f „£* r-rvm *f* ,*i." >£.* '*"' '-^Sffty'v'" -^^BP Surgeon General's Office No. y^ & $ .'J TIIE PRINCIPLES OF MIDWIFERY; INCLUDING THE DISEASES OF WOMEN AND CHILDREN. BY JOHN JJJIRNS, M. D. LECTURER ON MIDWIFERY, AJTD MEMBER OF THE FACULTY OF PHYSICIANS AND SURGEONS, GLASGOW. THE FOURTH AMERICAN, FROM THE THIRD LONDON EDITION, GREATLY ENLARGED. WITH IMPROVEMENTS AND NOTES, BY THOMAS C. JAMES, M. D. PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA. PUBLISHED BY EDWARD & RICHARD PARKER, BENJAMIN WARNEn, MATHEW CAREY & SON, BENJAMIN & THOMAS KITE, SOLOMON W. CONRAD, A>THONY FINXEY, AND MOSKS THOMAS. J. R, A. Skerrett, Printer. 1817. DISTRICT OF PENNSYLVANIA, TO WIT: Be it remembered, That on the seventh day of September, in the thirty-eighth year of the Independence of the United States of America, A.D. 1813, Benjamin and Thomas Kite, Johnson and Warner, Edward Parker, Kimber and Conrad, Mathew Carey, Moses Thomas, Anthony Finley, and Redwood Fisher, of the said District, have deposited in tliis office the title of a Book, the right whereof they claim' as Proprie- tors, in the words following, to wit: " The Principles of Midwifery; including the diseases of Women and " Children. By John Burns, Lecturer on Midwifery, and Member of " the faculty of Physicians and Surgeons, Glasgow. The third Ameri- " can, from the second London Edition, much enlarged. With Improve' *' merits andJYotes, by Thomas C. James, M. D. Professor of Midwifery "in the University of Pennsylvania" In conformity to the Act of the Congress of the United States, intituled, " An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts and Books, to the Authors and Proprietors of such copies during the times therein mentioned."—And also to the Act, en- titled, " An Act supplementsry to an Act, entitled' An Act for the En- couragement of Learning, by securing the Copies of Maps, Charts and Books, to the Authors and Proprietors of such copies during the times therein mentioned,' and extending the benefits thereof to the Arts of designing, engraving, and etching historical and other Prints." D. CALDWELL, Clerk of the District of Pennsylvania. PREFACE OF THE AUTHOR. IN preparing this work, I have endeavoured to pro- ceed as much as possible upon the method of induction. [ have collected with care the different cases which have been made public, as well as my.own private ob- servations. To these I have added the opinions and advices given by others, in so far as they seemed to be founded on facts, and supported by experience. From the whole I have deduced, in the different parts of my subject, both the symptoms and the practice. The anatomical descriptions, I have given from dis- sections and preparations before me whilst writing. I intended to have added to the text, copious re- ferences to the opinions and cases contained in systems, or scattered through other publications. This would have rendered the present book, in some manner, an index to those already published, and been of con- siderable service to practitioners, who wished to con- sult them upon any particular point. But in spite of all my endeavours, this work has extended to a length which rendered it necessary to strike out many re- ferences, and shorten the account of cases, to prevent it from swelling to a size which would have rendered it less generally useful. Whilst I thus state the plan on which I have pro- ceeded, I acknowledge myself deeply sensible, that its execution does not bear any proportion to the impor- IV tance of the subject. Should this work fall only into the hands of those, competent to judge on their profes- sion, it would, if faulty or deficient, do little harm: but should it ever be circulated more extensively, it must like other systems and elements, have an in- fluence on the opinions and future practice of the stu- dent of midwifery; and will prove useful or injurious to society, according to the correctness of the principles it contains. When I consider how important the dis- eases of women and children are, and how much de- pends on the prudent management of parturition, I feel the high responsibility which falls on those who pre- sume 1 give lessons in midwifery. I do, however, sincerely trust, that the precepts I have inculcated will, in general, be found agreeable to the experience and practice of our best teachers ; and, on a review of the whole, I cannot say that I have either wasted the reader's time in idle theory, or misled his opinion by mere speculation. In preparing a third edition for the press, I have carefully revised the whole work, and have made many additions, which I hope will prove useful. Glasgow, October, 1814. PREFACE OF THE EDITOR. IT is not the intention of the present editor to incur the fault so sharply reprehended by Johnson, and " re- tard the instruction" contained in the ensuing volumes, by an unnecessary and prolix preface. He will only briefly mention, that our author, " equally experienced as a teacher and practitioner," has, from the a( .iow- 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- hook, 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,f ls 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 lSlO; f The work was originally published in one volume VI One great advantage of this work to the student soli- citous of full and accurate information on the subjects of which it treats, is to be experienced in the very valu- able notes and references of the author, to almost all tliat has been communicated by practitioners of deserv- ed celebrity, on parallel subjects or cases. In tiiis point of view, it may be considered as the Common- place Book of an immense fund of the most useful practical knowledge, indispensable as a guide to the in- experience of the student, and earlier practitioner, and of no ordinary utility and aid, to the maturer acquire- ments of advanced and established professional skill. This edition has been considerably enlarged and im- proved by the author. The sections on abortion and uterine hemorrhage, will be found to have been very considerably extended, and rendered of far greater va- lue .—indeed, they may now be considered, as contain- ing the essence of his separate Treatises on those very interesting subjects, which have for some time enjoyed the approbation of the public. The new articles, totally omitted in the former edi- tion, but by the author introduced into this, are those on pneumonia, on ephemeral fever, on weed or intesti- nal fever, and on diarrhoea, as existing in the puerpe- ral state, and on chorea, on bronchitis, and on peri- tonitis, as the diseases of the infantile age. These, it is presumed, will not fail to give additional interest to the work. The editor has taken the liberty of introducing into the text, a section on the difference between the male and female pelvis; which as he conceived, the author ought not to have omitted; and Dr. Clarke's account of the cauliflower excrescence of the os uteri. Whether Ml this is only a variety of the spongoid tumour, he will leave to the reader to decide. It appears to assume some difference in its form and train of symptoms. The history is from the pen of an accurate observer of na- ture, and a judicious and experienced practitioner. As Baudelocque has explained the mechanism of parturition, more fully and minutely than almost any other writer, and as his work on midwifery has obtain- ed considerable reputation with the medical public of the United States, it has been judged proper, occasion- ally, to give a general view of his divisions of labour, together with the several species of presentations, which it may be useful to keep in recollection in actual practice. Some tables, relative to this part of our sub- ject, from the last edition of his valuable work that have not, as far as we know, been hitherto translated, will also be given in the appendix. These, it is hoped, will not be entirely devoid of interest, either to the stu- dent or practitioner. The chief mass of the notes in Dr. Chapman's edi- tion of our author's production, have been, by permis- sion retained in this; these are marked with the letter C. The notes added by the present editor have alpha- betical references, and are thus sufficiently distinguish- ed from those of the author, and of the intelligent editor of whose information we have availed ourselves, and to whom we have just alluded. These will be found to be altogether of a practical nature, and are intended solely to explain, or illustrate the text; as it has been found rarely necessary to differ in sentiment from one, whose opinions seem generally to be founded on the solid basis of practical truth. Any additions made to the text, or Author's notes, are included between brackets. viii The Author has rendered this last edition more in- teresting, by some valuable additional matter, and the Editor has subjoined a few notes, which he hopes will not be found entirely nugatory. Philadelphia, July 1st, 1817. CONTENTS. BOOK I. Of the Structure, Functions, and Diseases of the Pelvis and Uterine System, in the unimpregnated state, and during Gestation. CHAPTER I. Of the Bones of the Pelvis. Section 1. General view - Page 1 Section 2. Ossa innominata ... 2 Section 3. Sacrum and coccyx - 5 CHAPTER II. Of the Articulation of the Banes 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 female from male pelvis 14 CHAPTER III. Of the soft parts which line the Pelvis. Section 1. Muscles.....16 Section 2. Arteries - - - - - - 17 Section 3. Nerves.....18 Section 4. Lymphatics.....19 x CHAPTER IV. Of the Dimensions of the Pelvis. Section 1. Brim and outlet Section 2. Cavity - Section 3. Pelvis above the brim Section 4. Axis of the brim and outlet CHAPTER V. Of the Head of the Child, and its progress through the Pelvis in Labour. Section 1. Bones of the head - 24 Section 2. Size of the head ... - 26 Section 3. Passage of the head - 27 CHAPTER VI. Of Diminished Capacity and Deformity of the Pelvis. Section 1. Deformity from rickets 29 Section 2. Deformity from malacosteon - 31 Section 3. Deformity from exostosis and tumours 33 Section 4. Means of ascertaining the dimensions and size of the head when broken down - 35 CHAPTER VII. Of Augmented Capacity of the Pelvis, 36 CHAPTER VIII. Of the external Organs of Generation. Section 1. General view - 37 Section 2. Labia and nymphse ... 58 Section 3. Clitoris.....38 Section 4. Urethra .... 39 Section 5. Orifice of vagina and hymen - 41 CHAPTER IX. Of the Internal Organs of Generation. Section 1. Vagina - 42 Page 20 21 23 24 XI Section 2. Uterus and its appendages - Page 43 CHAPTER X. Of the Diseases of the Organs of Generation. Section 1. Abscess in the labium - - 47 Section 2. Ulceration of the labia - - 48 Section 3. Excrescences on the labia - 51 Section 4. Scirrhous tumours - - 51 Section 5. Polypous tumours - - 52 Section 6. OZdema .... 53 Section 7. Hernia, laceration, &c. - - 53 Section 8. Diseases of the nymphse - 54 Section 9. Diseases of the clitoris - - 55 Section 10. Diseases of the hymen 56 Section 11. Laceration of the perinaeum - 57 Section 12. Imperfection of the vagina - 59 Section 13. Inflammation and gangrene of the vagina ----- 59 Section 14. Induration, ulceration, and polypi 60 Section 15. Inversion 60 Section 16. Watery tumour - - - 61 Section 17. Hernia - - - 61 Section 18. Encysted tumour and varices - 62 Section 19. Spongoid tumour - - 63 Section 20. Erysipelatous inflammation - 63 Section 21. Fluor alhus 65 Section 22. Affections of the bladder - - 70 Section 23. Excrescences in the urethra - 74 Section 24. Deficiency and mal-forination of uterus 76 Section 25. Hysteritis ... 77 Section 26. Ulceration of the uterus - - 78 Section 27. Scirro-cancer - - - 80 Section 28. Tubercles - - - 84 . Section 29. Spongoid tumour - - 86 Section 30. Cauliflower excrescence from os uteri 87 Section 31. Calculi -.. gg Section 32. Polypi - - - - 90 Section 33. Malignant polypi - 95 VOL. t. 2 a xn Section 34. Moles . Page 96 Section 35. Hydatids - 97 Section 36. Aqueous secretion - 99 Section 37. Worms - 100 Section 38. Tympanites - 100 Section 39. Prolapsus uteri - 101 Section 40. Hernia - 107 Section 41. Dropsy of the ovarium - 108 Section 42. Other diseases of the ovarium 114 Section 43. Deficiency - 115 Section 44. Diseases of the tubes and ligaments 115 CHAPTER XL Of Menstruation, - 116 CHAPTER XII. Of Diseased States of the Menstrual Action. Section 1. Amenorrhoea - - - 121 Section 2. Formation of an organized substance 129 Section 3. Dysmenorrhea - - 129 Section 4. Copious Menstruation - - 131 Section 5. Menorrhagia - - - 131 CHAPTER XIII. Of the Cessation of the Menses, - 137 CHAPTER XIV. Of Conception, and the term of Gestation, - 139 CHAPTER XV. Of the Gravid Uterus. Section. 1. Size and position - - 143 Section 2. Developemcnt of the uterus, and state of its cervix - 144 Section 3. Muscular fibres - - 145 Section 4. Ligaments - 146 Section 5. Vessels - 147 Section 6. Of the foetus - 148 Section 7. Its peculiarities - - 153 Kill Section 8. Umbilical cord Section 9. Placenta Section 10. Membranes and liquor amnii Section 11. Decidua CHAPTER XVI. Of Sterility, CHAPTER XVII. Of Extra-uterine Pregnancy. Section 1. Symptoms, progress, and species Section 2. Treatment CHAPTER XVIII. Of the Signs of Pregnancy. CHAPTER XIX. Of the Diseases of Pregnant Women. Section 1. General effects - - - 177 Section 2. Febrile state - - - 179 Section 3. Vomiting - - - - 181 Section 4. Heartburn - - - 183 Section 5. Fastidious taste - - - 183 Section 6. Spasm of stomach and duodenum 184 Section 7. Costiveness - - - 184 Section 8. Diarrhoea - - 186 Section 9. Piles - - - - 187 Section 10. Affections of the bladder - 188 Section 11. Jaundice - - - 190 Section 12. Coloured spots - - 190 Section 13. Palpitation - - - 190 Section 14. Syncope - - - - 191 Section 15. Dyspnoea and cough - - 192 Section 16. Haemoptysis and heematemesis - 193 Section 17. Head-ache and convulsions - 193 Section 18. Tooth-ache - - - 195 Section 19. Salivation - - - 195 Section 20. Mastodynia - - - 196 Page 157 160 163 164 166 168 172 173 XIV Section 21. ffidema - - Page 196 Section 22. Ascites - - - 197 Section 23. Redundance of liquor amnii - 199 Section 24. Watery discharge - - 201 Section 25. Varicose veins - ► - 203 Section 26. Muscular pain - - 203 Sec tion 27. Spasm of ureter - - 204 Section 28. Cramp - - - 204 Section 29. Distension of the abdomen - 204 Section 30. Hernia ... 205 Section 31. Despondency - 206 Section 32. Retroversion of uterus - 206 Section 33. Antiversion - - - 213 Section 34. Rupture of uterus - - 214 Section 35. Abortion, and treatment of pregnant women ... - 217 Section 36. Uterine hemorrhage - - • 255 Section 37. False pains - - - 298 Notes 301 THE PRINCIPLES OF MIDWIFERY. BOOK I. OF THE STRUCTURE, FUNCTIONS, AND DISEASES OF THE PELVIS AND UTERINE SYSTEM, IN THE UNIMPREGNATED STATE, AND DURING GESTATION. CHAP. I. Of the Bones of the Pelvis. § 1. GENERAL VIEW. THE 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 the parts concerned in parturition, is the pelvis, which must be exa- mined, not only on account of its connection with* the uterus and vagina, but also of its own immediate relation to the de- livery of the child, and the obstacles which, in many instances, it opposes to its passage. vox. t. b 2 The pelvis consists, in the full grown female, of three large bones, two of which are very irregular, having no near resemblance to any other object; on which account they have been called the ossa innominata. These form the sides and front of the bason or pelvis. The back part consists of a triangular bone, called the os sacrum, to the inferior extremi- ty or apex of which, is attached, by a moveable articulation, a small bone, which, from its supposed resemblance to. the beak of a cuckoo, has been named the os coccygis. The os innominatum, in infancy, consists of three separate pieces: the upper portion is called the ilium, or haunch bone; the under, the ischium, or seat bone; and the anterior, which is the smallest of the three, is called the os pubis, or share bone. These all join together in the acetabulum, or socket, formed for receiving the os femoris, and are connected by a very firm gristle or cartilage. This, before the age of pu- berty, is converted into bone, so that the three different pieces are consolidated into one, though the names given to the bones originally are still applied to the different parts of the united os innominatum. The sacrum also, which seems to consist only of one curv- ed triangular bone, is really made up of several pieces, which, in the child, are nearly as distinct as the vertebrae, to which, indeed, they bear such a resemblance, that they have been considered as a continuation of them; but from their imperfect structure, and subsequent union, they have been called the false vertebrae. The bones of the pelvis are firmly joined together, by means of ligaments and intermediate cartilages, and form a very irregular canal, the different parts of which must be briefly mentioned. § 2. OSSA INNOMINATA. When we look at the pelvis, we observe, that the ossa innominata naturally divide themselves into two parts, the up- permost of which is thin and expanded, irregularly convex on its dorsum or outer surface, hollow on the inside, which 3 is called the costa, and bounded by a broad margin, extend- ing in a semicircular direction from before backwards, which is called the crest of the ilium. The under part of the os in- nominatum is very irregular, and forms, with the sacrum, the cavity of the pelvis. The upper expanded part has little influence on labour, and serves, principally, for affording attachment to muscles. In the under part, we have several points to attend to. 1st. The upper and under parts form an angle with each other, marked by a smooth line, which is a continuation of the margin of the pubis, or anterior part of the bone. It extends from the symphysis pubis, all the way to the junc- tion of the os innominatum with the sacrum, and is called the linea iliopectinea. It is quite smooth and obtuse at the sides, where the two portions form an angle; but at the anterior part, where the upper portion is wanting, it is sharp, and sometimes is elevated into a thin spine like the blade of a knife. 2d. The upper portion is discontinued exactly about the middle of this line, or just over the acetabulum; and at the termination, there is from this portion an obtuse projection overhanging the acetabulum, which is called the inferior spinous process of the ilium, to distinguish it from a similar projection about half an inch higher, called the superior spine. 3d. The under part of the bone is of the greatest import- ance, and in it we recognise the following circumstances. Its middle is large, and forms on the outside a deep cup or acetabulum, for the reception of the head of the thigh bone. On the inside, and just behind this cup, it forms a smooth polished plate of bone within the cavity of the pelvis, which is placed obliquely with regard to the pubis, and has a gen- tle slope forward. The cone of the child's head, in labour, moves downwards, and somewhat forwards, on this, as on an inclined plane; it may be called the plane of the ischium, although a part of it be formed by the ilium. 4th. Standing off from the back part of this, about two inches beneath the linea iliopectinea, is a short projection, 4 called the spine of the ischium, which seems to encroach a little on the cavity of the pelvis, and is placed, with regard to the pubis, still more obliquely than the plane of the is- chium. It must, consequently, tend to direct the vertex, as it descends, still more towards the pubis. 5th. Beneath this, the ischium becomes narrower, but not thinner; on the contrary, it is rather thicker, and terminates in a rough bump, called, the tuberosity of the ischium. 6th. Next, we look at the anterior part of the bone, and find, that just before the plane of the ischium, there is a large hole in the os innominatum. This is somewhat oval in its shape; and at the upper part within the pelvis, there is a depression in the bone, which, if followed by the finger or a probe, leads to the face of the pelvis. The hole is called the foramen thyroideum. 7th. Before this hole the two ossa innominata join, but form with each other on the inside, a very obtuse angle, or a kind of smooth rounded surface, on which the bladder partly rests. The junction is called the symphysis of the pubis. 8th. The two bones, where they form the symphysis, are joined with each other for about an inch and a half; then they divaricate, forming an angle, the limbs of which ex- tend all the way to the tuberosity of the ischium. This se- paration or divarication is called the arch of the pubis, which is principally constructed of the anterior boundary of the foramen thyroideum, consisting of a column or piece of bone, about half an inch broad, and one-fourth of an inch thick, formed by the union of the ramus of the pubis, and that of the ischium. 9th. At the upper part of the symphysis, or a very little from it, the os innominatum has a short obtuse projection, called the crest of the pubis, into which Poupart's ligament is inserted; and from this there runs down obliquely, a ridge on the outside of the 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 5 ischium, it extends backwards to join the sacrum; but in do- ing so, it forms a very considerable notch or curve, the con- cavity of which looks downwards. When the sacrum is joined to the bone, this notch is much more distinct. It is called the sacro-sciatic notch or arch : for one side is formed by the ischium, and is about two inches long; the other is formed chiefly by the sacrum, and is about half an inch longer. In the recent subject, strong ligaments arc extended at the under part, from the one bone to the other, so that this notch is converted into a regular oval hole. llth. Lastly, this notch being formed, the bone expands backwards, forming a very irregular surface for articulation with the sacrum; and the bones being joined, we find that the os innominatum forms a strong, thick, projecting ridge, ex- tending farther back than the spinous processes of the sa- crum. This ridge is about two inches and three quarters long, and is a continuation of the crest of the ilium, but is turned downwards; whereas were the crest continued in its former course, it would meet with the one from the opposite side, behind the top of the sacrum, forming thus a neat semi- circle; but this ridge, if prolonged on botli sides, would form an acute angle, the point of junction being opposite the bot- tom of the sacrum. From this strong ligaments pass to the sacrum, to join the two bones. § 3. SACRUM AND COCCYX. The sacrum forms the back part of the pelvis. It is a triangular bone, and gently curved; so that, whilst a line drawn from the one extremity to the other, measures, if it subtend the arch, about four inches; it will, if carried along the surface of the bone, measure full half an inch more. The distance betwixt the first or straight line, and the middle of the sacrum is about one inch. The breadth of the base of the sacrum, considered as an angular body, is full four inches : the centre of this base is shaped like the surface of the body of one of the lumbar vertebrse, with the last of which it joins, forming, however, an angle with it, called the 6 great angle, or promontory of the sacnun.