently desponding, and anticipating many evils. The men- strual action, if irregular, must, if possible, be rectified by appropriate remedies. The diet should be light, and rather sparing, and all causes of debility must be avoided. If particular symptoms should be frequently repeated, or the fits occur often, it may be useful to conjoin along with this plan, the exhibition of some anti- spasmodic medicine, such as yalerian, asafoetida, er camphor. Hysteria may occur during the course of other diseases, or in the stage of convalescence from them. In the first case, it may cause some deviation from the regular progress or train of symptoms of the disease, and, it is to be feared sometimes calls the attention of the practitioner from more serious parts of, the patient's malady. CHAP. XV. NOTE 1- p. 143.—In the eggs of fowls, we observe the following circum- stances. 1st, Upon removing the porous shell, we find the albumen inclosed in a membrane, consisting of two layers, and called sacciform by Levielle. These are separated from each other at the large end of the shell, so as to form a small sac, called the folliculus aeris. The albumen is divided into three strata; the first, or cortical, is most liquid; the second, or middle, is more abundant, and thick- er than the first, but less so than the third or central. The middle and central stra- ta are inclosed in a delicate membrane, called leucilyme by Levielle, which se- parates them from the cortical. 2nd, Within the albumen we have the vitellus or yolk, which is inclosed in a vascular membrane, called chlorilyme, or membra- na'vitelli, which again is enveloped by a membrane common to it and the in- testines of the chick, called entero-chlorilyme. 3d, To each end of the vitellus, we have connected a portion of the central albumen, wiled Ohshrza; and in %7; 36S each of these a membranous substance is discovered, attached to the membrane of the vitellus, and a vascular structure, which can absorb the albumen into the vitellus, to contribute to the nutrition of the chick. 4th, Upon the vitellus, we observe the cicatricula, or small sac, called by Harvey the eye of the egg, and which was supposed to contain the foetus, the rudiments of which are al- lowed by Malpighi, Haller, and Spallanzani. to be pre-existant to fecundation. This cicatricula was considered as analogous to the amnion, and supposed to contain a transparent fluid, called by Harvey colliquamentum candidum, or li- quor amnii. More modern observations ascertain that the embryo is not form- ed in the cicatricula, but very near it on the vitellus, and that the amnion inclo- sing it, can at first scarcely be distinguished from the embryo. The cicatric- ula soon disappears. Harvey's account must therefore be transferred to amnion. 5th, During incubation, the vitellus becomes specifically lighter than the albu- men, and rises towards the folliculus aeris. Two arteries and two veins go from the meserraic and hypogastric vessels of the foetus, to the membrane of the yolk, and are supposed to absorb the vitellus, which therefore is carried to the vena porta: of the chick, and nourishes the foetus. There is also a correction betwixt the intestines and vitelline membrane, by means of a ligamentous sub. stance, which was supposed by.Haller and Vicq. D'Azyr to be a tube, and cal- led vitello-intestinal canal, for it is said that ah* has been passed through it. It was supposed to absorb the yolk, by many villi on the inner surface of the vitel- line membrane ; but these are said by Levielle not to be vessels, but soft lamel- ated plates. At the end of the second day, red blood is observed on the mem- brana vitelli. A series of dots are formed, which are converted first into grooves, and then into vessels, which go to the foetus. This appearance has been called figura venosa, and the marginal vessel vena terminalis. 6th, The vitello-intesti- nal ligament, and these vessels, form an umbilical cord. But besides these, we find, after the fourth day, a vascular membrane at the umbilicus, called mem- brana umbilicalis, which rapidly increases, and comes presently to cover the in- ner surface of the membrane of the shell. It is the chorion, and has numerous vessels ramifying on it, like the chorion of the sow, and connected in like man- ner with the foetus. The blood of the umbilical artery is dark coloured, that of the vein bright. 