(a) From this thG bone is gently curved outward on each side, toward the sacro- iliac junction, contributing to the formation of the brim of the pelvis. The upper half of the side of the bone is broad and irre- gular for articulation with the os innominatum. The ante- rior surface of the bone is smooth and concave; but often we observe transverse ridges, marking the original separation of the bones of the sacrum. Four pair of holes are found dis- posed in two longitudinal rows on the face of the sacrum, communicating with the canal which receives the continua- tion of the spinal marrow; through these the sacral nerves issue. These holes slope a little outward, and betwixt the two rows is the attachment of the rectum. The posterior Surface of the bone is very irregular; and, we observe, 1st, The canal extending down the bone, for receiving the con- tinuation of the spinal marrow. 2d. At the upper part of this are two strong oblique processes, which join \vith 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 vertebrse. 4th. The rest of the surface is very irregular and rough; and we observe, corresponding to the holes for transmitting fhe 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 fi rst, al- together cartilaginous, and cylindrical in its shape, but it gradually ossifies and becomes flatter, especially at the up- per part, whicli has been called its shoulder. In men it is" generally anchylosed with the sacrum, or at least moves with difliculty, but it almost always separates by maceration. In women it remains mobile, and, during labour, is pressed back (a) But more commonly the projection of the sacrum. 7 so as to enlarge the outlet of the pelvis. By falls or blows it may be luxated; and if this be not discovered, and the bone replaced, suppuration takes place about the rectum, and the bone is discharged. CHAP. II. Of the Articulation of 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 observations, led to conclude, that each bone was first of all covered at its extremity with carti- lage, and then betwixt the two was interposed a.mcdium, like the intervertebral substance, which united them. This sub- stance consists of fibres disposed in a transverse direction. M. Tenonf has lately published an account of this articu- lation ; and is of opinion, that sometimes the one mode and sometimes the other obtains. I am inclined to think, that Dr. Hunter's description is applicable to the most natural state of the part; but we often, in females, find that the in- termediate fibrous substance, especially at the posterior part, is absorbed, and its place supplied with a more fluid sub- stance ; or, on the contrary, anchylosis may sometimes take place; a circumstance which Dr. Hunter says he never saw, but which I have met with. Besides this mode of connec- tion, there is also in addition a very strong capsule to the articulation, the symphysis being covered on cxery side with * Vide Med. Obs. and Inq. Vol. II. p. 333. | Vide Mem. de l'Institut des Sciences, Tome VI. p. 1T2. 8 ligamentous fibres, which contribute greatly to the strength of the parts. § 2. SACROILIAC 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 therefore, so far as it depends on this medium, cannot be very strong; but it is exceedingly strengthened by liga- mentous fibres, which serve as a capsule; and behind, several strong bands pass from the ridge of the ilium to the back of the sacrum; sometimes the bones are united by an- chylosis. At the lower part, additional strength is obtained by two large and strong ligaments, which pass from the ischium to the sacrum, and therefore are called the sacro- sciatic ligaments. The innermost of these arises from the spine of the ischium, is very strong, but at first not above a quarter of an inch broad; it gradually expands, however, becoming at its insertion about an inch and a quarter in breadth. It passes on to the sacrum, and is implanted into the lower part of the side of that bone, and the upper part of the coccyx. It converts the sacro-sciatic notch into a regular oval hole, the inferior end of which, owing to the neat expansion of the ligament, is as round and exact as the upper. As it makes a similar expansion downwards, there is a kind of semilunar notch formed betwixt it and the coccyx. The outer liga- ment may be said to arise from the side of the sacrum, and, like the other, is broad at that part. It runs for some time in contact with the inner ligament, and parallel to it; but afterwards it separates, passing down to be inserted in the tuber ischii; and, when the ligaments separate, their surfaces are no longer parallel to each other. There is, in conse- quence of tliis separation, a small triangular opening formed betwixt the ligaments; or rather there is an aperture like a bow, the string being formed by the under ligament, and the 9 arch partly by the spine of the ischium, and partly by the upper ligament. § 3. VERTEBRAL JUNCTION AND OBLIQUITY OF THE PELVIS. The pelvis is joined to the trunk above, by means of the last lumbar vertebra; to the extremities below, by the insertion of the thigh bones into the acetabula; and it is so placed, that when the body is erect, the upper part of the sacrum and the acetabula are nearly in the same line. The brim of the pelvis, then, is neither horizontal nor perpendi- cular to the horizon, but oblique, being placed at an angle of 35 or 40 degrees. Were the ligaments of the pelvis loosened, there would, from this position, be a tendency in the sacrum to fall directly towards the pubis, the ossa innominata reced- ing on each side. But the structure of the part adds greatly to the power of the ligaments; for it is to be observed, that in standing, and in various exertions of the body, the limbs re- act on the pelvis; and the heads of the thigh bones pressing on the two acetabula, force the ossa innominata more closely on each other at the symphysis, and more firmly on the sacrum behind. It is not possible, indeed, to separate the bones of the pelvis, unless the connecting ligaments be diseased, or external violence be applied, so as to act partially or une- qually on the pelvis. § 4. SEPARATION OF THE BONES. By external violence, the symphysis has been wrench- ed open, as was the case with Dr. Greene*; or the sacro- iliac junction mayjie separated, as in the case of the young peasant, related by M. Louis.f By some morbid affection of the symphysis, it may yield and become loosened during pregnancy, or may be separated during labour. Some have been inclined to consider this as an uniform operation of nature, intended to facilitate the birth * Phil. Trans. No. 484. f Vide Mem. de l'Acad. de Chir. Tome IV. p. 63. vol. I. c 10 of the child. Others, who cannot go this length, have never- theless conjectured, that the ligaments do become some- what slacker; and have grounded this opinion on the sup- posed fact of the pelvis of quadrupeds undergoing this relax- ation. But the truth is, that this separation is not an advan- tage, but a serious evil; and in cases of deformed pelvis, where we would naturally look for its operation, did it really exist, we do not observe it to take place.(6) When a person stands, pressure is made upon the symphy- sis, and therefore, if it be tender, pain will then be felt. In walking, pressure is made on the two acetabula alternately, and the ossa innominata are acted on b}' the strong muscles which pass from them to the thighs, so that there is a ten- dency to make the one os pubis rise above the other; but this, in a sound state of the parts, is sufficiently resisted by (b) There is an animal however, in which this separtion of the bones of the pelvis during pregnancy and parturition does really take place, and in whom it appears to be an operation of nature to facilitate the latter process.—This animal is the Guinea Pig. Le Gallois says, that upon comparing the pelvis of the female of the Guinea Pig with the head of a full grown Foetus, it appears utterly impossible, that the latter should pass through the former, if the pelvis constantly preserved the state and dimensions at any other time than that of gestation. When the female Guinea Pig is alive, the diameter of the pelvis is asserted to be but about one half of the head of the Foetus ; and nevertheless, Guinea Pigs are delivered with much ease. The duration of gestation in these animals being about 65 days.—About 3 weeks before delivery, the symphysis pubis is observed to acquire more thick- ness and a slight mobility; these are continually increasing. Eight or ten days before delivery, the two ossa pubis begin to separate from each other. This separation increases slowly at first, and only begins to go on rapidly for the three or four days which precede delivery.—At the moment of parturition, according to Le Gallois, it is such as readily to admit the middle finger, and sometimes both the middle and forefinger together. The delivery being accomplished, the bones of the pubis soon close. Twelve hours after, the distance of the separation has lessened more than one half; and 24 hours after, they are in contact at their anterior extremity; and in less than three days they are perfectly so through the whole extent of their symphysis, which then only presents a slight thickness and mobility. A few days after, nothing is to be seen. But when the females are old or sick, the union takes place more slowly. Vide Le G allois's Experiments. Note at the end of the Vol. 11 the ligaments. In a diseased state, however, or in a case of separation of the bones, there is not the same obstacle to this motion: and hence, walking must give great pain, or be alto- gether impossible: even attempts to raise the one thigh above the other, in bed, must give more or less pain, according to the sensibility or laxity of the symphysis. Standing has also an effect on the symphysis, as I have mentioned ; but some- times the person can, by fixing one os innominatum, with all the muscles connected with it, and throwing the chief weight of the body to that side, stand, for a short time, easier on one leg than on both. This is the case when one os innominatum has been more acted on than the other, at the sacro-iliac junc- tion. The person can stand easiest on the soundest side. The patient also, especially if the relaxation be accompanied with any degree of relaxation of uterine attachments, in- stinctively crosses her legs when standing, thereby obtaining relief. From these observations, we may learn the mischievous consequences of a separation of the bones, and also the cir- cumstances which will lead us to suspect that it has happened. If the bones be fully disjoined, then, by placing the finger on the inside of the symphysis, and the thumb on the outside, we can readily perceive a jarring, or motion, on raising the thigh. It is well known to every practitioner, that owing to the distension of the muscles during pregnancy, very consider- able pain is sometimes felt at the insertion of the rectus muscle into the pubis; and it is also known, that sometimes, in consequence of pregnancy, the parts about the pelvis, and especially the bladder and urethra, and even the whole vulva, may become very irritable. This tender state may be com- municated to the symphysis; or some irritation, less in de- gree than that I have mentioned may exist, which, in par- ticular cases, seems to extend to the articulation, producing either an increased effusion of interstitial fluid in the inter- mediate cartilage, and thus loosening the firm adhesion of the bones, or a tenderness and sensibility of the part, render- ing motion painful. In either case, exertion may produce a ia separation: and certainly, in some instances, has done so. The separation is always attended with inconvenience, and often with danger, especially when it occurs during parturi- tion ; for abscess may take place, and the patient sink under hectic fever; or inflammation may be communicated to the peritoneum, and the patient die in great pain. When the accident happens during gestation, it some- times takes place gradually, in consequence of an increasing relaxation of the articulation, from slow but continued irrita- tion. In the other instances, it happens suddenly after some exertion. It may occur so early as the second, or so late as the ninth month, and is discovered by the symptoms mentioned above; such as pain at the pubis, strangury, and the effects of motion. In some instances, considerable fever may take place, but in general, the symptoms are not dan- gerous, and I do not know any case which has terminated fatally before delivery. A state of strict rest, the applica- tion of a broad firm bandage round the pelvis, to keep the bones steady, and the use of the lancet and antiphlogistic re- gimen, if there be fever or much pain, are the chief points of practice. Nor must it be forgotten, for a moment, that although by these means, the symptoms arc 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 1 have been able to learn, a woman who has had this separation in one pregnancy, is not, in general, peculiarly liable to a return of it in a subsequent pregnancy, though there may be particular exceptions to this observation.1 When it happens during parturition, it sometimes takes place in a pelvis apparently previously sound; but in most instances, we have, during some period of gestation, symp- toms of disease about the symphysis; and so far from mak- ing labour easier, the woman often suffers more, when the symphysis is previously relaxed. The primary and imme- diate effects are the same as when the accident happens dur- ing pregnancy; but the subsequent symptoms are frequently 18 much more severe and dangerous, the tendency to inflamma- tion being strong. The pain may be either trifling or ex- cruciating at the moment, according to the sensibility of the parts. But even in the mildest case, great circumspection is required, violent inflammation having come on so late as a fortnight after the accident. The means used in the former case are to be rigidly employed, and the woman should keep her thighs together, and tie chiefly on her back. If the se- paration have been slight, re-union may take place in a few weeks, sometimes in a month;2 but if a great injury have been sustained, it may be many months, perhaps years before recovery be completed ; and, in such cases, it is probable, that at last, an anchylosis is sometimes formed. Either owing to the violence of the accident, or the pecu- liar state of the parts, it sometimes happens, that inflamma- tion takes place to a very considerable degree in the symphy- sis ; but it is to be remarked, that the symptoms are by no means uniformly proportioned in their severity to the degree of the separation. Inflammation is known by the accession of fever, with acute pain about the lower part of the belly, greatly increased by motion, succeeding to the primary ef- fects ; or, sometimes, from the first, the pain is very great, and not unfrequently it is accompanied by sympathetic derangement of the stomach and bowels, such as vomiting, nausea, looseness, &c. Presently matter forms, and a well marked hectic state takes place. The patient is to be treat- ed, at first, by the usual remedies for abating inflammation, such as general and local evacuation of blood, fomentations and laxatives. When matter is formed, we must carefully examine where it is most exposed, and let it out by a small puncture.3 The inflammation may be communicated to the peritoneum, producing violent pain in the lower belly, tumefaction and fever, and almost uniformly proves fatal; though frequently the patient lives until abscess takes place in the cellular sub- stance within the pelvis. If any thing can save her, it must be the prompt use of blood-letting and blisters. In almost every case of separation of the pubis, consider- 14 able pain is felt in the loins, even although the junction at the sacrum be entire, and the ossa pubis be very little asunder. But when the separation is complete, and in any way exten- sive, then the articulation of the sacrum with the ossa inno- minata,4 especially with one of them, is more injured,5 and the person is lame in one or both sides, and has acute pain about the posterior ridge of the ilium6, and in the course of the psoas and glutei muscles. The" mischief may also com- mence in the sacro-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 sacro-iliac articulation, the danger is greatly increased. In all cases of separation, when the patient has recovered so far as to be able to move, the use of the cold bath acce- lerates the cure; the general health is to be carefully attend- ed to, and any urgent symptom supervening, is to be obviated by suitable remedies. § 5. DIFFERENCE OF THE FEMALE FROM THE MALE PELVIS. [A slight inspection is sufficient to show the difference in form and proportions, between the female and the male pelvis. The crista, as well as the anterior and superior spinous processes of the ossa ilia, are farther separated in the female pelvis, hence affording a greater concavity to the iliac fossa?, and greater capacity to the large or superior pelvis. The two straits which terminate the cavity of the pelvis, differ also considerably in the two sexes. The circumference, or brim of the superior strait is larger and more rounded in the female, the sacro-vertebral projection is less prominent; the two tuberosities of the ischia are also less rough, less pro- jecting, and farther separated, than in the male; and finally, the extremity of the os coccygis does not approach so near to the arch of the pubis, which affords to the inferior strait, greater extent from its anterior to its posterior termination. With regard to the excavation of the pelvis, it is more 15 concave in the posterior part in the female, because the sa- crum has greater height and curvature; the arch of the pu- bis is broader,(c) and its branches are also turned more out- ward and forward. The region of the pubis is less convex, and the cartilage, which forms the symphysis, is thicker and shorter, offering towards the interior of the pelvis a promi- nence more remarkable than in the male. But in this very conformation, which nature appears to have intended to render labour more easy, there are certain circumstances exposing the female to peculiar inconveni- ences, which in men are more rarely observed; thus the su- perior spinous processes which anteriorly terminate the 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 epiploon, finding in this part less re- sistance and a larger aperture, must more frequently pass down and produce femoral hernia. Again, women having their hips farther separated, must necessarily step with less firmness than men: for in pro- gressing, when one leg is elevated, the centre of gravity of the body is less readily thrown upon the other, which rests on the ground; from hence results a species of clandication or vacillating gait, in which the trunk and the inferior ex- tremities, instead of advancing directly or in a straight line, describe greater or smaller arches of circles.J(d) (c) Soemmering observes, that the angle between the diverging branches ef the pubis, is in the male an acute one; but in the female forms an angle of from 80 to 90 degrees, and hence approaches nearer to the figure of an arch, from which it receives its name. (rf) Vide Capuron. cours theorique et practique, &c. Soemmering Tabuls Sceleti feminini juncta descriptions 16 CHAP. III. Of the soft Parts -which line the Pelvis. 51. MUSCLES. Various strong, and large muscles, pass from the spine and pelvis to the thigh bones, and act as powerful bands, strengthening, in a very great degree, the articulations of the pelvis. These it is not requisite to describe, but it will be useful, briefly to notice the soft parts which line the pelvis, and which may be acted on by the child's head during labour. 1st. When we remove the peritoneum from the cavity of the pelvis, we first of all are led to observe, that all the under portion of the os innominatum, and part of the sacrum, are covered with a layer of muscular fibres, which arises at the brim of the pelvis, and can be traced all the way down to the extremity of the rectum. This is the levator ani; it is a strong muscle, with many glossy tendinous fibres, especially at the fore part, where it lines the ossa pubis. Under the symphysis, it is pierced by the urethra and vagina; and dur- ing the passage of the child's head, those fibres which sur- round the vagina must be considerably distended; and this is more readily effected, as the anus is brought forwards when the 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 cusliion of flesh, the fibres running backwards and downwards, and ter- minating in a tendon, which passes over the sacro-sciatic notch, running on it as on a pully, in order to reach the root of the trochanter. 3d. We find the pyriformis arising from the under part of the hollow of the sacrum, and also passing out at the notch, to be inserted with the obturator; and in laborious parturi- 17 tion, the injury or pressure which these muscles sustain, is one cause of the uneasiness felt in moving the thighs. 4th. From the spine of the ischium, originates the coccy- geus, which runs backward to be inserted into the side of the coccyx, in order to move and support it. This gradually be- comes broader, as we recede from its origin, and is spread on the inside of the sacro-sciatic ligament. Thus the cavity of the pelvis is lined with muscular substance, whose fibres are disposed in a very regular order, and which are exhibited when the peritoneum and its cellular substance are removed. 5th. When we look at the upper part of the os innomina- tum, we find all the hollow of the ilium occupied with the ilia- cus internus, the tendon of which passes over the fore part of the pelvis, to reach the trochanter of the thigh. Part of this muscle is covered by the psoas which arises from the lum- bar vertebrae, and passes down by the side of the brim of the pelvis to go out with the former muscle: though just upon the brim, it does not encroach on it, so as perceptibly to lessen the cavity. These muscles afford a soft support to the intes- tines and gravid uterus. § 2. ARTERIES.(e) Running parallel with the inner margin of the psoas muscle, and upon the brim of the pelvis, along the posterior half of the linea iliopectinea, we have the iliac artery and vein; the artery lying, for the upper half of its course, above the vein, and for the under half on the outside of it; when filled, they, especially the vein, encroach a little on the brim. About three inches from the symphysis, they quit the brim, running rather more outward, over the part which forms the roof of the acetabulum, and pass out with the psoas muscle. The great lash of arteries and veins connected with the pel- vis, and inferior extremities, is placed on the sacro-iliac junc- tion. The iliac vessels, are so situated, that they escape pressure during labour, when the head enters the cavity of (e) Consult Engravings of the Arteries by C. Bell. Finley's Philadelphia Edition. VOL. I. P 18 the pelvis; but the hypogastric vessels must be more or less compressed, according to the size or position of the head, but the circulation is never interrupted. §3. NERVES. WThen we attend to the nerves, we find, 1st. Upon the ilium, at least four branches of cutaneous nerves, traversing the iliac, and psoas muscles, in order to pass out below Pou- part's ligament. The largest of these cutaneous nerves is the outermost, which has its exit towards the spine of the ilium. These nerves, which supply chiefly the skin of the thigh, cannot suffer during labour; but sometimes may, from the position of the child, or the inclination of the uterus, sus- tain pressure, during gestation, and occasion numbness and anomalous sensations in the thigh. 2d. Between the two muscles, and in part covered by the outer margin of the psoas, is the anterior crural nerve, which is formed by the second, third, and fourth lumbar nerves. It is of considerable size, and has a greater share than the others, in producing the uneasy sensations I have mentioned. 3d. Running parallel with the brim of the pelvis, but three quarters of an inch be- low it, in the cavity of the pelvis, is the obturator nerve, com- ing from the third lumbar, and which may be traced all along the side of the ilium to the thyroid hole. In many cases, it cannot fail, during labour, to be pressed on by the head. 4th. Beneath the vessels at the sacro-iliac junction, we have the great nerves which form the sciatic nerve, which is made up of the fourth and fifth lumbar nerves, and the first sacral nerve, which is as large as either of the former: to these are added the second and third sacral, which are much smaller. The fourth lumbar nerve passes down on the sacro-iliac junc- tion, and is quite covered with the vessels. The fifth tra- verses that curved part of the sacrum, which lies betwixt its promontory and side; like the former, it is hid by the ves- sels. In going to form the sciatic nerve, the fourth lumbar nerve passes under the gluteal artery, or the common trunk of the gluteal and ischiatic arteries, and the fifth passes over 19 it. The first sacral nerve passes along the upper margin of the pyriform muscle, to join with these at the sacro-sciatic notch. There a large plexus is formed, which, uniting into a single trunk, passes out, and is the greatest nerve in the body. The lumbar nerves may be pressed on early in labour; but from the cushion of vessels and cellular substance which defends them, they suffer little. When the head has de- scended lower, and is beginning to turn, the first sacral nerve may be compressed. Pressure of the nerve produces pain, numbness, and cramp in the thigh and leg. Different nerves are acted on in different stages of labour. In the very begin- ning, the anterior crural nerve may be irritated or gently compressed, producing pain in the fore part of the thigh; next the obturator, producing pain in the inside; and last of all, the back part suffers from the pressure on the ischiatic nerve. 5th. The second and third sacral nerves are small, compared to the first. They are covered by the pyriformis muscle, but part of them pierce it, forming a plexus, which joins the sciatic nerve, and sends twigs to the bladder, rectum, &c. This plexus may be pressed in the last stage of labour; and the irritation thus produced may be one cause of the passage of the faces, which generally takes place involuntarily. 6th. The fourth sacral nerve is altogether devoted to the ex- tremity of the rectum, and its vicinity. The great plexus, forming the sciatic nerve, as it lies in the sacro-sciatic notch, yields to any pressure it may receive, and cannot suffer in labour, at least, so as to cause inconvenience; but the nerves going to it may suffer, and the person not only have cramp and pain during labour, but palsy and lameness for a long time afterwards. Friction, and the warm bath, at first, may relieve the pain; and then, the cold bath may, with much advantage, be employed for perfecting the en*"1 § 4 LYMPHATICS. The lymphatics in the upper part of the pelvis follow the course of the iliac vessels, forming a large and very beau- tiful plexus, from Poupart's ligament to the lumbar vertebrse. 20 These are out of the way of pressure during labour. Nume- rous glands accompany them, which are sometimes enlarged by disease, but they do not interfere with parturition. The lymphatics of the cavity of the pelvis have glands in the course of the vagina and rectum: and these, if enlarged, may impede delivery. CHAP. IV. Of the Dimensions of the Pelvis. § 1. BRIM AND OUTLET. The pelvis has been divided into the great and the little, the first being formed by the expansion of the ilia, and the second, comprehending all that part which is called the cavity of the pelvis, and which lies below the linea ilio-pec- tinea. The cavity of the pelvis is the part of the chief im- portance in Midwifery, and consists of the brim, or entrance, the cavity itself, and the outlet. The brim of the pelvis has no regular shape, but approaches nearer the oval than any other. The short diameter of this, extends from the sym- physis of the pubis to the top of the sacrum. This has been called the conjugate, or antero-posterior diameter, and mea- sures four inches. The lateral diameter measures five inches and a quarter; and the diagonal diameter, or a line drawn from the sacro-iliac symphysis to the opposite acetabulum, measures five inches and an eighth; but as the psose muscles, and iliac vessels, overhang the brim a very little at the side, the diagonal diameter, in the recent subject, appears to be the longest, From the sacro-iliac symphysis to the crest of the pubis, on the same side, is four inches and a half. From the top of the sacrum, to that part of the brim which is directly above the foramen thyroideum, is three inches and a half. The line, if drawn to the acetabulum, in place of the foramen, is a quarter of an inch shorter; a line drawn across the fore 21 part of the brim, from one acetabulum to another, is nearly four inches and a quarter. The outlet of the pelvis is not so regular as the brim, in its shape, even when the soft parts remain; but it is somewhat oval. The long diameter extends from the symphysis pubis to the coccyx, and measures, when that bone is pushed back, as in labour, five inches, but an inch less when it is not. The transverse diameter, from the one tuberosity of the ischium to the other, measures four inches. The outlet of the pelvis dif- fers materially from the brim, in this respect, that its mar- gins'are not all on the same level; an oval wire will represent the brim, but, if applied to the outlet, it must be curved. The outlet, from the symphysis pubis to the tuberosity of the ischium, is semi-oval; but behind, it becomes more irregular, and bends upwards and backwards. The arch of the pubis, or the fore part of the outlet, is four inches broad at its base; and a perpendicular line, dropped from its centre to the bone, is fully two inches long. The top of the arch will permit a circular body to come in contact with it, whose diameter is an inch and a quarter. The length of each limb of the arch is three inches and a quarter. § 2. CAVITY. The cavity of the pelvis is the next part to be attended to; and the most important observation to be made, is, that it is of unequal depth. At the back part, it measures from five to six inches, according as the coccyx is more or less extended; at the side, a line drawn from the brim, to the tuberosity of the ischium, measures three inches and three-fourths. At the fore part, the depth of the symphysis pubis is an inch and a half. When the surface of the child's head, then, is paral- lel to the lower edge of the symphysis, the head is still far from having entered fully into the cavity of the pelvis; it cannot be considered in the cavity, until it be lodged fairly in the hollow of the sacrum. It may be proper to notice the dimensions of different parts of the cavity itself. An oblique line, drawn from the 25 sacro-iliac junction, on one side, down to the opposite tube- rosity, measures six inches; and the long axis of the child's head, before it takes the turn forwards, corresponds to this line. From the ramus of the ischium, to the opposite sacro- iliac junction, is five inches. From the top of the arch of the pubis, or orifice of the urethra, to the second bone of the sacrum, is four inches and five-eighths, to five inches. A line drawn from the top of the arch to the top of the sacrum, is about a quarter of an inch more than the anteroposterior diameter of the brim. From the top of the arch to the spine of the ischium, is three inches and a half. From the tubero- sity of the ischium to the centre of the sacrum is four inches. From the back part of the tuberosity to the sacro-iliac junc- tion on the same side, is three inches and a half. From the extremity of the tuberosity to the spine of the ischium, is two inches. From the spine to the sacrum is two inches, and from the top of the arch of the pubis to the plane of the ischium, is two inches. The breadth of the plane itself is two inches; 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 inqh and a half, the long diameter of the sacro-sciatic notch, is two inches and three-eighths; the short, one inch and three quarters^/) In the living subject, we can readily recognise these dif- ferent parts of the pelvis; and by the relation which one bears to tire rest, we can ascertain, by careful examination with the finger, not only the relative position of the head with regard to any one spot, and consequently, its precise situation and progress in the pelvis, but also the shape and dimensions of the pelvis itself.^) (/) There may be some variation in dimensions, as stated by different writers ; but it is probable, the above were given by our author, from actual measurement, of what he considered, a standard pelvis. A similar obser- vation may be applied to the dimensions of the child's head, as stated in the succeeding chapter. (g) The very ingenious and indefatigable Bichat has observed, that sta- ture has no influence, or at least very little, on the dimensions of the pelvis; and that the individual differences which may occur, are totally independ- 33 5 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 are of importance in estimating the deformity of a pelvis. From the symphysis pubis to the com- mencement of the iliac wing, at the 'inferior spinous process, is nearly four inches. From the inferior spinous process to the posterior ridge of the ilium, a line subtending the hol- low of the costa, measures five inches. The distance from the superior spine is the same. From the top of the crest of the ilium to the brim of the pelvis, a direct line measures three inches and a half. The distance betwixt the two supe- rior anterior spinous processes of the ilium, is fully ten inches. A line drawn from the top of the crest of the ilium to the opposite side, measures rather more than eleven inches, and touches, in its course the intervertebral substance betwixt the fourth and fifth lumbar vertebrae. A line drawn from the centre of the third lumbar vertebra, counting from the sacrum to the upper spine of the ilium, measures six inches and three quarters. A line drawn from the same vertebra to the top of the symphysis, measures seven inches and three quarters, and, when the subject is erect, this line is exactly perpendicular. To conclude my observations on the dimensions of the pel- vis, I remark, that the shape is different in the child and the adult. The dimensions of the brim are reversed in these two states; the long diameter of the foetal pelvis, extending from the pubis to the sacrum. By slow degrees, the shape changes; and nearly about the time of puberty, the conjugate and lateral diameters are equal. When the female is fully perfected, the brim becomes more oval, the long diameter extending from one side to the other. If a girl should, very ent of stature. It is acknowledged, continues he, that delivery is as easy in small as in large women, although the first may bring forth very bulky chil- dren, and who, indeed, may be disproportioncd to the bulk of their mother's bodies, if a comparison of size should be instituted between the two. Anutomie Descriptive, vol. I. p. 181—2. 24 early, become a mother, the shape of the pelvis may occasion a painful and tedious labour, (li) § 4. AXIS OP THE BRIM AND OUTLET. Finally, we are to remember that the brim, and the out- let of the pelvis, are not parallel to each other, but placed at a considerable angle. The axis of the brim will be repre- sented by a line drawn from near the umbilicus, downwards and backwards, to the coccyx; that of the outlet, by a line drawn from the orifice of the vagina to the first bone of the sacrum. The precise points, however, which these lines will touch, must vary a little, according to the conformation and obliquity of the pelvis, and the prominence of the abdomen. Each different part of the cavity of the pelvis has its own pro- per axis, and the line of motion of the child's head must al- ways correspond to the axis of that part of the pelvis in which it is placed. A pretty good idea of this subject, with regard to labour, may be obtained, by placing a small catheter, of the usual curvature, in the axis of the brim, and making its extremity pass out at the axis of the outlet. CHAP. V. Of the ffead 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 (A) This remarkable difference in the comparative dimensions of the fe- male pelvis before and after puberty, has been pointed out by analogy, and observed among the females of quadrupeds whose pelvis does not complete its developement, nor acquire the form and proportions necessary for the ex- pulsion of the foetus until the period of puberty, f/rf. Capuron. 25 with membrane. The frontal, temporal, parietal, and occi- pital bones, compose the bulging part of the cranium and their particular shape regulates the direction of the sutures. The occipital bone is connected to the parietal bones, by the lambdoidal suture, which is readily discovered through the integuments, by its angular direction. The parietal bones are joined to the frontal bone, by the coronal suture, which is distinguished by its running directly across the head, and they arc connected to each other by the sagital suture, which runs in a direct line from the occipital, to the frontal bone ; as the os frontis, in the foetus, consists of two pieces, it can sometimes be easily traced with the finger, even to the nose. Let the sagital suture be divided into three equal parts. From the middle one which I call the central portion a line or band may be drawn to the lateral part of the lower jaw, and which will traverse the parietal protuberance and the exter- nal ear. As this, in labour, is parallel to the axis of the brim of the pelvis, until the head makes its turn, I call it the line of axis. The upper and anterior angles of the parietal 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 suture, which is called the small fontanell. The first is known by its four corners, and by its extending forward a little betwixt the frontal bones, and whenever it is felt, in an examination, we may expect a tedious labour; for the head does not lie in the most favourable position. The little fon- tanell cannot, during labour, be perfectly traced, as it is lost in the angular lines of the lambdoidal suture, which, however, ought to be readily discovered. The head is of an oblong shape, and its anterior extremity at the temples is narrower than the posterior, which bulges out at the sides by a rising of the parietal bones, called the parietal protuberances: from these the bones slope backwards, like an obtuse angle, to the upper part of the occiput, which is a little flattened, and is called the vertex. The general shape of the back part is VOL. I. J? 26 hemispherical. From these protuberances, the head also slopes downwards and forwards to the zygomatic process of the temporal bone, becoming, at the same time, gradually narrower. § 2. SIZE OF THE HEAD. The longest diameter of the head is from the vertex to the chin, and this is near five inches.(i) From the root of the nose to the vertex, [which is called the long diameter,] and from the chin to the central portion of the sagital suture, measures four inches. From the one parietal protuberance to the other, [which is called the transverse diameter,] a transverse line measures from three inches and a quarter, to three inches and a half. From the nape of the neck to the crown of the head, is three inches and a half, [and is called the perpendicular diameter.] From the one temple to the other, is two inches and a half. From the occiput to the chin, along the base of the cranium, is four inches and a half. From one mastoid process to the other, along the base, is about two inches; from cheek to cheek is three inches. Al- though these may be the average dimensions of the head, yet, owing 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 correspond, in a regular degree, to each other. The size of the male head is generally greater than that of the female. Dr. Joseph Clarke,* an excellent practitioner, upon whose accuracy I am disposed fully to rely, says, that it is a twenty-eighth or thirtieth part larger. It is a well established fact, that owing to the greater size of male chil- dren, women who have the pelvis in any measure contracted, (0 This is termed the oblique diameter, to distinguish it from the next. When the vertex is stretched out in laborious births, it is sometimes ex- tended to six or seven inches. * Phil. Trans. VoL LXXVI ©7 have often a more tedious labour, when they bear sons than daughters; and many who have the pelvis well formed, suffer from the effects on the soft parts. Dr. Clarke supposes, that one half more males than females are born dead, owing to tedious labour, or increased pressure on the brain; and ow- ing to these causes, a greater number of males than females die, soon after birth. In twin cases, again, as the children are smaller, he calculates, that only one-fifth more males than females are still-born. Dr. Bland* says, that out of eighty-four still-born children, forty-nine were males, and thirty-five, females. § 3: PASSAGE OF THE HEAD. By comparing the size of the head with the capacity of the pelvis, it is evident that the one can easily pass through the other. But I apprehend that the comparison is not always correctly made, for the child does not pass with the long dia- meter of its cranium parallel to a line drawn in the direction of the long diameter of the brim of the pelvis; but it descends obliquely, so that less room is required. The central portion of the sagital suture passes first, the chin being placed on the breast of 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 circular1 body going through the brim, whose diameter is not above three inches and a half; and therefore, no obstacle or difficulty can arise from the size of the pelvis. There is so much space superabounding betwixt the pubis and sacrum, as to prevent all risk of injury from pressure on the bladder, urethra, or rectum; and as the long diameter of the head is descending obliquely, 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 additional pain or difficulty, « Phil. Trans. Vol. LXXf. 28 although the capacity of the pelvis be a little contracted. But when the shoulders, which measure five inches across, come to pass, then the brim is completely occupied. If, however, any contraction should take place in the lateral diameter, the child would still pass, the one shoulder descending obliquely before the other. It is of great consequence to understand the passage of the child's head in natural labour; for upon this depends our knowledge of the treatment of difficult labour. The head na- turally is placed with the vertex directed to one side, or a little towards the acetabulum, and the forehead, owing chiefly to the action of the promontory of the sacrum, is turned in the same degree towards the opposite sacro-iliac junction. When labour begins, and the head comes to descend, the chin is laid on the sternum, and the central portion of the sagital suture is directed downwards, nearly in the axis of the brim of the pelvis. When, by the contraction of the uterus, the head is forced a little lower, its apex comes to touch the plane of the ischium. Upon this the posterior sloping part of the pa- rietal bone slides downwards and forwards, as on an inclined plane, the head being turned gradually, so that, in a little 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 entirely into the cavity of the pelvis. As the bason is shallow at the pubis, the head is felt near the orifice of the vagina, and even touching the labia and perineum, before the turn is completed, and when the ear is still at the pubis. The whole of the cavity of the pelvis is so constructed, as to contribute to this turn, which is further assisted by the curve of the vagina, and the action of the lower part of the uterus, on the head of the child. The head, whilst its long diameter lies transversely-, continues to descend in the axis of the brim of the pelvis; but when it is turned, it passes in the axis of the outlet. When the turn is making, the direction of the motion is in some intermediate point; and this fact should, in operating with instruments, * Dr. Osborn attributes this turn to the action of the spines of the ischia on the two parietal bones, but not on opposite spot*. 