7th, As incubation advances, the amnion enlarges, and comes in contact every where with the chorion. The albumen is all consumed, being taken into the vitellus, which is in a great measure absorbed; and what re- mains is taken, together with the sac, into the abdomen of the chick, and the parietes close over it. On the 21st day, the chick breaks the shell and escapes By encreasing or diminishing the temperature within a certain extent, the pro- cess may be somewhat accelerated or retarded. The eggs of large birds require a longer time to be hatched; those of the ostrich, for example, take six weeks. Hence it appears, that the vitellus and albumen contribute to the increment •of the foetus, whilst the exterior membrane acts as lungs, the air being trans- mitted through the pores of the shell. The eggs pf fishes have a general resemblance to those of fowls, and consist of a vitellus and albumen, with their membranes; but in place of being fur* 363 nished with a shell, they have a tough, or sometimes a horny covering, and some, as those of the shark, torpedo, 8tc. are quadrangular in shape. The yolk is connected to the intestines of the foetus, and its membrane is very vas- cular. As in fowls, so in fishes, it is ultimately inclosed within the abdomen of the young. In the skate, numerous blood-vessels are formed in the albu- men, which Bupply the place of gills, and are supposed by Dr. Monro, to be afterwards covered and converted into gills. The two functions of a placen- ta, then, are still more distinctly fulfilled here than even in fowls, for the apparatus for nutrition and respiration has different or distinct terminations ; whereas in fowls and quadrupeds, all the vessels enter at one place. A sim- ilar fact is observed in the ova of frogs, for the umbilical cord in the tadpole goes to the head. The egg of the serpent is nearly the same with that of the fish, and is inclosed in a flexible membrane. The foetus is coiled up spirally within it, and the chorion is vascular, as in the egg of the fowl. The adder is a viviparous animal; its uterus is membranous, and divided, I.find, into eight or nine cells, each of which, in September, contains an ovum as large as a chesnut. This consists of an exterior membrane, which incloses a foetus about six inches long, and coiled up. About an inch from the tail, the umbilical cord passes out, which consists of vessels that go to ramify on the exterior membrane, which resembles the chorion of the sow. There is also a connection with a vitellus, which is as large as a hazel nut The coluber natrix is said, by Valmont-Bomare, to have a placenta and cord within the egg, but this is contrary to the general structure of eggs ; most likely the chorion has been taken for the placenta. The eggs of rep- tiles are often deposited in packets, the eggs being glued together. The egg of the turtle is as large as a hen's.and is inclosed in a covering like parchment. It is deposited in the sand, and is hatched in about 24 days. The egg of the alligator is similar in structure to that of the turtle; it is rather larger than a goose's egg, and covered with a thin skin, so transparent, how- ever, that the foetus may be seen through it. Those animals which are called oviparous hatch their egg» out of the body, either by sitting on them as we see in fowls, or by exposing them to the heat of the sun, as the turtle, crocodile, and many serpents. Oxiparous fishes, which comprehend alt those called osseous, expel their ova into the water, where they are fecundated by the male, but without copulation. Many fishes leave the sea, and come up the rivers to spawn. Others remain in the ocean; and the eggs, specifically lighter than the water, float on the surface. Many fishes attach them to marine plants, and in some cases the ova are fixed to the body of the parent. The ova are covered with a kind of mucus, which has been supposed to defend them from the water. The ova of frogs, be. are likewise fecundated and hatched out of the body. They are enveloped in a glary matter, which perhaps contributes to their in- crease ; for during incubation, the egg both enlarge! and changes its shape?, 364 • Those animals which hatch their eggs within the body are called ovo-vivi- parous, such as cartilaginous fishes, as the shark, skate and torpedo, &c. The scorpion and venemous serpents also belong to this class. Ovo-vivipa- rous animals expel the young fully formed, and therefore have been some- times considered as having uteri like quadrupeds, and a cord attached direct- ly to it. Spalanzani at first supposed that the foetus of the torpedo was at- tached directly to the uterus, but afterwards found that it was contained in a distinct ovum. Experiences, p. 294. See also Cuvier Lecons d'Anat. Com- pared, Tom. V. p. 142. The shark is said to have an uterus like the bitch, and Belon says he saw a female delivered of eleven young, attached by a cord. Its mode of gestation most likely is similar to the torpedo.. This class expel their young often very quickly. A female syngnatus hyppocampus was observed to expel at least a hundred in a very short time. Analogous to ovo-viviparous animals, are those which receive the ova into cells on. the surface of the body, where they are hatched. This is well seen in the pipa, a species of toad. Even the tadpoles are said to be metamorphosed in these cells. The opossum tribe has a modification of this gestation ; for in them the foetus, when very small, is expelled into a bag situated on the belly, and immediately attaches itself to a nipple. The utero-gestation of the opos- sum of North America lasts only from 20 to 26 days, and the embryo when expelled does not exceed a grain- It remains in the sac about 50 days, and ac- quires the size of a mouse. In other animals, as for instance the bat, the young after birth attach themselves to the nipple, partly for the convenience of being transported or carried about. In plants, we find likewise a placenta or structure intended for the nour- ishment and respiration of the foetus- To take the kidney bean for an exam- ple, we find within the membranous covering two parenchymatous lobes, or cotyledons; and at the margin betwixt these, there is the corculum or cica- tricula. During incubation, we find that this sends up a small shoot called the plumula, and downa radical into the earth. But to support the plant until the root and leaves are capable of maintaining it, we find the cotyledons rise up out of the earth, on each side of the plumula, forming what are called seed leaves. These both serve for the respiratory organs, and also supply pabulum, which is absorbed by proper vessels, and in consequence thereof they presently are destroyed. When there are more lobes than two in the seed, there are a corresponding number of seed leaves. In many cases these cotyledons do not rise out of the ground, but the plumula alone appears. This is the case with the garden pea, but the cotyledons still perform their functions below the ground, and exist until the foliage of the plant, or adult organs, be formed. The greatest part, then, of a vegetable seed or ovum, consists, like the eggs of fowls, of an apparatus intended for the nutriment and respiration of the foetus, whilst the embryo itself is very small. The cotyledoms consist, in many cases, of a farinaceous substance. In other seeds it is oily and farinaceous, and in some is almost all oily. 365 Vegetable ova sometimes are contained in a dry pericarpium, and are shed into the earth when it bursts. But others have an apparatus provided, not only for their present growth, but also for accelerating their incubation in the earth. In stone fruit and nuts, we find that vessels pierce the shell at the bottom, and pass on toward the top, and reach the kernel or lobes, which are contained within the shell, enveloped in a soft membrane. They are inserted very near the embryo. Now. for the farther support of these parts, we find that stone fruits are covered with a quantity of nutritious mat- ter. The almond, for example, has its ligneous nut covered with a fleshy substance about an inch thick, inclosed in a proper membrane. The rham- nus lotus has the stone surrouifded with farinaceous matter which tastes like gingerbread. Other seeds are contained in a parenchymatous or succulent substance, as the apple or pear, or in a firm white substance like cream or marrow, or in a mucilaginous matter as the gooseberry, or in an organized pulp as the orange and garcinia mangostona. Some are deposited in a lus- cious fluid at first, which ultimately becomes farinaceous, as the plantain. CHAP. XVII. NOTE 1. p. 151.—In Dr. Clark's case, the morning sickness, and other signs of pregnancy, appeared very regularly. At the end of nine months, attempts were made to expel the foetus. These were followed by inflamma- tion and decline of health. Then suppuration took place, and the patient sunk. Transactions of a Society, &c. Vol. II. p. 1. In Mr-Mainwaring's case, in the same work, p. 287, the patient suffered much from morning sickness, and pain at the groins. < NOTE 2. p. 151.—In the Journal de Scavans for 1756, we are told of a woman at Louvain, who at first had so dreadful pain when she went to stool, that she thought her bowels were coming out—In Pouteau's case, the woman suffered great pain till after the second month. Melanges, p. 333. NOTE 3. p. 151.—Bianchi mentions a case, in which, in the first months, the woman complained of great pain in the lower belly, with nausea and fainting fits. The motion of the child ceased in the fifth month, and then milk was secreted. DeNat in Hum. Corp. Vitiosa Morbosaque Gener. p. 166.—In Dr. Mounsey's case, the pain, vomiting, and fainting fits, continued till the woman quickened. Phil. Trans. Vol. XLV. p. 131.—In Dr. Fern's case, the person complained of great pain till the third month ; and from that period till the 8th month, was subject to convulsions and syncope. Phil. Trans. Vol. XXI. p. 121. NOTE 4. p. 151.—In Dr. Perfect's case, no labour pains came on, but the motion of the child ceased at the end of nine months. The abdomen neither increased nor diminished in size for two years and seven weeks; but she was afflicted with constant pains in the hypogastric region, attended with fever, and finally sunk under marasmus. Cases in Midwifery, Vol. II. p. 164. NOTE. 5. p. 151.