29 be studied and remembered. When the pelvis is narrow above, and the sacrum projects forward, the hemispherical part of the head is long of reaching the inclined plane of the ischium; and when the head is lengthened out, so as to come in contact with it, we find, that although the projection of the sacrum directs the vertex sometimes prematurely a little for- ward, yet, the tendency to turn fully, is resisted by the situa- tion of the 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 extre- mity of the long diameter of the head; the integuments may be tumefied, and a bloody serum be effused between them, so as greatly to disfigure the presentation. As, therefore, in tedious labour, occasioned by a deformed pelvis, the skull may be much lengthened and mishapen, we are not to judge of the situation of the head, by the position of the apex of the tumour which it forms; but we must feel for the ear, which bears a steady relation to that part of the head which presents the obstacle. The back and upper part of the head are com- pressible, but the base of the skull and the face are firm. A line drawn from the neck to the forehead, passing over the ear, is to be considered as the boundary betwixt these parts of opposite character; and therefore we attend to the relative situation of the ear, as it ascertains both the position of the head, and its advancement through the brim. CHAP. VI. Of Diminished Capacity, and Deformity of the Pelvis. § 1. DEFORMITY FROM RICKETS. The pelvis may have its capacity reduced below the na- tural standard, in different ways. It may be altogether upon 30 a small scale, owing to the expansion stopping prematurely, the different bones, however, being well formed, and correct in their relative proportions and distances. This may occa- sion painful labour, but rarely causes such difficulty as to re- quire the use of instruments. Sometimes the bones are all of their proper size, but the sacrum is perfectly straight, by which, although both the brim and outlet are sufficiently large, yet the cavity of the pelvis is lessened; or when all the other parts are natural, the spines of the ischium may be exuberant, encroaching on the lower part of the pelvis. Another cause of diminished capacity, is the disease called rickets, in which the bones in infancy are defective in their strength, the proportion of earthy matter entering into their composition being too small. In this disease, the long bones bend, and their extremities swell out; the pelvis becomes de- formed, the back part approaching nearer to the front, and the relative distance of the parts being lost. The distortion may exist in various degrees. Sometimes the promontory of the sacrum only projects forward a very little more than usual, or is directed more to one side than the other;1 and the cur- vature of the bone may be either increased or diminished. If the sacrum project only a little, without any other change, the capacity of the brim alone is diminished: but if the cur- vature be at the same time smaller than usual, the cavity of the pelvis is lessened : but unless the ischia approach nearer together, or the lower part of the sacrum be bent forward, the outlet is unaffected ; and in most cases of moderate defor- mity, the outlet is not materially changed. In greater de- grees of the disease, the anterior part of the brim becomes more flattened, the linea iliopectinea forming a small segment of a pretty large circle. The sacrum forms part of a concen- tric circle behind ; and thus the brim of the pelvis, instead of being somewhat oval, is rendered semicircular or crescen- tic, and its short diameter is sometimes reduced under two inches. The promontory of the, sacrum may either corres- pond to the symphysis pubis, or may be directed to2 one side, rendering the shape of the brim more irregular and the di- mensions smaller on one side than the other. In some in- 31 stances, the shape of the brim is like an equilateral triangle; and although the diameter from the pubis to the sacrum be not diminished, yet the acetabula being nearer the sacrum, the passage of the head is obstructed. § 2. DEFORMITY FROM MALACOSTEON. The pelvis is likewise, especially in manufacturing towns, sometimes distorted by malacosteon, or softening of the bones of the adult. This is a disease which sometimes begins soon after delivery, and very frequently during pregnancy. It is, indeed, comparatively rare in those who do not bear children, and it is always increased in its progress by gestation. It must be carefully attended to, for, to a negligent practitioner, it has at first very much the appearance of chronic rheuma- tism. It generally begins with pains about the back, and region of the pelvis. These pains are almost constant, or have little remission. They are attended with increasing lameness, loss of flesh, weakness, and fever; but the distin- guishing mark is diminution of stature, the person gradually becoming decrepid. In malacosteon, the pelvis suffers, but the distortion is generally different from that produced by rickets; for whilst the top of the sacrum sometimes sinks lower in the pelvis, and always is pressed forward,3 the ace- tabula are pushed backwards and inwards towards the sa- crum and towards each other ;* so that, were it compatible with life, for the disease to last so long, these parts would meet in a common point, and close up the pelvis, or at least convert its cavity to three slits. The ossa pubis form a very acute angle; so that the brim of the pelvis, instead of being a little irregular as in slight cases of rickets, or semicircular as in the greatest degree of that disease, consists, when mala- costeon has continued long, of two oblong spaces on each side of the sacrum, terminating before, in a narrow slit, formed betwixt the ossa pubis.' In this narrow space, when the woman is advanced in her pregnancy, the urethra lies, and the bladder rests upon the pendulous belly; so that, if it be necessary to pass the catheter, we must sometimes use one 33 made of clastic materials, or a male catheter, directing the concavity of the instrument towards the pubis. If the in- strument be large, and the ossa pubis very near each other, it may be jammed betwixt them, if it be incautiously intro- duced. In this disease, as well as in rickets, it is to be re- membered, that the promontory of the sacrum may overhang the contracted brim, so as more effectually to prevent the head from entering it. Rickets being a disease, which is at its greatest height in infancy, we have not at present to consider the treatment. Malacosteon is, on the contrary, a disease of the adult; and it would be of great importance to child-bearing women, to know how to check its progress. But the means capable of doing this with any tolerable degree of certainty, have not yet been discovered. As gestation uniformly increases the dis- ease, it is proper that the woman should live absque marito. As there is evidently a deficiency of earth in the bones, it has been proposed to give the patient phosphate of lime, but little advantage has been derived from it; and indeed, unless we can change the action of the vessels, it can do no good to pre- scribe any of the component parts of bone. We have, in the present state of our knowledge, no means of rendering the action more perfect, otherwise than by endeavouring to im- prove the general health and vigour of the system, by the use of tonics, the cold bath, and attending to the state of the bowels. Anodyne frictions, and small blisters, sometimes relieve the pain.*(fe) * Upon the subject of deformity of the pelvis, and for tables of many par- ticular instances of distortion, I have great pleasure in referring the reader to the works of Dr. Hull, a practitioner of sound judgment, and extensive knowledge. (fc) Deformity of the pelvis, from the above causes, may be considered as comparatively a rare disease in the United States. In the course of my obstetrical practice, I can at present recollect but four or five cases, where embryulcia and the employment of the crotchet became indispensably necessary; and what may be worthy of remark, these were in individuals natives of Europe, chiefly of Ireland. A deformed pelvis is scarcely known among the aborigines of our country. This subject shall again be taken up when embryulcia is treated of; an operation, which we fear, is frequently resorted to very unnecessarily at least, to make use of the mildest term. 33 § 3. DEFORMITY FROM EXOSTOSIS AND TUMOURS. The pelvis may be well formed externally, and yet its capa- city may be diminished within, by exostosis from some of the bones; or it may be affected in consequence of the fracture of the acetabulum, from which I have seen extensive and pointed ossifications stretch for nearly two inches into the pelvis ; or steatomatous or schirrous tumours may form in the pelvis, being attached to the bones or ligaments, of which I have known examples.6 An enlarged ovarium,7 or vaginal hernia,8 may also obstruct delivery, even so much as to re- quire the crotchet; and therefore, although they be not indeed instances of deformed pelvis, yet as they diminish the capacity of the cavity, as certainly as any of the former causes which I have mentioned, it is proper to notice them at this time.* Enlarged glands in the course of the vagina, poly- pous excrescences about the os uteri or vagina, schirrus of the rectum, and firm encysted tumours in the pelvis, may likewise afford an obstacle to the passage of the child. Some tumours, however, gradually yield to pressure, and disappear until the child be born; others burst, and have their contents effused in the cellular substance. A large stone in the blad- der may also be so situated during labour, as to diminish very much the cavity of the pelvis; and it may he even neces- sary to extract the stone before the child be delivered. Tumours in the pelvis are produced either by enlargement of some of its contents, as for instance the ovarium or glands • or, by new formed substances. The former kind are often moveable, the latter generally fixed; and they may consist of fatty, or fibrous substance, or fluid contained in a cyst. These have only cellular attachments, and are removed easily by making an incision through the vagina, and turning out the tumour, or evacuating its contents ;9 other tumours are car- tilaginous, and these, instead of being connected only by cel- lular matter, are attached to the pelvis firmly, or grow from * In all cases of moveable tumours, as well as in stone in the bladder it is evident, that they ought, in the very beginning of labour, to be pushed above the brim, and preventedfrom entering it before, or along with the head VOX. I. I 34 it. They adhere cither by a pedicle, or by an extensive base. In the first case the tumour is more moveable than in the se- cond, where the fixture is firmer. These can only be extir- pated by cutting deeply into the cavity of the pelvis, and the incision requires to be made through the perineum and leva- tor ani, like the incision in the operation of lithotomy in the male subject. We are much indebted to Dr. Drew for the first case of an operation of this kind; and as the tumour ad- hered by a neck, it was easily cut off, and the success was complete. In a dreadful case which I met with lately, the attachments were extensive, and the tumour so large as to fill the pelvis, and permit only one finger to be passed between it and the right side of the bason. It adhered from the symphysis pubis round to the sacrum, being attached to the urethra, obturator muscle and rectum, intimately adhering to the brim of the pelvis, and even overlapping it a little towards the left aceta- bulum. It was hard, somewhat irregular, and scarcely move- able. The patient was in the 9th month of pregnancy. There was no choice, except between the cesarean operation, and the extirpation of the tumour. The latter was agreed on, and with the assistance of Messrs. Cowper, Russel and Pattison, I performed it on the 16th of March, a few hours after slight labour pains had come on. An incision was made on the left side of the orifice of the vagina, perineum, and anus, through the skin, cellular substance, and transversalis perinei. The levator ani being freely divided, the tumour was then touched easily with the finger. A catheter was introduced into the urethra, and the tumour separated from its attachments in that quarter. It was next separated from the uterus, vagina, and rectum, partly by the scalpel, partly by the finger. I could then grasp it as a child's head, but it was quite fixed to the pelvis. An incision was made into it with the knife, as near the pelvis as possible; but from the difficulty of acting safely with that instrument, the scissars, guided with the finger, were employed when I came near the back part; and instead of going quite through, I stopped when near the posterior sur- face, lest I should wound the rectum, or a large vessel, and 35 completed the operation with a spatula. The tumour was then removed, and its base or attachment to the bones dis- sected off as closely as possible. Little blood was lost. The pains immediately became strong, and before she was laid down in bed they were very pressing. In four hours she was delivered of a still-born child, above the average size. Peri- toneal inflammation, with considerable constitutional irrita- tion, succeeded; but by the prompt and active use of the lancet and purgatives, the danger was soon over, and the recovery went on well. On the 18th of April, when this was written to go to press, the wound was nearly healed. On examining per vaginam, the vagina is felt adhering as it ought to do, to the pelvis, rectum, &c. The side of the pelvis is smooth; and a person ignorant of the previous history of the case, or who did not see the external wound, would not be able to discover that any operation had been performed. § 4. MEANS OF ASCERTAINING THE SIZE OF THE HEAD, &c • In order to ascertain the degree of deformity, and the capa- city of the pelvis, different instruments have been invented. Some of these are intended to be introduced within the pelvis, and others to be applied on the outside, deducting a certain number of inches for the thickness of the pubis, sacrum, and soft parts. But these methods are so very uncertain, that I do not know any person who makes use of them in practice. The hand is the best pelvimeter, and must in all cases, where an accurate knowledge is necessary, be introduced within the vagina. By moving it about, and observing the number of fingers which can be passed into different parts of the brim, or the distance to which two fingers require to be separated in order to touch the opposite points of the brim, or the space over which one finger must move in order to pass from one part to another, we may obtain a sufficient knowledge, not only of the shape of the brim, cavity, and outlet of the pelvis, but also of the degree to which the soft parts within are swelled, as well as of the position and extent of any tumour which may be formed in the pelvis. We may be farther r,6 assisted by observing, that in great degrees of deformity or contraction, the head does not enter the brim at all; in smaller degrees it engages slowly, and the bones of the cranium, form an angle more or less acute, according to the dimen- sions of the brim, into which it is squeezed. As in many cases of deformed and contracted pelvis, it is necessary to break down the head in order to get it through the cavity, it will be proper to subjoin the dimensions of the foetal head when it is reduced to its smallest size. When the frontal, parietal, and squamous bones are removed, which is all that we can expect to be done in a case requiring the crotchet, we find that the width of the base of the cranium, over the sphenoid bone, is two inches and a half. The dis- tance from cheek to cheek is three inches. From the chin to the root of the nose is an inch and a half; and by separating the symphysis of the jaw, the two sides of the maxilla may recede, so as to make this distance even less. From the chin to the nape of the neck, when the chin is placed on the breast, is two inches and three quarters. When, on the contrary, the chin is raised up, and the triangular part of the occiput laid back on the neck, the distance from the throat to the occiput is two inches. The smallest part of the head, then, which can be made to present, is the face; and when this is brought through the brim, the back part of the head and neck may, although they measure two inches, be reduced by pressure so as to follow the face. The short diameter of the chest when pressed, is an inch and a half; that of the pelvis is the same. The diameter of the shoulder is one inch. CHAP. VII. Of Augmented Capacity of the Pelvis. A very large pelvis,* so far from being an advantage, is attended with many inconveniences, both during testation and parturition. The uterus, in pregnancy, does not ascend 37 at the usual time out of the pelvis, which produces several uneasy sensations; it is even apt, owing to its increased weight, to be prolapsed: or, if the bladder be distended, it may readily be retroverted. At the very end of gestation, the uterus may descend to the orifice of the vagina; and, dur- ing labour, forcing pains are apt to come on before the os uteri be properly dilated, by which both the child and the uterus may be propelled, even out of the vagina; and in many instances, although this should not happen, yet the pains are severe and tedious, especially if the practitioner be not aware of the nature of the case. CHAP. VIII. Of the External Organs of Generation. § 1. GENERAL 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 clitoris, 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 nympha, or labia mino- res or interiores. On separating them, we observe, about nearly an inch below the clitoris, the extremity of the ure- thra; and, just under it, the orifice of the vagina, which is partly closed up, in the infant state, by a semilunar mem- brane called the hymen* These parts are all comprehended 38 under the general name of vulva, or external organs of generation. § 2. LABIA AND NYMPHJE. The labia have nothing peculiar in their structure, for they are merely duplicatures of the skin, rendered prominent by a deposition of fatty matter. Externally they have just the appearance of the common integuments; and at the age of puberty, are, together with the mons veneris, generally covered with hairs. Internally they resemble the inside of the lips or eye-lids, and are furnished with numerous seba- ceous glands. They are placed closer together below than above ; and at their junction behind, a small bridle called the fourchette, extends across, which is generally torn when- ever a child is born. The nymph* at first appear to be merely duplicatures of the inner surface of the labia, but they are, in fact, very dif- ferent in their structure. They are distinct vascular sub- stances inclosed in a duplicature of the skin. When injected by filling the pudic artery, each nympha is found to be made up of innumerable serpentine vessels, forming an oblong mass. This at the upper part joins the clitoris, to which, perhaps, it serves as an appendage; whilst the loose dupli- cature of skin in which it is lodged, by being unfolded, per- mits the labia to be more safely and easily distended, during the passage of the child. § 3. CLITORIS. The clitoris is a small body resembling the male penis, but has no urethra. It consists of two corpora cavernosa, which arise from the rami of the ischia and pubis, and unite at the symphysis of the pubis. These are furnished with two muscles analogous to the erectores penis of the male. When the crura and nymphse are filled with wax, we find on each side, two vascular injected bodies, one of them in close contact with the bones, the other more internal with regard 39 to the symphysis of the pubis. When the one is injected, the other is injected also, and both are connected together at the upper part. The clitoris, formed by the junction of its crura, is apparently about the eighth part of an inch long, a part of it not being seen, and it is supported by a pretty strong suspensory ligament which descends from the sym- physis. When distended with blood, it becomes erected and considerably longer, and is endowed with great sensi- bility. § 4. URETHRA. On separating the nymphse, we find a smooth hollow or channel, extending down from the clitoris for nearly an inch; and at the termination of this, and just above the vagina, is the orifice of the urethra, which although not one of the or- gans of generation, deserves particular attention. The bladder is lodged in the fore part of the pelvis, immediately behind the symphysis pubis ; but when distended, it rises up, and its fundus has been known to extend even to the umbili- cus. The urethra is the excretory duct of the bladder; it is about an inch and a half long, and passes along the up- per part of the vagina, through which it may he felt like a thick fleshy cord. The structure of the urethra is extremely simple, for little can be discovered except a continuation of the internal coat of the bladder, covered with condensed cellular substance. On slitting up the canal, numerous mu- cous lacunar may be discovered in its course, and two of these at the orifice are peculiarly large. The urethra is very vascular, and, when injected and dried, its orifice is perfect- ly red. In the unimpregnated state, it runs very much in the direction of the outlet of the pelvis ; so that a probe, in- troduced into the bladder, and pushed on in the course of the urethra, would, after passing for about three inches and a half, strike upon the fundus uteri, and, if carried on for an inch and a half farther, would touch the second bone of the sacrum. The uterus being much connected with the bladder at its lower part, it follows, that when it rises up in preg- 40 nancy, the bladder will also be somewhat raised, and pressed rather more forwards, and the vagina being elongated, the urethra, which is attached to it, is also carried a little higher, and, in its course, is brought nearer the inside of the symphysis pubis. In those women who, from deformity of the pelvis, or other causes, have a very pendulous belly, the bladder, during pregnancy, is sometimes turned over the pubis, the urethra curved a little, and its opening somewhat retracted within the orifice of the vagina. When it is neces- sary to pass the catheter, it is of great consequence to be able to do it readily, and this is by no means difficult to do. The woman ought to be placed on her back, with her thighs separated, and the knees drawn a little up: a bason is then to be placed betwixt the thighs, or a bladder may be tied firmly to the extremity of the catheter to receive the urine. The instrument is then to be conveyed under the thigh, and the labia separated with the finger. The clitoris is next to be touched, and the finger run gently down the fossa that leads to the orifice of the urethra, which is easily distin- guished, by its resemblance to an irregular dimple, situated just above the entrance to the vagina. The point of the in- strument is to be moved lightly down the fossa after the fin- ger, and it will readily slip into the urethra. It is then to be carried on in the direction of the axis of the outlet of the pelvis, and the urine drawn off. This operation ought al- ways to be performed in bed, and the patient is never to be exposed. In cases of fractures, bruises, &c. where the woman cannot turn from her side to her back, the catheter may be introduced from behind, without moving her. When the bladder is turned over the pubis, as happens in cases of great deformity of the pelvis, it is sometimes requisite to use either a flexible catheter, or a male catheter, with its con- cavity directed forward. When the uterus is retroverted, if we cannot use a female catheter, we may employ a male catheter, directing the concavity backwards. When the head of the child in labour has entered the pelvis, the urethra is pushed close to the symphysis of the pubis ; then the flexi- ble or flat catheter must be introduced parallel to the sym- 41 physis, and the head of the child may be raised up a little with the finger. This, indeed, of itself, frequently permits the urine to flow; and when the urine is retained after de- livery, it is often sufficient to raise up the uterus a little with the finger. § 5. ORIFICE OF VAGINA AND HYMEN The orifice of the vagina is situated nearly opposite to the anterior part of the tuberosity of the ischium, about an inch and a half below the symphysis of the pubis, and in the di- rection of the axis of the outlet of the pelvis. It is, in all ages, but more especially in infancy, considerably narrower than the canal itself, and is surrounded by a sphincter mus- cle, which arises from the sphyicter ani, and is accompanied with avascular plexus, called plexus retiformis. In children, it is always shut up by a membrane called the hymen, which consists of four angular duplicatures of the membrane of the vagina; the union of which may be discovered by correspond- ing lines on the hymen. At the upper part there is a semi- lunar vacancy, intended for the transmission of the menses. Sometimes it is imperforated, or partially or totally absorbed. When the hymen is ruptured, it is supposed to shrivel into three or four small excrescences at the orifice of the urethra, called the caruncul» myrtiformes.(/) 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. (/)Haller, in his Elementa Physiologic, asserts that the hymen is peculiar to the female of the human species; but Duverney, in a Memoir read before the Institute and the School of Medicine, at Paris, asserts, that it is common to others of the mammalia. VOX. I. G 4® CHAP. IX. Of the Internal Organs of Generation. % 1. VAGINA. The internal organs of generation consist of the vagina, with the uterus and its appendages. The vagina is a canal, which extends from the vulva to the womb. It consists principally of a spongy cellular sub- stance, endowed with some elasticity, and having an admix- ture of indistinct muscular fibres. It is lined by a continua- tion of the cutis from the inner surface of the labia ; and this lining, or internal coat, forms numerous wrinkles, or trans- verse rugae, on the anterior and posterior sides of the vagina. They are peculiar to the human female, and are most dis- tinctly seen in the virgin state; but after the vagina has been distended, they are more unfolded, and sometimes the sur- face is almost smooth. In the whole course of this coat, may be observed the openings of numerous glandular follicles, which secrete a mucous fluid. In the 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 turpentine, the vessels are seen to be both large and numerous. Just below the symphysis pubis, we observe a great congeries of vessels surrounding the urethra and upper part of the vagina. The vagina forms a curved canal, which runs very much in the course of the axis of the outlet and cavity of the pel- vis. It is not round, but considerably flattened; it is wider above than below, being in young subjects much contracted about the orifice. At its upper part, it does not join the lips of the os uteri directly, but is attached a little above them, higher up behind than before, so that the posterior lip of the uterus is better felt than the anterior. In the infant, the va- gina is attached still higher up, so that the lips of the uterus project in it something like a penis. 43 The inner coat of the vagina is reflected over the lips of the uterus, and passes into its cavity, forming the lining of the uterus. The junction of the uterus and vagina is so inti- mate, that we cannot make an accurate distinction betwixt them; but may say, that the one is a continuation of the other. The vagina adheres before very intimately to the urethra, behind, it comes gradually to approach to the rec- tum, and at its upper part it is pretty firmly connected to it. This union forms the recto-vaginal septum. These connec- tions of the vagina are formed by cellular substance, there being only a very small part of its upper extremity covered with peritoneum. When the finger is introduced into the vagina in situ, the urethra is felt on its fore part, resembling a firm fleshy cylin- der. Behind, the rectum can be traced down to the point of the coccyx. At the side, the ramus of the ischium and of the pubis, together with the obturator internus muscle are to be distinguished. In a well formed pelvis, the finger cannot easily reach beyond the lower part of the sacrum; during labour, however, the parts being more relaxed, the bone may be felt more easily, but its promontory cannot be touched with the finger. § 2. UTERUS AND ITS APPENDAGES. The uterus is a flat body somewhat triangular in its shape, being considerably broader at its upper than at its under part. It is scarcely three inches in length, about two inches broad above, and one below. It is divided by anatomists into the fundus or upper part, which is slightly convex, and lies above the insertion of the fallopian tubes; the cervix or narrow part below; the body, which comprehends all the space betwixt the fundus and cervix ; and last of all, the os uteri, which is the termination of the cervix, and consists of a small transverse chink, the two sides of which have been called the lips of the uterus. The uterus contains a small cavity of a triangular shape, which opens into a narrow chan- nel formed in the cervix, and is continued down to the os 44 uteri. At the upper angles may be perceived the openings of the fallopian tubes. Both the cavity and the channel are lined with a continuation of the inner coat of the vagina, but it has a very different appearance from that which it exhibits in the vagina. The surface of the triangular cavity is smooth, and the skin whicli covers it is very soft and vascular. The surface of the cervical channel again is rugous, and the rugae are disposed in a beautiful manner, so as to have some resemblance to a palm tree. This part is by no means so vascular as the cavity above; but it contains betwixt the ruga several lacunas, 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,(w) disposed very irregularly, and having a considera- ble quantity of interstitial fluid interposed, with many vessels ramifying amongst them. A dense succulent texture is thus formed, which constitutes the substance of the uterus. On cutting open the womb, we observe that its sides are about a quarter of an inch thick, but are rather thinner at the fundus, than elsewhere, though the difference is very trifling. Several irregular apertures may be perceived on the cut surface: these are the veinous sinuses. The fibres which we discover are muscular; but we cannot, in the unimpregnated state, ob- serve them to follow any regular course. The arteries of the uterus are four in number, with corres- ponding veins. The two uppermost arteries arise either high up from the aorta, or from the emulgent arteries. They de- scend, one on each side, in a serpentine direction behind the peritoneum, and are distributed on the ovaria, tubes, and up- per part of the uterus. These are called spermatic arteries. The two lowermost, which are called uterine, arise from the hypogastric arteries. They run, one on each side, toward the cervix uteri, and supply it and the upper part of the vagi- na. Thus the fundus uteri is supplied by the spermatic artc- (m) The reader is referred to a very interesting paper " on the muscularity of the uterus, by Charles Bell, Esq. F. R. S. Ed. &c." published in the 5th vol. of the Eclectic Repertory, p. 37, and § 9. 45 ries, and the cervix, by the uterine arteries; and these, from opposite sides, send across branches which communicate one with the other. But besides this distribution, the uterine ar- tery is continued up the side of the uterus, and meets with the spermatic, so that, at the two sides, we have arterial trunks, from which the body of the uterus is liberally supplied with blood. The veins correspond to the arteries. The nerves of the uterus, like the blood vessels, have also a double origin, and follow nearly the same course. Those which come from below are derived from the sacral nerves, especially from the fourth pair. Those from above come chiefly from the meso- colic plexus, and trunk of the intercostal. The renal plexus furnishes nerves to the ovarium. The lymphatics, in the unimpregnated state of the uterus, are small, and not easily discovered. Those from the upper part of the womb, and from the ovaria, run along with the spermatic vessels, terminating in glands placed by the side of the lumbar vertebrae. Hence, in diseases of the ovaria, there may be both pain and swelling of the glands. But the greatest number of lymphatics run along with the uterine artery, seve- ral of them passing to the iliac and sacral glands, and some accompanying the round ligament. This may explain why, in certain conditions of the uterus, the inguinal glands swell. Others run down through the glands of the vagina; and hence, in cancer of the womb, we often feel those glands hard and swelled, sometimes to such a degree, as almost to close up the vagina. The uterus is covered with the peritoneum, which passes off from its sides, to reach the lateral part of the pelv is, a little before the sacro-iliac symphysis; and those duplicatures, which, when the uterus is pulled up, seem to divide the cavity of the pelvis into two chambers, are called very improperly the broad ligaments of the uterus. When the uterus is raised, and those lateral duplicatures of the peritoneum are stretched out, we observe, that at the up- per part they form two transverse folds or pinions, one before. and the other behind. In the first of these, the fallopian lubes arc placed: in the second, the ovuria. 46 Besides these duplicatures, we likewise remark other two which extend from the sides of the fundus uteri to the linea ilio-pectinea at the side of the pelvis, and then run on to the groin. These contain, on each side, a pretty thick cord, which arises from the fundus uteri, and passes out at the in- guinal canal, being then lost in the labia pudendi. These cords, which are called the round ligaments of the uterus, consist of numerous blood-vessels, some lymphatic, small nerves, and fibrous matter. The fallopian tubes, in quadrupeds, are merely continua- tions of the horns of the uterus; but in the human female, they are very different in their structure from the womb. They appear to consist in a great measure of spongy fibrous substance, which, as Haller observes, may be inflated like the clitoris. This is hollow, forming a canal of about three inches long, lined with a continuation of the internal coat of the uterus; and as they lie in the anterior pinion of the broad ligaments of the uterus, they are covered of necessity with a peritoneal coat. They originate from the upper corners of the uterine cavity by very small orifices, but terminate at the other extremity in an expanded opening with ragged margins, which are called the fimbria of the tube. The internal sur- face of the canal is plaited, the plicse running longitudinally. The ovaria1 lie in the posterior pinion of the broad liga- ment. They are two oval flattened bodies, of a whitish colour, and grandular consistence. They are cellular, but not very vascular, although vessels run to their coat. After puberty, they contain numerous minute vesicles, the largest of which are near the surface, and even form slight projections from it. These are the ova of the female, and are filled with a coagulable lymphatic matter. Their number is uncertain, but Haller says he never saw above fifteen in one woman. In old women they disappear, or shrivel. The ovarium is covered with the peritoneum; but when the ovum is impregnated and becomes prominent, the peri- toneum which covers it is absorbed, the ovum passes into the fallopian tube, and the little scar which remains on the stir- face of the ovarium, is called corpus luteum. 47 In the foetus, the ovaria and tubes are placed on the psoae muscles; but in the adult, they lie loosely in the pelvis, and the uterus sinks within the cavity. The os uteri is directed forward, and the fundus backward, being in general found opposite to, or resting on the second bone of the sacrum. CHAP. X. Of the Diseases of the Organs of Generation. % 1. ABSCESS IN THE LABIUM. The labia are subject to several diseases: of these, the first whicli I shall mention, is phlegmonoid inflammation. This may occur at any period of life, and under various cir- cumstances ; but frequently it takes place in the pregnant state, especially about the sixth and seventh month of gesta- tion. Sometimes it appears suddenly, and oftener than once in the same pregnancy. Occasionally it makes its attacks in childbed, in consequence of the violence which the parts may have sustained in labour. It is marked by the usual symptoms of inflammation, namely, heat, pain, throbbing, and more or less swelling, not unfrequently attended with fever. The swelling is sometimes hard and moveable, like a gland, especially when the progress is slower than usual. In general, the course of the disease is rapid, the pain, and inflammation are at first very acute, and the part swells speedily. In a few hours, especially if a poultice have been applied, the abscess begins to point at the inside of the labium, and the nympha is either lost, or if it remain, appears pushed out of its place. Sometimes it bursts within thirty-six hours from its appearance. By means of cold saturnine applica- tions, and gentle laxatives, the inflammation may sometimes be resolved, but most frequently it ends in suppuration, which is to be promoted by fomentations and warm cata- plasms. If necessary, an opiate may be given to abate the 18 pain, and a pillow must be placed between the knees, to keep the part from pressure. If possible, the abscess ought not to be punctured, but, if the pain and tension be unbearable, we must indulge the patient by making a small opening; a good deal of blood will in this case come with the matter. After the abscess bursts, the parts may be dressed with any mild ointment. Should the opening of the abscess be higher than its bottom, it will be necessary, if the discharge con- tinue,* to lay it open, after which it will speedily heal. § 2. ULCERATION OF THE LABIA. The internal surface of the labia is often the seat of ulce- ration and excoriation, which may generally be avoided by the daily use of the bidet. The general form under which excoriation appears, is that of a raw surface, as if the cuticle had been peeled from a blistered part. Most frequently these sores are the consequence of acrimony, produced by inattention to cleanliness, especially in children; and in their case the labia, if care be not taken, may cohere. The treatment consists in keeping the parts clean, bathing the sore with a weak solution of sulphate of zinc, and prevent- ing cohesion. Should the parts not heal readily, they may be washed with brandy, or a very weak solution of nitrate of silver, or touched with caustic. When adhesion takes place, it may, if slight, be destroyed, by gently pulling the one labium from the other; if firmer, the parts must be se- parated with the knife. In either case, reunion must be pre- vented, by washing the surface frequently with solution of alum, and applying a small piece of lint spread with simple ointment. Simple itching of the parts may be removed by the tepid bath, a dose of castor oil, and fomenting the parts with milk and water. Sometimes we meet with deeper ulcerations, which it is of great importance to the domestic happiness of individuals to distinguish from chancre. Nothing seems easier in a * Vide Mr. Hey's Surgical Observations, p. 188. 49 book, than to make the diagnosis, but in practice it is often very difficult. A well marked chancre begins with circum- scribed inflammation of the part; then a small vesicle forms, which bursts, or is removed by slough, and displays a hol- low ulcer, as if the skin had been scooped away or nibbled by a small animal; its surface is not polished, but rough, and covered with pus, which is generally of a buff or dusky hue; the margins are red, and the general aspect of the sore is angry. But the most distinguishing character of the chancre, is considered to be a thickening or hardness of the base and edges of the ulcer. The progress of the sore is generally slow, either towards recovery or augmentation. When remedies are used, the first effect produced is remov- ing the thickening by degrees, and lessening the discharge, or changing its nature, so that the surface of the sore can be seen; it has then in general a dark fiery look, which con- tinues until all the diseased substance he removed, and the action of the part be completely changed. Now, from this description, we should, it may be supposed, be at no loss in saying, whether a sore were venereal; but in practice, we find many deviations from this description. The thickening may be less in one case than another, and may not be easily discovered, yet the sore may be certainly venereal. Pecu- liarity of constitution, or of the part affected, can modify greatly the effects of the virus. There may be extensive in- flammation, or phagedpenic ulceration: and yet the action may be venereal. It is, however, satisfactory to know in these cases, that in a little time, unless extensive sloughing 'have taken place, the appearance of the sore becomes more decided, the proper character of chancre appears, and the usual remedy cures the patient. Phagedena is a xevy troublesome, and sometimes a for- midable disease, especially of infants. I shall here only notice that form which appears in adults, and which, as it is infectious, may be mistaken for syphilis. It commences with a livid redness of the part, succeeded speedily by vesi- cation and ulceration, which extends Laterally, and some- times penetrates deep. The ulcer has an eating appearance, VOL. I. H 50 is painful, discharges a great quantity of matter, and very often is attended with fever. A variety of this disease is attended with superficial sloughing, which may be fre- quently repeated, and is generally preceded by a peculiar appearance of cleanness in the sore. This is not to be con- founded with sloughing, produced by simple inflammation or irritation of the parts, which is similar in its nature and treat- ment to common gangrene. We must foment the sore with decoction of camomile flowers, mixed with a little tincture of opium, and then apply mild dressings. Rest is essential to the cure: and if a febrile state exist, it is to be obviated by laxatives, acids, mild diaphoretics, and decoction of bark. If there be no fever, mercury, or the nitrous acid, often effec- tually change the action of the parts. Sometimes irritable sores appear on different parts of the labia, or orifice of the vagina, in succession, healing slowly one after another. These have an inflamed appearance, the margins are sometimes tumid, and the surface is at first irre- gular and depressed, but afterwards it forms luxuriant granu- lations. There is another sore met with on the inside of the labium, and which generally spreads to the size of a six- pence. The surface is quite flat, and sunk a little below the level of the surrounding parts. The margins are thickened, and sometimes callous, the discharge thin, and the ulcer not in general painful, the surface soft and spongy without a hard base. These sores generally agree best with stimulants, especially caustic and escharotics. When they do not yield to this treatment, it will be proper to have recourse to a cau- tious course of mercury. Some of these, like the phaged£end| are infectious. ** Some of these sores are occasionally productive of second- ary symptoms, such as ulcers in the throat. When these succeed a sore, which has run its course differently from chancre, and been healed without the use of mercury, it is allowable to suppose, that they also may be cured, merely by attending to the general health, and perhaps by local applica- tions. But if they continue without amendment, or threaten gi danger to any important part, we must not delay making trial of mercury. § 3. EXCRESCENCES ON TIIE LABIA. Sometimes after a slight degree of inflammation, producing heat and itching of the parts, numerous excrescences appear within the labia. These are either soft and fungous, or hard and warty. Both of these states may be induced by previous venereal inflammation; but they may also occur independent- ly of that disease. Even where there is an offensive discharge from the fungi or warts, we are not always to conclude that they are syphilitic, but be guided in our judgment by conco- mitant circumstances. Warty excrescences are most readily removed, by the application of savin powder by itself, or mLxed with red precipitate; and during its operation, the parts may be washed with lime water. The powder must be applied to the roots of the warts, for their substance is al- most 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 escharotic 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 infusion of belladona. Should there be ground for suspecting a syphilitic action, mercury must be given, at the same time that we make suitable locak applications; but in doubtful cases, I have seen this medicine given without any benefit. These excrescences, from their appearance, their great pain, and foetid discharge, may suggest an opinion of their being cancerous; but they begin in a different way, and generally yield, though sometimes slowly, to proper applications, § 4. SCIRRHOUS TUMOURS. Solid tumours may form in the labia, and are distinguished by their hardness, and by their moving under the skin, until yz adhesion from inflammation takes place. These tumours are sometimes scrophulous and have little pain, even when they have gone on to suppuration. Oftener, however, they are cancerous; and these are distinguished from the former, by their great hardness and inequality, and by their shooting pain. If they are not removed, the cancerous abscess points to the inner surface of the labium, its top becomes dark co- loured, sloughs off, a red fluid is discharged, and presently fungus appears. Soon after this the glands at the top of the thigh, and sometimes those in the course of the vagina, swell. If all the diseased parts can be removed, an operation must be performed. If they cannot, we must palliate symptoms by proper dressing and opiates.(n) § 5. POLYPOUS TUMOURS. Soft fleshy 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 therefore, early removed by the knife or the ligature. If the base be broad, the double ligature must be employed; but should (7») An immense tumour was successfully extirpated from the labia of a ne- gro woman by Dr. Hartshome at the Pennsylvania Hospitalin December, 1815, said to be produced by the kick of a horse, and of upwards of ten years stand- ing. In this case, the labia were much enlarged, and almost as hard as cartilage. The hardness and enlargement of the integuments extended anteriorly thttfe inches above the pubis, and posteriorly to within two inches of the anus. The patient walked with great difficidty, as the circumference of the middle of the tumour was at least twenty inches, and its lower part almost reached the knees. The weight of the tumour removed, was upwards of eleven pounds. On the evening of the 3d day after the operation, unequivocal symptoms of Tetanus appearing, and the violence of the spasms increasing, caustic potash was freely applied to the neck, over the cervical vertebrae. The effect of this application in lessening the convulsive action of the muscles was very evident. The woman was discharged well, on the 6th of April, ensuing. In Larrey's Memoirs, vol. 1. p. 299. will be found a description of a similar tumour; and in plate X, an engraving. 53 there he any hardness about the part where the ligature would be applied, it is best to dissect the whole growth out. Encysted tumours may form in the labia. They are elas- tic, and contain a glairy fluid. A sctpn may be passed, or the cyst may be laid bpen.(o) § 6. OEDEMA. CEdematous tumour of the labium is either a consequence of pregnancy, or a symptom of general dropsy. The tumour is variable in its size. When it depends on pregnancy, it is seldom necessary to do any thing; and even in time of labour, although the tumour be great, we need be under little appre- hension, for it will yield to the pressure of the child's head. But if at any time, during gestation, the distension be so great as to give much pain, then one or two punctures may be made, in order to let out the fluid, but this is very rarely ne- cessary. Gentle laxatives are generally useful. Blisters ap- plied to the. vicinity of the part have been proposed, but they are painful and even dangerous. When the swelling depends on dropsy, diuretics are to be employed; but if the woman be pregnant, they must be used cautiously. § r. HERNIA, LACERATION, &c. Pudendal hernia is formed in the middle of the labium. It may he traced into the cavity of the pelvis, on the inside of the ramus of the ischium, and can be felt as far as the vajrina extends. It differs farther from inguinal hernia, which also lodges in the labium, in this, that there is no tumour discover- able in the course of the round ligament from the groin. It sometimes goes up in a recumbent posture, or it may by pres- sure be returned. A pessary has little effect in keeping it up, unless it be made inconveniently large. It is not easy to adapt a truss to it, but some good is done with a firm T-band- (o) Would it not be more eligible, when practicable, to extirpate the cyst completely by the knife, to prevent the risk of its sloughing away ? 