—In a case of a French mulatto woman, which ultimate- ly terminated fatally, the outlines of which 1 was favoured with by Dr. 366 Chisholm, the pain was so great, that it could not be allayed by the strongest opiates. NOTE 6. p. 151.—Vide cases by Longius, in his Epistolae, Tom. II. p. 670. Tulpius Opera, lib. IV. c. 39. p. 358.—Pouteau in his Melanges, p. 373.— Mr. Shiever, in Phil. Trans. No. 303. p. 172.—Winthrop. Phil. Trans. Vol. XLIII. p. 304, and Simon, p. 529.—Lindestaple, Vol. XLIV. p. 617. Morley, Vol. XIX. p. 486. Gordon, in Med. Comment. Vol. XVIII. p. 323. Cammel, in Lond- Med. Jour. Vol. V. p. 96. Case by M. Bergeret, in the Recueil Peri- od ique, Tom. XIV. p. 289. NOTE 7. p. 151.—Vide Marc«l. Donatus, De Med. Hist. Mirab. lib. IV. c. 22.—Horstii Opera, Tom. II. p. 536. In this case, the foetus was discharged both by the vagina and rectum.—Benevoli, in his Dissert, p. 104, gives an instance where the greater part of the child was expelled by the vagina, but the woman died before the process was completed.—Mr- Smith's case, in Med. Comment. Vol. V. p. 314.—In Mr. Colman's case, pains came on, and the head was felt in the pelvis at the time of her reckoning, and long after- wards, but the os uteri could not be perceived. In some time, hectic fever, with diarrhoea and sore mouth, appeared. Six months after her attempts at labour, an opening was felt in the vagina, but very unlike the os uteri. The hand was introduced, and a putrid child was extracted. Some faeces continu- ed to come by the wound, but at last she got well. Med. and Phys. Jour. Vol. II. p. 262.—See also Camper's case, in his Demonst. Anat. Path. lib. II. p. 16; and Dr. FothergHFs case, in Mem. of Med. Society, Vol. VI. p. 107. NOTE 8. p. 151.—Vide Stalpart Vander Wiel Opera, Tom. I. p. 305. In this case, bones came away with the urine.—In the case of Ronseus. the child was discharged partly by the bladder, but chiefly by the anus. Epist. Med. A similar instance is related by Morlanne, the extraneous matter forming a nucleus for a calculus. Recueil Period. Tom. XIII. p. 70—In prof. Josephi's ease, the child was found altogether in the bladder. Med. and Phys. Jonr. Vol. XIV. p. 519. NOTE 9. p. 151.—Vide case of Mrs. Stagg. in Lond. Med. Obs. and In- quiries, Vol. II. p. 369; and cases by Mr. Jacob, Dr. Maclarty, and others. NOTE 10. p. 151.—In Mr. Gifford's case, the child was expelled entire by the anus, and even the cord was found hanging out of the intestine. Phil. Trans. Vol. XXXVI. p, 435.—See also Mr. Goodsir's case, in Annals of Medicine, Vol. VII. p. 412. NOTE 11. p. 151.—In Dr. M'Knight's case, although the cesarean ope- ration was performed before any bad effects were produced on the health, no part of the placenta could be found. NOTE 12. p. 152.—In Dr. Clarke's case, the tube burst in the second month, and the woman died from loss of blood. Transactions of a Society, Vol. I. p. 216.—Vide case by Duvervey, in his works, Tom. II. p. 353 : and by M. Littre in the Memoirs of the Acad, of Sciences, for 1702, and by Riolan, in his works. See also Med. Comment. Vol. I. p. 429.—In Mr. T. 367 Blizard's case, rupture took place at a very early period, for the woman had miscarried only five weeks previous to this event. Vide Edin. Phil. Transi Vol. V. p. 189. NOTE 13. p. 152.—I have known the foetus retained for twenty years ; and there are some instances, where it has been retained thirty, forty, or fifty years, Mrs. Ruff, whose case is related in the Med. and Phys. Jour, for May 1800, carried the child fifty years, Middleton's patient carried it sixteen years. Phil. Trans. Vol. XL1V. p. 617—Mounsay's thirteen years, Vol. XLV. p. 121. Steigertahl's forty-six years, Vol. XXXI. p. 126. Broomfield's nine years, Vol. XLI. p. 696. Sir P. Skippon's patient discharged it by sup- puration at the groin, after retaining it twenty years, Vol. XXIV. p. 2070. See slso cases by M. Grivel, in Edin. Med. Jour. Vol. II. p. 19, and Dr. Cald- well, p. 22. Sometimes no attempt is made to expel, but the foetus is conver- ted into a substance, which Fourcroy finds to resemble the gras des cimetieres. System, Tom. X. p. 83. Sandifort relates a case, where, after attempts at lab- our, no further inconvenience was sustained, but the child was found after twenty-two years to be indurated. Observationes, lib. II. p. 36. He quotes Nebel for a case, where it was retained fifty-four years. Cheselden found it converted into earthy matter. The late Mr. Hamilton of this place had a preparation of a foetus, covered with calcareous matter, which was retained 32 years. This woman had pains at the end of nine months, after which the belly decreased in size. NOTE 14. p. 152.—In the 5th Vol. of the Edin. Med. Essays, there is re- lated a case, in which the patient seemed to have a second extra-uterine pregnancy before she got quit of the first.