54 age, or one similar to that used for prolapsus ani. If it can- not be reduced, we must support it by a proper bandage, which is not to be drawn tight. Sometimes the labia are naturally very small, at other times uncommonly large; one side may be larger than the other. Laceration of the labia is to be treated like other wounds. When the hemorrhage is great, the vagina must be plugged, and a firm compress applied externally, with a proper band- age. § 8. DISEASES OF THE NYMPHiE. The most frequent disease to which the nympha is subject,. is elongation. When the part protrudes beyond the labia, it becomes covered with a white and more insensible skin. But sometimes it is fretted, on which account, or from other causes, women submit to have the nympha cut away. This is done at once by a simple incision; but, as the part is exceed- ingly vascular, we must afterwards restrain the hemorrhage,' either with a ligature or by pressure. By neglect, the patient may lose blood, even ad deliquium. In some countries, this elongation of the nympha is very common.1 In others, the nymphse, together with the preputium clitoridis, are removed in infancy.2 The nymph® are subject to ulceration, tumour, and other diseases, in common with the labia. Sometimes by falls, but oftener3 in labour, the vascular structure of the nympha is injured, and a great quantity of blood is poured out into the cellular substance of the labia, producing a black and very painful tumour.4 This may take place even before the child is expelled; and, in a case of this kind, the midwife, mistaking the swelling for the protruded membranes, actually perforated the labium, and caused a considerable discharge of blood.5 More frequently, however, the tumour appears immediately after delivery,6 and the attention is directed to it both by its magnitude and its sensibility, which is sometimes so great as to cause syn- tope. It is tense, throbbing, and may also be accompanied 55 by severe pain in the legs, and violent bearing-down efforts,7 as if another child were to be born, or, as if the womb were inverted. It has, however, been known to advance so slowly, as not to attract attention for two days. There are also instances where the inflammation runs high, and the recto- vaginal septum sloughing, fauces are discharged by the vagina.8 In the course of a short time the tumour bursts, and clotted and fluid blood is discharged. This process should be hast- ened by fomentations and poultices, and the pain be abated by opiates; but if it be very great, relief may bo obtained, by making a small puncture in the inside of the labium.9 Whe- ther the tumour burst, or be punctured, the previous inflam- mation may close the vessels so as to prevent hemorrhage; but if it do not, the vagina is to be gently filled with a soft cloth to prevent the fluid from extending along the sides of the pelvis. A compress is also to be firmly retained externally, to check all hemorrhage from the aperture. If inflammation run high, it is to be abated by the usual means. § 9. DISEASES OF THE CLITORIS, The clitoris may become scirrhous, and even be affected with cancerous ulceration. In this disease, it is generally thickened, enlarged,10 and indurated, and the patient comr plains of considerable pain. Presently ulceration takes place, and fungus shoots out. In no case of this kind that I have met with, has an operation been submitted to; and, indeed, unless the whole of the diseased part, can be removed, we must be satisfied with palliating symptoms. In one case, however, related by Kramer," where the clitoris was en- larged, with cauliflower-like excrescences, and the right nym- pha indurated, the parts were successfully removed by the knife, after failing with the ligature, which produced insup- portable pain. The clitoris sometimes becomes preternaturally elongated; and if this take place in infancy, and be accompanied with imperfect or confused structure of the other parts, the per- 06 son may pass for an. hermaphrodite.*2 This is said to be most frequent in warm climates; and in these, extirpation is sometimes performed. Haller assigns a cause for the en- largement. § 10. DISEASES OF THE HYMEN. The most frequent disease of the hymen is imperforation; in consequence of which the menses are retained,13 the uterus is distended, and the orifice of the vagina protruded, so as sometimes to resemble polypus, or a prolapsus uteri ;14 or it becomes fretted and covered with scabs. Even the perinseura may be stretched, as if the head of a child rested on it." 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;14 such a case may, therefore, by inattention, be mistaken for parturition.17 The sufferings of the patient are, in some in- stances, increased by the addition of suppression of urine," or pain in passing the faeces,19 or convulsions.* Imperforated hymen is by no means uncommon, and the treatment is very simple, for the part is easily divided.20 The retained fluid is thus evacuated, sometimes in very great quantity. It has very rarely the appearance of blood, being generally dark coloured, and pretty thick, or even like pitch. Febrile and inflammatory symptoms may follow the operation.21 The hymen is sometimes perforated as usual, but very strong, so as to impede the sexual intercourse ; yet in those cases impregnation has taken place, and the hymen has been torn,23 or cut in the act of parturition. It is asserted that con- ception may take place, although the hymen be imperforated.! When the hymen is torn in coitu, some blood is evacuat- ed, which, in many countries, is considered as a mark of virginity. But as even the presence or absence of a hymen cannot he looked upon as affording any certain proof relative * 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. 57 to chastity, this test must be considered as altogether doubt- ful. When the hymen is ruptured, and there is an inflam- mation about the external parts, some have, in cases of al- leged rape considered the crime as proven. But whoever attentively examines the subject must admit, that these are very fallacious marks; that they may exist without any violence having been employed; and that a woman may have, if previously stupified, been violated without exhibiting any mark of injury. Practitioners therefore ought, in a legal question of this nature, to be cautious how they give any opinion, especially if they have not seen the person im- mediately after the crime has been committed.* § 11. LACERATION OF THE PERINJEUM. 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 management than rest, and attention to cleanliness. But as the recto-vaginal septum is carried forwards and down- wards, when the perinseum is put on the stretch previous to the expulsion of the head, it sometimes happens, that the laceration extends along this septum, and a communication is formed betwixt the rectum and vagina. In some cases, the sphincter ani remains entire, although the rectum be lacerated; in others it also is torn. This accident is at- tended with considerable pain and hemorrhage, and suc- ceeded by an inability to retain the fseces, which pass rather by the vagina than the rectum. Prolapsus uteri is also, in some instances, a consequence of this laceration. This ac- cident is sometimes produced by attempts to distend the parts previous to delivery, or by the use of instruments; but it may also take place, even to a great degree, in a la- bour otherwise natural and easy, and in which no attempts * Vide Baudelocque, FArt. &c. sec, 342, el Fodere Med. Legale, Tome n. p. 3. vot. I. I 58 have been made to accelerate delivery. The most effectual way to prevent laceration is by supporting the perineum with the hand, when it is stretched, and keeping the head from being suddenly forced out. When the parts have been actually torn, our first attention is to be directed to the re- pressing of the hemorrhage, which is sometimes considera- ble; and this is best effected by compression and rest, which favour the formation of coagula. Next, we are to consider how the divided parts may be united. Rest, and retaining the thighs as much together as possible, together with frequent ablution, in order to remove the urine, which sometimes, for a few days flows involuntarily, or the lochia and stools, are requisites in every mode of treatment. As there is nothing in the structure of the parts to prevent their re-union, it has very feasibly been proposed to induce a state of costiveness, and prevent a stool for many days. But with only one or two exceptions, this method has failed; the subsequent expulsion of the indurated faeces tearing open the parts, if adhesion had taken place. An opposite prac- tice, that of keeping the bowels open, and the stools soft or thin, by gentle laxatives, has been much more successful, the parts in some instances healing in a few weeks. During this period, the stools are, at least for a time, passed some- times involuntarily ; but in other instances, they can from the first be retained, if the patient keep in bed. Sutures have been also employed, and ought certainly to be had re- course to, if re-union cannot otherwise be effected.^) If ne- cessary, the edges of the divided parts must be made raw. It would appear that there is no occasion for putting a liga- ture in the recto-vaginal septum. It is sufficient to place two in the perinamm. When the sphincter ani remains en- tire, but the septum is torn, some have considered it neces- sary 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 com- presses dipped in balsams; but it is better to apply merely 00 Sutures should be very rarely had recourse to, as they rive srreat imtaUon, and are subject to be torn out. 39 a pledget, spread with simple ointment, to the part. If the radical cure fail, the patient must use a compress, retained with a T-bandage.*3 § 12. IMPERFECTION OF THE VAGINA. The vagina may be unusually small. I have known it not above three inches long, and sometimes it is very narrow. The size, if necessary, may be enlarged with a tent of pre- pared sponge.* Should pregnancy take place before it be fully dilated, we need be under no apprehension with regard to delivery; for during labour, or even long before it, relaxa- tion34 takes place. Sometimes the vagina is wanting or im- pervious, or all the middle portion of the canal is filled up with solid matter. More frequently, however, there is only a firm septum stretched across, behind the situation of the hymen, or higher up in the vagina; and this" it may be ne- cessary to divide. In some cases, there is a great confusion of parts, and, indeed, it is impossible to describe the varie- ties of conformation; for the vagina may follow a wrong course, or communicate with the urethra, or the rectum86 may terminate in the vagina, &c. Malformation does not always prevent pregnancy27. § 13. INFLAMMATION AND GANGRENE OF THE VAGINA. In consequence of very severe labour, inflammation, fol- lowed by gangrene of the vagina, may be produced. If the sloughs be small, then partial contraction of the diameter of the canal may take place, and cause much inconvenience from retention of the menses,28 or during a subsequent la- bour ; but in this last case, the parts gradually yield, and it is seldom necessary to perform any operation: the pain, however, is sometimes excruciating till the part yield.f In some instances the sloughs are so extensive, that the whole vulva is destroyed, or part of the urethra and vagina * Vide Van Swieten Comment, in aph. 1290. f Harvey, excrcit. LXXIII. p. 492. (30 come 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 obstructed, the discharges .can- not take place; and sharp pains, or even convulsions, may be the consequence. Sometimes calculous concretions form beyond the adhering part.* Whenever we have reason to expect a tender state of'the parts after delivery, we must be exceedingly attentive; and if the vagina, or any other organ, be inflamed or tender, we must bathe the parts frequently, and inject some tepid water gently, to promote cleanliness. Saturnine fomentations and injections are often of service, but they must not be thrown high. The urine must be regularly evacuated; and should a slough take place, we must, by proper dressings, or the use of a thick bougie, prevent coalescence of the vaginal canal2'. § 14. INDURATION, ULCERATION AND POLYPI. The vagina may be contracted by scirrhous glands in its course, or induration of its parietes, which become thick and ulcerated, and communicate with the bladder or rectum. This disease is generally preceded by, or accompanied with, scirrhous uterus, and requires the same treatment. Foreign bodies in the vagina may produce ulceration, and fungous excrescences. The source of irritation being re- moved, the parts heal; but we must, by dressing and injec- tions, prevent coalescence. Polypous tumours may spring from the vagina, and are to be distinguished from polypus of the uterus by examination. The diagnosis betwixt polypus and prolapsus, or 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 any ma- * Vide Puzos Traite, p. 140.—Case by Mr. Purton, in Med. and Phvs .lour. Vol. VI. n. 2 } ' 61 terial change in the.state of the womb, and without symptoms of uterine irritation, farther than slight pain in the back, and a little mucous discharge. We find a fleshy substance pro- truding at the back part of the vulva, having an opening be- fore, leading into the vagina. If the procidentia be consider- able, the rectum is carried forward, and in every instance is relaxed. At first the tumour is soft; hut after sometime, if the part has been irritated, it may inflame, indurate, or ulce- rate. It is cured by strict attention to the state of the bowels, thereby preventing accumulation in the rectum, by astringent injections into the vagina, tonics, and, if these fail, by a globe pessary, or by pregnancy ;* but it sometimes returns after delivery.30 § 16. WATERY TUMOUR. Water sometimes passes down from the abdominal cavity, betwixt the vagina and rectum, protruding the posterior sur- face of the vagina in the form of a bag; and the accumula- tion of water in the cavity of the pelvis is sometimes so great as to obstruct the flow of the urine, or produce strangury. When the person lies down, the swelling disappears. It large, a candle held on the opposite side, sometimes shows it to be transparent; and in every case, fluctuation may be felt. As this symptom is connected with ascites, the usual treat- ment of that disease must be pursued, and, if necessary, the water may be drawn off by tapping the abdomen, or rather by piercing31 the tumour, which is to be rendered tense, by pressing it with the finger. § 17. HERNIA. Sometimes the intestine passes down betwixt the vagina and rectum, forming perineal hernia, or protrudes either at the lateral or posterior part of the orifice of the vagina, like the watery tumour; but is distinguished from it by its firmer * Pechlin, lib. i, obs, 20. 63 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 foeces may be felt. As the os uteri is pushed forward and *he posterior part of the vagina occu. pied by the herniary tumour, this complaint may put on some appearance of retroverted uterus. A case of thi3 kind is mentioned by Dr. John Sims, in Mr. Cooper's work on hernia. This complaint is frequently attended with a bearing-down pain; and on this account, as well as from its appearance, it has also been mistaken for prolapsus uteri. Sometimes the tumour does not protrude externally; but symptoms of stran- gulated hernia may appeal', the cause of whicli cannot be known, unless the practitioner examine the vagina. In a case occurring to Dr. Maclaurin, and noticed by Dr. Den- man, the patient died on the third day, and the disease was not discovered till the body was opened. Should Vi woman have vaginal hernia during pregnancy, we must be careful to return it before labour begin, for the intestine may become inflamed, and the faeces obstructed, by the head entering the pelvis; or the labour itself, if the head cannot be raised and the intestine returned, maybe impeded so much as to require the use of instruments. Vaginal hernia requires the use of a pessary. The rectum sometimes protrudes into the vagina, and al- ways does so more or less in an inversio vaginae. This is remedied by the globe pessary, after all the indurated fseces have been removed. The farther accumulation is prevented by laxatives. § 18. ENCYSTED TUMOURS AND VARICES. Indolent abscess, or encysted tumours, may form betwixt the vagina and neighbouring parts. These are distinguished from hernia and watery tumours, by being incompressible, and not disappearing by change of posture. The history of the disease assists the diagnosis, and examination discovers the precise seat and connections of the tumour, though it cannot with certainty point out the nature of the contents. 63 These tumours seldom afford obstinate resistance to delivery; by degrees they yield to the pressure of the head, but some- times they return after delivery. The treatment is similar to that required in other cases of tedious labour, and the tumour must be opened if we cannot deliver the woman otherwise, with safety to the child. Even in the unimpreg- nated state, if it cause irritation, or if the bulk of the tumour be so great as to impede the evacuation of the urine or faeces, an opening must be made. After delivery, in those cases where no operation is performed, the tumour sometimes in- flames and indurates even so low as the perineum. Friction on the perineum, has In these circumstances done good. Varicose tumours of a knotted form, disappearing or be- coming slack by pressure, and aneurismal tumours, distin- guishable by their pulsation, may form about the vagina, and ought not to be interfered with, except by supporting them with a globe pessary in the vagina. § 19. SPONGOID TUMOUR. A very dreadful disease, which I have called spongoid tu- mour, may form either within the pelvis, or about the hip joint, or tuberosity of the ischium, and spread inwards, pres- sing on the bladder and rectum, sometimes so much as to re- quire the use of the catheter. We recognise the disease, by its assuming very early the appearance of a firm elastic tu- mour, as if a sponge were tied up tightly in a piece of bladder. Presently it becomes irregular, and the most prominent parts burst, discharging a red fluid, which is succeeded by fungous ulceration. But I have never known it proceed to this last stage within the pelvis. I know of no remedy, and would dissuade from puncturing, except in the very last extremity. I have never met with a case where it was necessary. §20. ERYSIPELATOUS INFLAMMATION. The orifice of the vagina, together with the labia, and indeed the whole vulva, may be affected by erysipelatous 64 inflammation. This appears under two conditions: 1st, il may originate in the vulva, and spread inwards, even to the uterus; or, 2dly it may begin in the womb, and extend out wards. The parts are tumid, painful, and of a dark red colour. The second affection is most frequent after parturi- tion ; but the first may occur at any age, and under a variety of circumstances. It may be confined to the external parts alone, or it may quickly spread within the pelvis, and destroy the patient; for this disease generally terminates in gan- grene. Vigarous,* says, this state may be distinguished from abscess of the labium, by both labia being equally affected. The general history of the case, and proper exami- nation, will point out the difference. When the disease is confined to the external parts, we may hope for a cure, and even for the preservation of the parts, by giving early, bark and opium internally, and applying to the surface, pledgits dipped in a weak solution of sulphate of zinc, with the addition of a tenth part of camphorated spirit of wine. When this application gives continued pain, fomentations with milk and water, or with decoction of chamomile flowers may be sub- stituted. A highly sensible or inflamed state of the parts may occur in nymphomania, or libidinous madness, either as a primary or secondary affection; and should the patient die under the disease, the parts are generally found black. The tepid bath and fomentations give relief,but sometimes spirituous applica- tions are beneficial. If the patient be feverish she ought to be blooded, and have cathartics administered, and be put on spare diet. Nauseating doses of tartar emetic, or full doses of the medicine, given so as to operate briskly, are of service, especially if followed by sleep. Strict and prudent attention must be paid to the mind. A constant heat and tenderness of the parts, if not occasioned by uterine disease, may be relieved by bathing with solution of sulphate of zinc. ■ Maladies desFemmes, Tome II. p. 169. 65 § 21. FLUOR ALBUS. The vagina is always moistened with a fluid, secreted by the lacunas on its surface. To this is added the secretion from the glands of the cervix uteri and the serous exhalation from the membrane of the uterine cavity. Naturally the balance between secretion and absorption is such, that except on particular occasions, no fluid is discharged from the va- gina. But in a diseased state, the quantity of the secretion is greatly increased, and the discharge, whether proceeding solely from the vagina, or partly also from the womb, re- ceives the name of fluor alhus, or leucorrhoea. Some confine the term strictly to a discharge from the inner surface of the womb ; and in order to determine whether the secretion proceeds from the uterus or not, it has been proposed to stuff the vagina completely for some time, and then inspect the plug, to ascertain whether that part corresponding to the os uteri be moistened.* But this test is not satisfactory, and will seldom be submitted to. When the discharge proceeds from the womb, it some- times injures the function of that organ so much, or is de- pendent on a cause influencing the uterus so strongly, as to interfere with menstruation, either stopping it altogether, or rendering it too abundant or irregular in its appearance, and in such cases the woman seldom conceives. Very fre- quently, however, the menses do continue pretty regularly 5 and in those cases, the other discharge disappears during the flow of the menses, but is increased for a little before and after menstruation. When the menses are obstructed^ it is not uncommon for the fluor alhus to become more abun- dant, and to be attended with more pain in the back about the menstrual period. If a woman, who has uterine leucor- rhcea conceives, the discharge stops, but a vaginal secretion is, on the contrary, not unfrequently increased. This it has been thought dangerous to check suddenly, but it ought not to be allowed to continue profuse, as it causes abortion. * Chambon Malart. d<«s Filles, p. 104 VOL 1. K 65 Fluor albus may occur in two very different states of the constitution, either as an effect of these, or produced in them by accidental causes. These are a state of plethora, or dis- position to vascular activity, and a state of debility. The one is marked by a full habit, a good complexion and a clear healthy skin. The other by a pale countenance, a sal- low surface, a feeble pulse, and generally a spare habit. The one is attended with vertigo, or disease produced by ful- ness. The other by dyspepsia, palpitation, and those com- plaints which are connected with debility. The discharge is produced cither by the lacunae of the va- gina, or the glandular and exhalent apparatus of the uterus. The most ample and the most frequent source is from the vagina. The discharge itself may consist simply of the natural mucus of the part increased in quantity, in which ease it is glairy and transparent; or it maybe so far changed as to become opaque, and white like milk, which is par- ticularly the case when the organs of secretion of the upper part of the vagina and cervix uteri are affected; or it may be purulent. These may all occasionally be mixed with a little blood from the uterine vessels, if there be a tendency to menorrhagia, but not otherwise, unless there be organic disease. In those cases where the discharge is yielded by diseased structure, it is modified by the nature of that struc- ture, and by the existence of ulceration and erosion. When it proceeds from the morbid part itself and not from the irritating effects of that part on the vagina, by sym- pathy, it is generally foetid, and purulent, often of a dark colour mixed with blood, and alternated by uterine hemorr- hage. There is often heat about the parts, and other symp- toms of disease. In all ambiguous, and in every chronic case, it is necessary to examine carefully the state of the uterus and vagina. We must bear in mind that fluor albus may be caused by local irritation, including the effect of diseased structure, or misplaced uterus; by a state of increased vascular action; and by debility, either preceded by increased action, or di- rectly produced by weakening causes. 67 Fluor albus is usually accompanied with pain, and sense of weakness in the back. The functions of the digestive organs are always ultimately injured, and in those women who are of a weak habit, they are impaired from the first. In them the discharge adds greatly to the debility, and all the diseases arising from that state increase, such as indigestion, derange- ment of the hepatic secretion, torpor of the bowels, palpita- tion, swelling of the feet, &c. In the more plethoric patients the debilitating effects are longer of appearing, but they are not exempted from affection of the stomach. Fluor albus may be excited by the presence of a polypus in utero, or in consequence of prolapsus uteri, or of disease of the womb; but in such cases it is symptomatic, and is not at present to be considered. The idiopathic fluor albus may be produced by various exciting causes, such as abortion, monorrhagia, frequent parturition, excessive venery, cold or fatigue after a miscarriage or a delivery at the full time, and whatever can weaken the action of the uterus.* It was at one time supposed, that it might also be produced by a bad state of the fluids of the body, a bilious cacochymy, a leuco- pldegmatic habit, passions of the mind, &c. The applica- tion Of cold or other circumstances exciting irritation of the vaginal membrane may produce it in the same way as they produce catarrh. Worms may cause it. In treating fluor albus we must consider whether it be symptomatic of polypus, prolapsus, or cancer, &c. If it be not, we have then to attend to the general state of the con- stitution. Should the patient be plethoric, or robust, it is necessary, in the first instance, to diminish the fulness and activity of the vessel, by mild, and perhaps, spare diet, by moderate doses of laxative medicine, and even, if requisite, by the lancet. Regular exercise, is in this view, of benefit, but in all cases fatigue increases the discharge. Then we give bitters with alkali to improve the state of the stomach and bowels, and employ an injection of solution of acetite of lead, which is to be thrown three or four times a day into * Chamboa Malad. des Fillcs, p. 104. 68 the vagina, and this may afterwards be exchanged for one of a more astringent quality. If the disease occur in a weak habit, or if the plethoric state, though it existed at one time, has now been removed, the internal remedies must be more directly tonic, and injec- tions of various astringents must be employed; of those the two best are solution of sulphate of alumin and decoction of oak bark. The action of cold and damp are to be avoided, as these are hurtful in every aifection of mucous membranes, whether chronic or acute. Of the internal remedies some are intended to act by sympathy on the secreting parts, as emetics, others as general tonics. Emetics are of very con- siderable advantage, on account of their operation on the stomach and alimentary canal, and are accordingly advised by most writers.* Purges have also been used,f in order to carry off noxious matter; but they are only to be given, so as to keep the bowels regular,:): for brisk and repeated purg- ing is hurtful.^ Tonic medicines and those which improve the action of the chylopoetic viscera, such as lime water, myrrh, bark, steel, rhubarb, uva ursi, &c. are also of much utility, and along with them we may, with great advantage, employ tltc cold bath. The diet is to be light and nourishing, and the patient ought not to indulge in too much sleep. Various medicines have been proposed with a view of act- ing specifically on the secreting parts, such as cicuta, balm of gilead, diuretic salts, calomel, resins, cantharides, electri- city, arnica, &c. have been proposed; but they have very little good effect, and sometimes do harm. Of all these the tincture of cantharides(^) and oil of turpentine, by excitttg * Smellie, Vol. I. p. 67.—Vigarous, Tome I. p. 261.—Mead Med. precepts, chap. XIX. sect. 3d.—Denman, Vol. II. page 104.—See also Ettmuller, Ri- verius, &c. &c. f Chambon Malad. des Filles, p. 107.—Mead, Med. precepts, chap, xix, section 3d. t Stoll. Prselectiones, Tomus II. p. 385. § Vigarous, Malad, des Femmes, Tome I. p. 261. (7) 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 69 the uterine vessels in chronic secretions seem to be the best, but no internal medicine can be much depended on in this view. By suckling a child, the discharge has in some in- stances been removed. Plasters and liniments have been applied to the back, and sometimes relieve the aching pains. Opiates are occasionally required, on account of uneasy sen- sations. When the discharge is very opaque, and attended with considerable pain in the back and loins, there is reason to think that the cervix uteri is in a state of irritation, and by examination it may be found tender to the touch, and the mouth soft and enlarged a little. This state does not con- stitute disease of structure though it may lead to it, but it con- sists merely in an affection of the glands. It is to be man- aged in the first stage, by the warm sea water hip-bath, mild mercurial preparations, laxatives, and avoiding all irritation. After the tender state is nearly subdued, and the discharge has become more chronic, the cold bath, tonics, and mild vegetable astringent injections are proper. Purulent discharge implies previous inflammation, and the present existence either of abscess, ulceration, or a morbid change of a secreting surface. The two first states are ascer- tained by examination. The last chiefly by the smarting in making water, and other symptoms excited by the action of a virus. To this species belongs the gonorrhoea, which is to be cured by mild laxatives, and injections, first of acetite of lead, and then of sulphate of zinc, dissolved in water. The two first states are to be managed according to the causes which give rise to them. this powerful article of the materia medica, in obstinate cases of Leucor- rhoea; and recites a number of instances, in which it appears to have pro- duced the best effects. In his exhibition of this medicine, he generally begun with about jij or jijss of the tincture, in gvj of water; a table-spoonful of which was given thrice a day. He continued gradually increasing the dose, until his patient had taken Jiv of the tincture in 24 hours, 5j of the tincture being added to gvj of water. It was generally given, until con- siderable pain, and a puriform discharge from the vagina was produced. I cannot say, that in the few trials I have made of it in this complaint, the beneficial effects have bewi so conspicuous. 70 On the whole then, our practice in fluor albus, unaccom- panied with organic affection, consists in rectifying the con- stitution, bringing it as far as possible to a state of perfect health, employing topical applications in the form of injec- tions, and avoiding the farther operation of exciting causes. § 22. AFFECTIONS OF THE BLADDER. The bladder is subject to several diseases. The first I shall mention is stone. This excites very considerable pain in the region of the bladder, remarkably increased after making water. There is also irritation about the urethra, with a frequent desire to void the urine; but it does not always flow freely, sometimes stopping very unexpectedly. The urine deposits a sandy sediment, and is often mixed with mucus. These symptoms lead to a suspicion that there is a stone in the bladder, but we can be certain only by pas- sing a sound. By means of soda,(r) the warm bath, and (r) Our author has omitted to mention the efficacy of magnesia in calcu- lous complaints, as recommended by Messrs. Brande and Hatchet. The result of the inquiries of these ingenious gentlemen, on this very interesting sub- ject, has been communicated to the scientific world in a paper printed in the Philosophical Transactions for the year 1810, entitled " Observations on the Effects of Magnesia, in preventing an increased formation of the Uric Acid, by William T. Brande." This gentleman (in a communication to Sir John Sinclair) says, that the best method of giving the magnesia, is in plain water, or milk, to be taken in the morning early, and at mid-day. If the stomachi* weak, and this produces flatulency or uneasy sensations, some common bit- ters, such as gentian, may be taken with it: if it purges, a little opium may be added. He supposes its beneficial operation depends, on preventing the for- mation of acid in the stomach. , The dose of magnesia, he observes, must always depend upon the circum- stances of the case;—generally, five grains twice or thrice a day to children ten years of age ; fifteen or twenty grains to adults. Mr. Brande has always given the common magnesia, although he remarks, that, the calcined may be occasionally used with advantage. For fuller infor- mation on this subject, the reader is referred to Brande's paper, above quoted in the Phil. Trans, and to a letter from Sir John Sinclair, vide Eclectic. Reper- tory, voL III. p. 120. Dr. Gilbert Blane, so well known in the medical world, has also written an interesting paper on the effects of large doses of mild vegetable alkali, or potassa carbonata in gravel, and the beneficial effects of opium combined v. ith it. 71 opiates, much relief may be obtained, and very often the stone may be passed, for the urethra is short and lax. But when these means fail, an operation must be performed. This has been done during pregnancy,* but is only allow- able in cases of great necessity. Sometimes the stone makes way, by ulceration, into the vagina.f It has even been known to ulcerate through the abdominal integuments4 In many cases the symptoms of stone are met with, although none can be found in the bladder. This is most frequently the case with young girls, previous to the establishment of the catamenia, or with women of an irritable habit. There is no organic disease, nor have I ever known it, in such peo- ple, end in a diseased structure of the bladder or kidneys; indeed, they rarely complain of uneasiness about the kid- neys. I have tried many remedies, such as soda, uva ursi, narcotics, antispasmodics, tonics, and the warm and cold bath, but cannot promise certain relief from any one of these.33 In process of time, the disease subsides and disap- pears. The use of a bougie may be of service. Induration, or scirrhus of the bladder, produces symptoms somewhat similar to calculus, but there is a greater quantity of morbid mucus mixed with the urine ; and blood with pu- rulent matter is discharged, when ulceration has taken place. No stone can be found, but the bladder is felt to be hard and thick. Sometimes it is much enlarged with such appear- ances, as give rise to an opinion, that the uterus is the part principally affected.34 The scirrhus and ulceration may ex- pend 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 j keep the bowels open, with an emulsion containing oleum ricini; and allay irritation by means of the tepid bath and opiates. Mercury, cicuta, uva ursi, &c. with applications to the blad- der itself, have seldom any good effect, and sometimes do harm. * Deschamps Traite de 1'Oper. de la Taille, Tome IV. p. 9. f Ilildanus, cent. I. obs. 68 and 69. Vide Case by M. Caumond in Recuefl Petiaa. Chronic inflammation of the mucous membrane of the blad- der, produces frequent desire to void urine, and the discharge of viscid mucus which sometimes has a puriform appearance. Cicuta and balsam of copaiba seem to be the best remedies. Polypous tumours35 may form within the bladder, produc- ingthe usual symptoms of irritation of that organ. Most dread- ful sufferings have been caused by worms in the bladder. In consequence of severe labour, or the pressure of instru- ments, the neck of the bladder may become gangrenous, and a perforation take place by sloughing. The woman com- plains of soreness about the parts, and does not void the urine freely. In five or six days the slough comes off, and then the urine dribbles away by the vagina. In all cases of severe labour, and indeed in every case 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 distension and farther irritation of the bladder; and the parts must, if there be a tendency to slough or to ul- cerate, be kept very clean, and be regularly dressed, in order to prevent improper adhesions. If the bladder should give way, we must try, by keeping in attentively an elastic cathe- ter,* to make the urine flow by the urethra, and then perhaps the part may heal. If this have been neglected, it will be proper to make the edges of the opening raw by paring, if it be large, or by caustic if it be small, and afterwards use the catheter. When an incurable opening is left, we must, by introducing 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 opening.56 Puzos justly remarks, that it is always the blad- der, and not the urethra, that suffers. Sometimes, after a severe labour, the woman is troubled with incontinence of urine, although the bladder be entire. This state is often produced directly by pressure on the neck * This succeeded in a very bad case related by Sedilliot, Recueil Period Tome I. p. 187. 73 of the bladder; sometimes it is preceded by symptoms of in- flammation about the pelvis, and, in such cases, the os uteri is often found afterwards to be turned a little out of its proper direction, and the patient complains much of irregular pains, about the hypogastrium and back. When the woman is in bed some of the urine collects in the vagina, and comes from it when she rises; after she is up, it comes from the urethra alone, which distinguishes this from the complaint last described. Time sometimes cures this disease. The cold bath is useful, unless it increase the pain; and, in that case, the warm bath should be employed. It may be proper to use the bougie daily, and also try the effect of tincture of cantharides. The bladder may descend, in labour, before the uterus, pro- ducing much pain; or it may prolapse for some time previous to labour, attended with pains resembling those of parturition, and sometimes with convulsive or spasmodic affections.37, When the prolapsus vesicae takes place as a temporary oc- currence during labour, or antecedent to parturition, we must be careful not to mistake the bladder for the membranes, for thus irreparable mischief has been done to the woman. The bladder when protruded, is felt to be connected wilh the pubis. It retires when the pain goes off. If the patient be not in la- bour, the uneasiness is to be mitigated by keeping the bladder empty, and allaying irritation with opiates, and taking a little blood if feverish or restless. If labour be going on, the blad- der must likewise be kept empty, and may, during a pain, be gently supported, by pressing on it with two fingers in the vagina, by which the bladder is preserved from injury. In the unimpregnated state, it sometimes descends betwixt the vagina and pelvis, so as to form a tumour within the vagina, or at the vulva. It produces a procidentia of the vagina, but the" tumour is formed at the anterior part of the vulva, instead of the back part, as in the ordinary procidentia. There is some degree of bearing-*lown pain in walking, particularly when the bladder is full. Some patients complain of pain in the groin, others at the navel, and some suffer little or no in- convenience, except pain about the bladder when it is dis- tended. If the disease has continued long, or if the prociden- vol. I. L 7* tia of the anterior part of the vagina be considerable, the os uteri is directed backward, and when the finger is introduced into the vagina, the anterior part of that canal can be pushed up farther than usual over the fore part of the cervix uteri, which then appears to be elongated, and perhaps in some cases the anterior lip is actually lengthened. In a case dis- sected by my brother, the bladder was found to form a hernia on both sides of the pelvis, hanging like a fork over the ure- thra. This procidentia is called a hernia* vesicalis, and is often attended with suppression of urine. If this be inatten- tively examined, it may be taken for prolapsus uteri; but it will be found to diminish, or even disappear, when the urine is voided, and by pressure, the urine may be forced through the urethra. The hernia vesicalis is to be remedied by the use of a globe pessary. Sometimes it is combined with cal- culus in the bladder. In this case, it has been proposed to open the bladder, extract the stone, and keep up a free dis- charge of urine through the urethra, in order to allow the communication with the vagina to heal. Deschamps advises, that the opening should be made near the pubis, and not at the posterior part of the tumour, lest that part of the bladder be cut, which, when the tumour is reduced, would communi- cate with the abdominal cavity. I can see no necessity for making any change in the mode of extracting the stone on account of the procidentia. § 23. EXCRESCENCES IN THE URETHRA. Excrescences may, notwithstanding the opinion of Mor- gagni, form in the course, or about the orifice of the ure- thra,38 and generally produce great pain, especially in mak- ing water; on which account, the disease has sometimes been mistaken for a calculous affection. The agony is at times so great, as to excite convulsions, and it is not un- common for the patient to have an increase of her sufferings * Vide the Memoirs and Essays of Verdier and Sabbatier, and Hoin. Sandi- fort, Diss. Anat. Path. lib. I. cap. iii. and Cooper on Hernia, part II. p. 66. 7* about the menstrual period. The tumour is vascular, florid, moveable, and exceedingly tender. When excrescences grow about the orifice of the urethra, they are readily dis- covered ; but when they are high up, it is much more diffi- cult to ascertain their existence. Dr. Baillie* says, they cannot be known, but by the sensation given by the catheter passing over a soft body. They, however, in one case, were discovered, by turning the instrument to one side, so as to open the urethra a little.39 When their situation will per- mit, it is best to extirpate them with the knife or scissars ; or if near the orifice, as they generally are, a ligature may be applied. Sometimes they have yielded to the bougie, though they had returned after excision.f The removal of large excrescences, has occasionally been attended with very severe symptoms.40 The daily use of the bougie, for some time after extirpation, is of service.41 Sometimes the urethra is partially, or totally inverted,42 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 urethra, with difficulty of voiding water, the bougie is often of great service, even although there should be no con- traction of the canal itself. Sometimes the urethra is preter- naturally dilated,43 but this does not necessarily cause incon- tinence of urine. The mucous coat of the urethra is sometimes thickened, and its vessels become varicose. This produces general swelling of the urethra felt by the finger in the course of it, pain or pressure, and in coitu, with a discharge of mucus, and tormenting desire to make water. When the patient bears down, the urethra is partially inverted, and appears swelled and vascular. These vessels should be scarified, the * Morbid Anatomy, p. 321. f Broomfield's Surgery, Vol. II. p. 296. 76 part bathed with an astringent lotion, and gentle pressure made with a thick bougie. § 24. DEFICIENCY AND MAL-FORMATION OF THE UTERUS. The uterus may be larger than usual, or uncommonly small44, or it may be altogether wanting45. Unless these circumstances be combined with some deficiency, or unusual conformation of the extenial parts or vagina, the peculiar organization is not known till after death. It is, however, not uncommon for the external parts to be very small, when the uterus is of a diminutive size; and when it is altogether wanting, the vagina is either very short, or no traces of it can be found. In either of these cases, no attempts should be made to discover a uterus by incisions, unless, from symp- toms of accumulation of the menses, we are certain that a uterus really exists.* The uterus may be 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 impregnation. The uterus is sometimes divided into two, by a septum stretching across at the upper part of the cervix ;f or the os uteri is almost, or altogether shut up,47 by a continuation of the lining of the womb or vagina, or by adhesion, consequent to ulceration, or by original conformation ; and in this last case, the substance of the os uteri is sometimes almost car- tilaginous. The menses either come away more or less slow- ly, according to the size of the aperture, or are entirely re- tained when there is no perforation. As long as the menses are discharged, nothing ought to be done; but if they are completely retained, and violent and unavailing efforts made for their expulsion, an opening must, as a matter of neces- sity, be made from the vagina. In such cases, the uterus * Nabothus mentions a rash operator, who undertook, by incision, to find the uterus; but after cutting a little, he came to some vessels which obliged him to stop. t Baillie's Morbid Anatomy, e-hap. xix n has been tapped with success ;* but it has also happened, that fatal inflammation has succeeded the operation. The vessels are sometimes enlarged; and I have seen the spermatic veins extremely varicose, in an old woman who had been subject to piles; but I do not know that any particular inconvenience results from the veinous enlargement § 25. HYSTERITIS. The uterus is subject to inflammation; but in the unim- pregnated state, it is not common for the womb to be the original seat of acute inflammation. After parturition, it is very frequently inflamed, and this will hereafter be consider- ed. Inflammation is discovered by pain in the hypogastric region, accompanied with tension, and the part is tender to the touch; there is acute pain stretching to the back and groins; the bladder is rendered irritable; and acute fever accompanies these symptoms. Blood letting, purges, fomen- tations, and blisters are to be used, as in other cases of peri- toneal inflammation. Wounds of the uterus are dangerous, in proportion to the inflammation they excite.f Chronic inflammation of the cervix uteri is not uncommon. The os uteri is open, soft, and tender to the touch. The cervix is not materially affected in size or hardness. There is a considerable discharge of white mucus which sometimes becomes puriform, and this is often mixed with blood; or there may be very considerable uterine hemorrhage. The patient feels pain in the uterine region, but generally com- plains more of pain in some distant part of the abdomen, not unfrequently near the liver. There is no fever, but the pa- tient becomes weak from discharge, irritation, and those hysterical affections which may accompany the complaint. The warm sea-water hip-bath, gentle saline purgatives, * The menses being retained, and great pain excited, they were let out with a trocar by Schutzer. Vide Sandifort, p. 69. ■j- In one instance the woman was murdered, by thrusting a piece of glass up the vagina; and Haller notices a fatal case, in which a piece of lead was thrust into the uterus. 