—See also Primrose de Morb. Mul. p. 326—Mr. Hope, in the 6th Vol. of the Med. and Phys. Jour. p. 360, de- tails a case, where the woman in the seventh month of pregnancy had pains, which continued for three weeks, and then went off, leaving a hard tumour on the left side, which was somewhat painful; she then had another preg- nancy, and a fortnight after delivery, began, after taking a laxative, to vomit, and continued to do so, ultimately throwing up feculent matter. The case ended fatally.—See also Turk, in Haller, Disp. Chir. IV. 793. NOTE 15. p. 152.—In Mr. White's case, related in Med. Comment Vol, XX. p. 254, the symptoms were very like those of retroversion, and the case was only distinguished by the result. In Mr. Cammel's case, there was not only a tumour betwixt the vagina and rectum, but the os uteri was turned upward and forward. Lond. Med. Jour. Vol. V. p. 96. Mr. Kelson's case very much resembled retroversion, for in the tenth week, both the urine and stools were obstructed, In about a fortnight, the impediment was suddenly removed, and the uterus felt in situ. She continued well till the ninth month, when labour ineffectually came on; but in process of time, the child was discharged by the anus. Med. and Phys. Jour. Vol. XI. p. 293. NOTE 16. p. 152.—Boehmer long ago observed this; and Dr. Baillie, in the 79th Vol. of the Phil. Trans, mentions, that Dr. Hunter had a prepara- tion of tubal pregnancy, in which the uterus was found enlarged to double 368 its natural size, and containing decidua. He also states, that in an ovarian case, the uterus was enlarged, thick, and spongy, and its vessels enlarged. Dr. Clarke found the uterus, in the second month of an extra-uterine preg- nancy, exactly of the same size as if the embryo had been lodged within it. The decidua was formed, and the cervix filled with gelatinous matter. Trans- actions of a Society, Vol. I. p. 216. See also a case by Saviard, in Phil. Trans. No. 222. p. 314. A case, similar to Dr. Clarke's is related by Mr. T. Blizard, in the Edin. Phil. Trans. Vol. V. p. 189. See also Annals of Med. Vol. III. p. 379. NOTE 17. p 152.—In Mr. Houston's case, the cervix was so closed up that it would not admit a probe. Phil. Trans. Vol. XXXII. p. 387 The decidua would appear sometimes to enlarge, and form a mass like placenta, which in Mr. Turnbull's case was expelled with hemorrhage. Mem. of Med. Society, Vol. III. p 176. NOTE 18. p. 153.—In the case related by Varocquier, the ovarium did not acquire a larger size that an egg. The woman died, after suffering violent pain in the left side, low down. The viscera were slightly inflamed Mem. de l'Acad. de Sciences, Tom. CXI1I p 76. In the case by L'Eveille, the foetus was apparently betwixt three and four months old. Rapport de la So- ciety Philomatique, Tom. I. p. 146. See also a case in the Recueil Period. Tom. XIII. p. 63 ; and in the Recueil des Actes de la Societe de Sante de Lyon. NOTE. 19. p. 153.—Vide Chambon, Malad. de la Grossesse, Tom. II. p. 373. Case by St. Maurice, in Phil. Trans. No. 150. p. 285. In the case re- lated by La Rocque, the ovarium was found ruptured, and the abdomen full of blood. Journ. de Med. 1683. Boehmer found the ovarium ruptured, and the foetus half expelled. Obs. Anat. fasc prim. Dr. Forrestier's patient, af- ter violent cholic pains, voided blood by the anus. The hemorrhage and fain- ing fits proved fatal. The foetus was found in the ovarium. Annals of Medi- cine, Vol. III. p. 379. NOTE 20. p. 153.—Vide Rccderer, Elemens. c. 15, f 758. In Mr. Dumas' case, a fluid like chocolate was drawn off by tapping, which was twice per- formed. The ovarium contained hair, bones, &c. La Med. Eclaree, Tom. IV. p. 65. Mr. Bell's tubal case excited ascites. NOTE 21. p. 153.—Vide Dr. Kelly's case, in Med. Obs. and Inquiries, Vol. HI. p. 44. In Mr. Clarke's case, the placenta was attached to the kidneys and intestines. Mem. of Med. Society, Vol. III. p. 197. In the Mem. of the Acad, of Sciences, there is a case related, where the placenta adhered to the lumbar vertebrae. In the history by La Coste, it was placed under the stom- ach and coion. Vide (Euvresde Duverney, Tom. II. p. 363. In Mr. Turnbull's case, it was very thin, and adhered to the intestines. Mem. of Med. Society, Vol. III. p. 176. A case of ventral pregnancy, complicated with hernia, is re- lated by M. Martin in the Recueil des Actes de la Societe de Sante de Lyon. Courtial found it adhering to the stomach and colon. 369 NOTE 22. p. 154.—Dr. Maclarty relates the case of a negre&s, where the breech of the child protruded through an ulcer, at the lower part of the abdo- minal tumour, and the arm at the upper part of the tumour. The intermediate portion of skin was divided, and the foetus extracted. The head of the child stuck pretty firmly, but was brought out with the forceps. There was no pla- centa, but putrid matter was discharged with the child. The woman recover- ed. Med. Comment. Vol. XVII. p. 481. Another case is related by Duver- ney, where the child was extracted from the groin ; and this is one of the rare instances where the placenta was not destroyed. It was extracted with the child. (Euvres, Tom. II. p. 357. Cyprianus gives an instance of the child being removed, after having been retained twenty-one months. Histor. Foetus. Hum. Salva Matre, ex Tuba. Excisi. Mr. Brodie enlarged the navel with a lancet. Phil. Trans Vol. XIX. p. 580. See also M. Baynham's case, in Med. Facts, Vol. I. p. 73. In Mr. Bell's case an incision four inches in length was made, and the bones of two children extracted. Med. Comment. Vol II. p. 72. Dr. Haighton relates an interesting case, where some bones were dis- charged by the vagina, but the tumour also pointed above the pubis, and through this one of the ribs appeared The practitioner made an incision, but so great hemorrhage came on, that he was obliged to apply a bandage till next day, when he extracted the bones. The woman recovered. Med» Records, p. 260. Dr. M'Knight performed the operation in the twenty-second month, although the woman enjoyed tolerable health : very dangerous symp- toms supervened, but the woman, who certainly was brought into a very haz- ardous state by the premature operation, did recover. No placenta was found. Mem of Med. Society, Vol IV. p. 342. NO I'E 23. p. 155.—In Dr.Morley'scase, this happened two years after the original abscess had healed. Phil. Trans. Vol. XIX. p. 486. Mr. Moyle de. tails a history, where the abcess first of all burst, in consequence of leaping over a hedge. Bones continued to be discharged for a year, without much in- jury to the health. The abscess then healed, but three years afterwards a tumour again appeared, and, in consequence of exertion, burst; when about a yard of intestine protruded. Some days elapsed before Mr. Moyle saw her. The intestine was then gangrenous, but she lived 12 days longer, and the por- tion was thrown off before death. Med. Jour. Vol. VI. p. 52. NOTE 1. p. 186—Mr. Pearson relates a case, where the uterus was retro- verted, in consequence of being scirrhous. Vide Pearson on Cancer, p. 113. Dr. Marcet gives an instance where the uteius was retroverted, without preg- nancy producing constipation and vomiting. Vide Cooper on Hernia, part II. p. 68. NOTE 2. p. 186.—M. Baudelocque relates a case, where the fundus uteri protruded at the os externum, the patient at the same time having violent inclination to expel something. He was, however, able speedily to reduce the womb to the proper state. Vide l'Art, &c. } 251. In Dr. Bell's case, a gortion of the rectum was protruded by the .uterus, Med Facts, Vol. Vtlk p. 32 5 A 370 NOTE 3. p. 187-—M. Baudelocque gives a case of this kind, § 253. In Dr, Bell's case, as the woman complained for five weeks of dysuria only, it is likely that for that period the retroversion was not complete. Med. Facts, Vol. VIII. p. 32. Dr. Hunter supposed that it might take place in various degrees; it might be complete, or semi-complete, or even the os uteri might remain in its natural situation. He says, that Dr. Combe and he saw a case, where the os uteri was pushing out as in a procidentia; but this, perhaps, will not be admitted to have been retroversion. Med. Obs. and Inq. Vol. V. p. 38S. In the same volume, p. 382, Dr. Garthshore relates an instance of semi« retroversion. NOTE 4. p. 187.—In the case described by Dr. Hunter, Med. Obs. and Inq. Vol. IV. p. 400. the bladder after death was found to be amazingly disten- ded, but not ruptured. NOTE 5. p. 187—In Mr. Lynn's case, the bladder burst, and immediately afterwards the woman miscarried, but the uterus after death was found to be still displaced. Med. Obs. and Inq. Vol. V. p. 388. Dr. Squire relates an in- stance in which the bladder also gave way. Med. Review for 1801. NOTE 6. p 187.—In Mr. Wilmer's case, the belly was greatly distended; six pints of urine were drawn off, but the woman soon died. On inspecting the body, the bladder, from the disease of its surface, was found to contain a quantity of coagulated blood, and the inflammation had spread to the colon. In this case, the umbilicus was protruded like half a melon, and the disease was at one time taken for hernia. The uterus was found to be so firmly wedg- ed in the pelvis, that it could not be raised up till the symphysis pubis was sawed away. Wilmer's Cases, p. 284. NOTE 7. p. 187.—In Dr. Ross's patient, after the uterus was reduced, abortion took place ; and the woman dying, the bladder was found to be thick- ened, and adhering to the navel. Annals of Medicine Vol. IV. p. 284, NOTE 8. p. 187-—This is illustrated by Dr. Garthshore's patient, who, notwithstanding these symptoms, ultimately did well. After the reduction of the womb she miscarried, and foetid lumps were for some time discharged from the bladder. Med. Obs. and Inq Vol. V. p. 382. NOTE 9. p. 187-—In Mr. Croft's case, the disease was of a month's stand- ing, the woman was oedematous, and she was supposed to have dropsy; but by introducing the catheter, seven quarts of urine were drawn off. The in- troduction was daily repeated for some time, and then occasionally, as circum- stances required, for three weeks. The swelling of the legs went off, and the uterus gradually rose. Med. Jour. Vol. XI. p. 381. NOTE 10. p. 187.—A case is related by Mr. Ford, in which the catheter, being allowed to slip into the bladder, produced a sinous ulcer. Med. Facts, Vol. I. p. 96. NOTE 11-p- 188.—In Mr Hooper's case, whenever the tumor was press- ed back, the woman called out that she could now make water Med. Obs. and Inq- Vol. V. p. 104. 371 NOTE 12. p. 188.—This was done by Dr. Cbeston. The woman remained long very ill, but she carried her child to the full time, and recovered. Med. Commun. Vol. II. p. 96. In one instance, by using a long trocar, the uterus was wounded, and the woman died. NOTE 13. p. 188.—Dr. Hun ter mentions a case, in which the uterus re- covered itself immediately after the bladder was emptied. Med. Obs. Vol. IV. p. 408. And In Mr. Croft's second case, the water having been drawn off for six days, the uterus suddenly rose. Lon. Med. Jour. Vol XI. p. 384. NOTE 14. p. 189—Both Dr. Ross's patient, and Dr. Cheston's patient, the latter of whom recovered, complained of uneasiness in the throat, which Dr. C. considers as a mark of slow peritoneal inflammation. NOTE 15. p. 190.—This circumstance has been mentioned by different wri- ters, and a distinct case is related by Mr. Merriman, in the Med. and Phys. Jour. Vol. XVI. p. 388. Mrs. F. being about five months pregnant, was sud- denly terrified, and felt as if her inside were turned upside down. The symp- toms, however, were not very acute, for she voided the urine in the last month of gestation, though with pain and some difficulty. On the 16th of June, she had some pains, and a discharge of serous fluid ; no os uteri could be felt, but a large semi-globular tumour at the back part of the vagina, bearing down to- ward the perinseum. The pains brought on fever, and at last delirium and convulsions. She was bled, and had a clyster, after which she got some sleep, and the pains continued moderate, though regular, for two or three days, and she passed both urine and stools On the 20th, nothing like os uteri could be felt; but on the 21st, there was perceived a thick flattened fleshy substance descending into the vagina, and very soon the uterus was restored to its na- tural situation. The substance was found to be the scalp of the child, con- taining loose bones. The child and placenta were delivered, and the mother recovered. NOTE 16. p. 191.—In Mr. Bird's case, the accident succeeded to stooping, inwashingclothes. Med. Obs and Inq. Vol. V. p. 110. In Mr Hooper's case the woman was frightened by an ox, and in attempting to escape, fell down, after which the symptoms appeared. Mr. Evan's patient ascribed it to lifting a burden. Med. Comment. Vol. VI. p. 215 ; and Mr. Swan's patient to a fall, p. 217. Mr. Merriman's patient first complained after being suddenly terrified; and Mr Wilmer's patient had the uterus retroverted, after being fatigued with weeding. NOTE 17. p. 192.—Vide Chambon. Malad. de la Grossesse, p. 16. M. Bau- delocque relates a case from the practice of Choppart, where it was produ- ced in the second month of pregnancy, by the action of an emetic. L'Art, &c. } 255. NOTE 18. p. 192.—Sometimes the hemorrhage proves fatal. A singular case is to be met with in the Medical Facts, Vol. III. p. 171, by Canestrini, where the woman had a double uterus. One of the uteri, after some pains, burst in the fourth month. The ovum was found entire in the abdomen, and much blood was effused. 372 NOTE 19. p. 192.—A twin case is related by Dr. J. Hamilton, where the uterus was so thin, that even the sutures of the head could be felt through the abdominal parietes. Violent pains were produced by the motion of the child, the uterus felt very light, and the woman had been exposed to a degree of vie lence. This case had a very considerable resemblance, in some respects, to a ruptured uterus, but she was delivered safely of two children. Cases, p. 124. NOTE 20. p. 192.—Sometimes the tumour rather increases. In Dr. Percival's case, the belly became much larger after the accident, and continued so for about a year. Then it subsided all at once, when the woman was in a recum- bent posture. Med. Comment. Vol. II p. 77. NOTE 21. p. 193—Dr. Drake's case, where the uterus seemed to burst in the fourth month, terminated by suppuration at the navel. Excrement was for some time discharged at the opening. Phil. Trans. Vol. XLV. p. 121.—A washerwoman at Brest had the uterus ruptured by a fall in the seventh month, and ultimately expelled the foetus at the navel. Mem. of Acad, of Scien- ces for 1709.—Guillerm, in the same work for 1746, mentions a woman who had the womb ruptured by a fall in the sixth month. She immediately fainted, and a discharge took place from the vagina. The child was expelled by the anus.—See also the cases by Dr. Percival, Mr. Wilson, &c. NOTE 22 p. 193. In the Journ. de Med. for 1780, there is a case of a wo- roan, who had the uterus ruptured in the fourth month of pregnancy. The ac- cident was followed by uterine hemorrhage, which continued for some time. The menses returned, but the belly did not subside. In the ninth month she died. The uterus was found of the natural size, but the rent was still percep- tible. NOTE 23. p. 193. In the Journal de Med. for 1780, a case is detailed of a woman, who, in the month of January, being then seven months pregnant, was squeezed betwixt the wall and a carriage, and had the uterus ruptured. She instantly felt violent pain in the belly, and a discharge took place from the va- gina, which continued in variable quantity for six weeks. The strength gradually sunk and in June she began to vomit, and continued to do so for several days, when she died. The abdomen was found inflamed, and contain- ed the remains of a putrid child. The rent was visible in the womb NOTE 24. p. 193.—In Mr. Wilson's patient, the accident was produced by being kicked. She complained of pains all night after the injury, and next day had a sanguineous discharge from the vagina, and soon afterwards was attacked with violent griping pain. The foetus was ultimately discharged. by an abscess, bursting externally. Annals of Med. Vol. II. p. 317, and Vol. IV. p 401.—Dr. Garthshore's patient ascribed it to violent exercise. Med. Jour- nal, Vol. VIII. p. 334.—Mr. Goodsir's patient to exertion. Annals of Med. Vol. VII. p. 412.—In the 5th and 6th volume of the Journal de Med. are two cases, the first produced by a fall from a tree, the second by a bruise from a waggon. Other instances, if necessary, might be added, 373 BOOK II. CHAP. II. NOTE 1. p. 291.—" The Greenlanders, mostly, do all their common business M just before and after their delivery; and a still-born or deformed child is fr seldom heard off." Crantz's History of Greenland, Vol. I. p. 161. Long tells us, that the American Indians, as soon as they bear a child go into the water and immerse it. One evening he asked an Indian where his wife was ; " he supposed she had gone into the woods, to set a collar for a partridge." 'In about an hour she returned with a new born infant in her arms, and coming up to me, said, in Chippoway, " Oway saggonash pay- '• shik shomagonish;" or, " Here, Englishman, is a young warrior." Tra. vels, p. 59. " Comme les accouchemens sont tres-aises en Perse, de meme que dans les ** autxes pais chauds del'Orient, il n'yapointde sages femmes. Lesparentes " agees et les plus graves, font cet office, mais comme il n'y a gueres de vi- " eilles matrones dans le haram, on en fait venir dehors dans le besoin." Voyages de M. Chardin, Tom. VI. p. 230. Lempriere says, " Women in this country, (Morocco,) suffer but little in- «' convience from child bearing. They are frequently up next day, and go " through all the duties of the house with the infant on their back." Tour, p. 328. Winterbottom says, that, " with the Africans, the labour is very easy, " and trusted solely to Nature, nobody knowing of it till the woman appears «• at the door of the hut with the child." " Account of Native Africans," &c. Vol. II. p. 209. The Shangalla women, " bring forth children with the utmost ease, and " never rest or confine themselves after delivery; but washing themselves " and the child with cold water, they wrap it up in a soft cloth, made of the «• bark of trees, and hang it up on a branch, that the large ants with which " they are infested, and the serpents, may not devour it" Bruce's Travels, Vol. II. p. 553. In Otaheite, New South Wales, Surinam, &c. parturition is very easy, and many more instances might, if necessary, be adduced. We are not how- ever to suppose, that in warm climates women do not sometimes suffer ma- terially. In the East Indies, " many of the women lose their lives the first «' time they bring forth." Bartolomeo's Voyage, chap. 11. Undomesticated animals generally bring forth their young with consider- ble ease, but sometimes they suffer much pain, and, when domesticated, oc- casionally lose their lives 374 CHAP. II. NOTE 1. p. 313.—Dr. Smellie relates two cases of this kind. In the first he brought away the indurated portion, but the woman died from hemorr- hage. In the second he left the adhering portion, and the woman recovered. Coll. 23. c 1, and 2. Seea lso Giffard's cases, c. 119, and 127; and La Motte, c. 358, and 362. In these, although the adhesion was very intimate, he brought away the placenta in pieces. END OF THE FIRST VOLUME. -J ■ AT B.tfc7f«-. ■ . n «ie& 3fr J : 'V? ' v v. ■■»•• :t^' * ^H i^H ■ ■ ■ h •>>■;-* ^H ■ K* ^^l