78 injection of decoction of hemlock, mild diet, and the use of cicuta as an anodyne are useful at first; and afterwards when the symptoms are so far subdued, the use of the cold sea-bath, bark combined with bitters, and mild injections of vegetable astringents are proper. In obstinate cases mer- cury ought to be tried, with a view of altering the action of the parts. § 26. ULCERATION OF THE UTERUS. The uterus may, from irritation, become ulcerated like any other part; purulent matter is discharged, the woman feels pain in coitu, or when the uterus is pressed, and some. times the finger can discover the ulcer. Simple ulceration is very rare, and, I apprehend, will always heal, by keeping the parts clean with mild injections. Ulceration from mor- bid poison is more frequent. Of this kind is the phagedena, a most obstinate and dreadful disease of the womb, which begins about its mouth, and goes on, gradually destroying its substance, until almost the whole of it be removed; and sometimes it spreads to the neighbouring parts. This dis- ease is marked by excruciating pain of the burning kind, in the region of the uterus, copious foetid, purulent, or sanious discharge, alternating with some hemorrhage, small but fre- quent pulse, wasting of the flesh, and occasionally swelling of the inguinal glands: no tumour is felt externally, but the belly is flat. Examination, per vaginam, discovers the destruction which has taken place, and how far it has pro- ceeded. It also ascertains, that the part which remain^ is not enlarged. On inspecting the body after death, the pelvis is gene- rally found filled with intestines, matted, and adhering to the pelvis, and to one another. In the midst of the mass, there are sometimes one or two simple abscesses, containing healthy pus. On tearing out the mass, the uterus is discover- ed to be ate away all to the fundus, or a small part of the body. The substance is very little thickened, but resembles soft cartilage, with here and there small cysts, not larger 79 than pin heads. The ulcerated surface is dark, nocculent, and has a dissolved appearance, whilst the substance in its immediate vicinity is vascular and livid. The rapidity of the destruction is various in different cases. It is very diffi- cult to cure this ulcer, or even to check its progress. Some- times mercury has effected a cure, either by itself, or com- bined with cicuta; or hyocyamus, or other narcotics, have been given alone. Nitrous acid occasionally gives * relief, and, when greatly diluted, forms a very proper injection. A very weak solution of nitrate of silver, is also a good topi- cal application. Should the pain be great, tepid decoction of poppies, or water with the addition of tincture of opium, will be of service as an injection. Fomentations to the lower belly, and friction with camphorated spirits on the back, also give relief; but very frequently opium, taken in- ternally, affords the only mitigation of suffering, and the quantity required is often great. There is another kind of ulcer, which attacks the cervix and os uteri. It is hollow, glossy, and smooth, with hard margins; and the cervix, a little beyond it, is indurated, and somewhat enlarged, but the rest of the uterus is healthy. The discharge is serous, or sometimes purulent The pain is pretty constant, but not acute; and the progress is generally slow, though it ultimately proves fatal, by hectic. In this, and all other diseases of the uterus, the morbid irri- tation generally excites leucorrhcea, in a greater or less de- gree; but examination ascertains the morbid condition of the part. Although this disease be very different in its na- ture from the former, yet the mode of treatment is very much the same. Material benefit may be derived from the warm salt-water bath, and the regular use of a solution of some saline purgative, or a laxative mineral water, such as that of Harrowgate or of Cheltenham. This is especially the case, when the ulcer is small, or when the part is only indurated, ulceration not having yet taken place. In this stage, the cervix is felt hard and sensible to the touch, and there is leucorrhcea, and pain in the uterine region! A gentle mercurial course is occasionally of sen ice. Some 80 may consider this disease as a species of cancer, but the ulcer is never fungous. Excrescences of a firm structure, and broader at the ex- tremity than at the attachment, may spring from theos uteri, and generally, I apprehend, originate from a lobulated or fis- sured state of the parts. It bleeds readily and profusely, but when it is not irritated, the discharge is serous and so great, that thick folds of cloth are soon wet as if the liquor amnii had been coming away. It is evident that astringents cannot ef- fect a cure, as they do not alter the nature of the substance which secretes. If a ligature could be passed so as to destroy the circulation in the excrescence, a cure might be expected. When this cannot be done we can only palliate symptoms. Venereal ulceration may, although the external parts be sound, attack the uterus, producing a sense of heat with pain. There is at first, very little discharge, and this consists of mucus; but if the disease be allowed to continue, foetid puru- lent matter comes away. The ulcer is at first small, and there is no hardness about the os uteri, nor is it perceived to be di- lated; but it is painful to the touch, and sometimes bleeds after coition. The purulent discharge appears earlier t&an in can- cer, but the health for a time is not affected. Then the ulcer spreads, and may destroy a great part of the womb and blad- der, and occasion fatal hectic. The history of the patient may assist the diagnosis. The cure consists in a course of mercury, which I have always found produce a good effect soon after the commencement.* § 27. SCIRRO-CANCER. Scirro-cancer generally, if not always, begins in the cervix uteri. It may take place in the prime of life, but is most fre- quent about the time of the cessation of the menses. It be- gins with a feeling of heaviness or heat, and darting pains about the hypogastrium, aching in the back, dull pain about the upper and inner part of the thighs, with a sense of bearing- * Vide Med. Comment. Vol. XIX. p. 257.—Pearson on Cancer, p. 119. 81 down, together with dysuria and mucous discharge with the urine: glowing heat, or sometimes stinging pain betwixt the pubis and sacrum, with itchiness of the vulva. There is from the first, a leucorrhteal discharge. The patient is troubled with flatulence, heartburn, and sometimes with vomiting, and cutaneous eruptions from sympathy with the stomach. The general health suffers, the countenance becomes sallow, the pulse quickens, the strength declines, and the body wastes. If the menses have not entirely ceased, they become irregular and profuse. Presently a foetid, purulent, or bloody matter is discharged, which indicates that a cyst has burst, and the disease has proceeded to ulceration. Repeated hemorrhages are now apt to take place, and hectic is established. The pain is constant, but subject to frequent aggravations, and the weakness rapidly increases. At length the pain, fever, want of rest, discharge, and loss of blood, completely exhaust the patient; and death terminates at once both her hopes and sufferings. At first, by examination per vaginam, the uterus is felt as if it were enlarged; the cervix is thickened, and the os uteri hard, open, irregular, and more sensible to the touch, a cir- cumstance which causes pain in coitu. The cervix is either totally indurated, or has imbeded in it a hard tumour, which may acquire considerable size. A little blood is often observed on the finger after an examination. In some time after this, the os uteri is turgid, as if it contained a small cyst, and pre- sently it is felt to be ulcerated and fungous; but sometimes the fungi are less perceptible, deep excavations being formed, the sides of which, however, after death, are found to be fun- gous. The cervix uteri is sometimes considerably enlarged before ulceration takes place; but, in other cases, the augmentation is much greater after ulceration, than before it.48 If the dis- ease originally formed a distinct tumour in the cervix, that tumour may become as large as the first, adhering to the pel- vis so that it cannot be moved, and pressing so much on the rectum or bladder, according to its situation, as to give rise VOL. i. m 82 to much obstruction in the evacuations from cither of these parts. The uterus itself is seldom much enlarged in genuine cancer, but it is possible whilst the cervix is affected with this disease, that the body of the uterus may have undergone a different morbid change. The tubes and ovaria have been said to participate in the disease.* In some patients the disease proves fatal very early if there be profuse hemorrhage; in others, great devastation takes place, and the bladder49 or rectumf are opened. In most cases, the vagina becomes hard and thickened, or irregularly contracted with swelled glands, in its course. On examining the diseased part after death, it is found to be thickened and indurated, and sometimes its cavity is en- larged. The substance is of a whitish or brownish colour, in- tersected with firm membranous divisions ; and betwixt these are numerous small cysts, the coats of which are thick and white. They contain a vascular substance, which, when wiped clean, is of a light olive colour. In proportion as the disease advances, some of the cysts enlarge, and thicken still more; and, when opened, are found to contain a bloody lymph, and to have the inner surface covered with a spongy vascular substance, similar to that which fills the small cysts, but rather more resembling fungus. Presently some of these cysts augment so much as to resemble abscesses, though they arc not properly speaking abscesses, and soon afterwards they burst. It is extremely rare for a cyst to burst, or fungi to shoot out on the exterior surface of the uterus, which is covered with the peritoneum. The position of the uterus is often na- tural, but sometimes it is inclined to one or other side, or approaches to a state of retroversion. As this disease is apt to be mistaken for fluor albus, mo- norrhagia, nephritis, or dyspepsia, it is of great importance that the practitioner should be on his guard, and examine * Vide Trochaska Annot. Acad. fasc. 2d. f M. Tenon found, in a case of cancerous uterus, all the posterior part of the womb ulcerated, the rectum diseased, and a communication formed betwixt 'hem 83 early and carefully per vaginam. Much harm is done by the use of astringent injections meant to cure the supposed fluor albus. This is a very hopeless disease, but still much may be done to check its progress, or mitigate its symptoms. When un- easy sensations, about the cessation of the menses, indicate a tendency to uterine disease, we find advantage from the insertion of an issue in the arm or leg, the use of laxative waters,* and spare diet,50 and flannel dress. If by examina- tion we discover any alteration in the shape, size, or sen- sibility of the womb, the most effectual treatment we can have recourse to, is the daily use of from two to three drachms of sulphas 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 are of service, 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, for the longer we can keep a scirr- hus from going into a state of activity and inflammation, the longer do we keep the disease at bay. It is therefore scarcely necessary to add, that if the patient be married she must not sleep with her husband. We keep the parts clean, by inject- ing tepid water, or decoction of camomile with hemlock or opium; allay pain by anodynes; attend to the state of the bowels; and correct stomachic affections by bitters, and other suitable remedies. Mercury, iron, arsenic, sarsaparilla, aconitum, cicuta, &c. have been given internally, but have seldom a good effect. It has been proposed to produce, with an extracting instrument, a prolapsus uteri, and then cut off the protruded womb; but this operation is not likely to be resorted to. * Roederer relates a case where scirrhous swelling was cured by keepinr the bowels open, and giving every third evening, from ten to twenty grains of calomel.—Haller Disp. Med. Tomns IV. n. 670. 8h § 28. TUBERCLES. Tubercles are common in the uterus, insomuch that M. Bayle says, that in seven months he met with fourteen cases. They consist at first of fleshy matter, but in process of time become more like cartilage, or even bony, especially on their surface.* On examining the tumour, it is sometimes found to be intersected with membranous divisions; and a section always exhibits a pretty compact granulated surface without vessels. A tubercle may take place in one spot, and all the rest of the uterus may be healthy, and nearly of the natural size. The magnitude of the tubercle is very variable, and it may either project on the outer surface, or within the cavity of the womb; and in this last case, the adhesion to the sur- face of the cavity is generally slightf after the tubercle has fully projected. In this it differs, even in its most detached. state, from polypus, which is attached not by cellular sub- stance, but by a pedicle. Sometimes there are a great many tubercles, which are found in various stages of projection, and the uterus may become greatly enlarged, and very irre- gular externally.:): I have never seen the tubercle end in ulcer- ation, nor the substance of the uterus, although thickened, have abscess formed in it. The effects of this disease are chiefly mechanical and often altogether trifling; at other times, we have a pain in the back, and sometimes in the hypogas- trium, which is swelled, hard, and irregular, if there be much enlargement of the womb, dyspeptic symptoms, leucorrhcea, and at length feverishness and gradual loss of strength. The progress is generally slow, unless the cervix uteri, which is always sound with regard to this disease, be affected with phagedena or cancer, or unless simple inflammation be ex- cited by pressure on some neighbouring part. Sometimes one or more tubercles are thrown off, with pains like those of labour. * Sandifort Obs. Anat. Path. lib. I, cap. viii.—Bayle in Jour, de Med. Tome V.—Murray de Osteosteamate, p. 14. et seq. f Baillie's Morbid Anatomy, chap. xix. * I have found the uterus as large as a child's head of a year old, with manv projections and tubercles.—Peyer has a similar case, Parerg. Anat p. 131. 85 Menstruation may be rendered irregular, but sometimes continues unaffected. In the very last case I saw, the size of the womb was large, and two thick hard ridges could be felt in the abdomen, extending obliquely up by the sides of the umbilicus. The lower and anterior part of the womb was large, and filled the brim of the pelvis like a child's head; whilst near the promontory of the sacrum, the os uteri was felt healthy though compressed. This woman had no com- plaint except what proceeded from bulk; the bladder contrary to expectation, was not in any degree affected; the stools easy, and menstruation regular. This disease can only be confounded with diseased ovarium, but it is harder when felt through the belly, not so moveable at first, and a difference may generally be felt per vaginam. It maybe combined with tumour of the ovarium. No remedy has any power in removing the diseased sub- stance, and therefore our treatment consists in palliating symptoms, especially in attending to the bladder and bowels. We also upon general principles keep down activity, and guard against inflammatory action. The antiphlogistic regi- men should be pursued in moderation. The bowels espe- cially should be kept open, and every source of irritation removed. The tepid bath is usefuL Women may live a long time, even although these tumours acquire considerable magnitude. Sometimes the whole uterus is a little enlarged, and cjianged into a white cartilaginous substance, with a hard irregular surface; or it may be enlarged and ossified," and these ossi- fications may take place even during pregnancy.* Stcato- matous or atheromatous tumours of various sizes,f or sarco- matous* or 8cirrhns-like$ bodies, may be attached to the uterus. All these diseases sometimes at first give little trouble. * Vide Observ. on Abortion, 2d. edition, p. 37. t Vide Rhodius, cent. HI. ob. 46.-Boehmer Obs. Anat. fuse. 2d -Stoll Ra Uo Med. part. II. p. 379. own Ha- * Vide Friedas, in Sandifort's Observ. lib. I. c. viii. and a case by Sandifort nimselt, where the tumour adhered by a cord, lib. IV. p. 113 § Beader Obs. Med. ob. 29. p. 170. 86 Even their advanced stage has no pathognomonic mark, by which they can be discovered, as they produce the usual effects of uterine irritation. I must also add, that they are very little under the power of medicine. The most we can do, is to palliate symptoms; by which, however, we greatly melio- rate the condition of the patient. § 29. SPONGOID TUMOUR. The uterus is more frequently affected with spongoid hi- mour than is supposed; many cases of that disease passing for cancer. This is a firm, but soft and elastic tumour, the substance of which bears some resemblance to brain, and contains cysts of different sizes, filled with red serum or blood, or bloody fungus according to circumstances. There is no certain way of distinguishing or discovering this dis- ease in its early stage, for it often gives very little trouble, and any symptoms which do occur, are common to other diseases of the womb. The tumour, however, enlarges, and can at length be felt through the abdominal parietes. It is soft and elastic, and on the first application of the hand, feels very like a tense ventral hernia. There may be two or more tumours of unequal sizes in different parts of the belly, which can be felt to have a connection with each other and may frequently be traced to the pubis. Per vaginam, the staje varies in different cases; but by pressing on the external tumour at the same time, we discover its connec- tion with the womb below. We may find ulceration, or the os uteri soft, and tumified, and opened, or the posterior,lip may be lost in a soft elastic tumour, and quite obliterated, whilst the anterior one, after a pretty careful examination, is felt high up, and apparently sound. Pressure seldom gives pain, till ulceration is about to take place, and no blood is usually observed on the finger after examination, unless a fungus has protruded. So far as I have seen, fluor albus is a rare attendant on this disease in the early stage, and little inconvenience is at that period produced, except what results from pressure on the bladder, causing strangury 87 or suppression of urine, attended with fits of considerable pain, like those excited by a stone. The complexion is sal- low, but the health is tolerably good, till ulceration or in- flammation take place. Ulceration may happen in different parts ; it may be directed to the vagina, and then we have foetid bloody discharge, or sometimes considerable hemorr- hage, and ultimately the bladder or rectum are involved in the destruction : or bloody fungus may protrude from the exterior surface of the uterus into the general cavity of the abdomen, and at length the bowels become inflamed and glued together: or the tumour may adhere to the parietes of the abdomen, and the skin after becoming livid gives way, and a fungus shoots out from the belly. As the disease advances towards ulceration, the health is more impaired, hectic fever takes place, and the patient is ultimately cut off. The whole treatment, I am sorry to say, consists in pal- liating such sympathetic or local symptoms as may arise in the course of the disease. [§ 30. CAULIFLOWER EXCRESCENCE FROM THE OS UTERI. Dr. John Clarke of London, considers himself as the first writer who has taken notice of this disease. The cauliflower excrescence, according to him, arises al- ways from some part of the os uteri. As several of the early symptoms are not very distressing to the patient, the tumour in the beginning is rarely the subject of medical attention. The first changes of structure have therefore not been ob- served. In general the tumour is not less than the size of a blackbird's egg. At this period it makes an irregular pro- jection, and has a base as broad as any other part of it, attached to some part of the os uteri. The surface has a granulated feel, considerable pressure on handling it, does not occasion any sense of pain. The remainder of the ois uteri, will 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 88 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 the cauliflower, when it begins to run to seed. In most cases it is of a brittle consistence, so that small parts of it will come away, if it be touched too rudely; and such pieces appear to be very white. Sometimes, though no violence has been used, small portions of a white sub- stance come away with the urine of the patient, and in the discharge from the vagina. When the tumour has arrived at a size greater than that of the os uteri, it spreads very much, and as the base is the smallest part of the tumour, persons, not conversant with the disease, have often mistaken it for polypus. A little at- tention however, to the feel of the tumour, and the breadth of its base, will be sufficient to distinguish them. In the very early state of the cauliflower excrescence, a discharge from the vagina takes place like fluor albus; it very soon becomes thin and watery, and is sometimes tinged with blood. In most cases upon coming away, it is apparently as thin and transparent as pure water; but the linen on which it is received, when dry becomes stiff, as if it had been starched. The quantity of the discharge when the excres- cence is large, will sometimes be sufficient to wet thoroughly, ten or twelve napkins in a day. Now and then a discharge of pure blood occurs. When this ceases the discharge of thin transparent fluid re-appears. An offensive odour generally accompanies the discharge, which is greatest when there has lately been an evacuation of pure blood, or of the cata- menia. Mucus has sometimes been found in the fluid dis- charged, but pus never. Patients labouring under this disorder, are variously af- •V( ted with regard to pain. In the commencement none w 89 felt; but during its progress pain is in some cases experi- enced. Generally in the advanced stage, the patient feels pain in the back, and in the direction of the round ligaments of the uterus. The pain is not described to be lancinating, as in cancer, and is without any sensible aggravation by paroxysms; but on the whole, it is most felt after the patient has been in a perpendicular attitude. The disease attacks indiscriminately women of all ages. The patient is destroyed by the debility occasioned by the profuse discharge; and in the course of the disease, she al- ways becomes extremely emaciated from the above cause. It always terminates fatally. Respecting the treatment of this disease, nothing satisfactory can be offered. All stimu- lating substances either in diet or medicine, seem to aggra- vate it, by increasing the discharge; and no astringents in- ternally given appear to lessen it. The only means from which any benefit has been derived, is the injecting into the vagina three times a day, a strong decoction of cortex gra- nati, or of cortex quercus, in winch 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 ihe occa- sional symptoms of suppression of urine, and costiveness, are to be relieved by the use of a catheter and mild laxa- tives.^)] § 31. CALCULI. Earthy concretions are sometimes formed in the cavity of the uterus, and produce the usual symptoms of uterine irritation; and Vigarous considers them as very apt to excite hysterical affections. As in the bladder of urine, the con- stant presence of a calculus tends to thicken its coats ; so the («) 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. VOE. I. N 90 irritation of a stone in the uterus can excite a disease of the substance of the womb, and produce ulceration, which may extend to the rectum. The disease in question is very rare, and can only be discovered by feeling the concretion with the finger, or a probe introduced within the os uteri, which is sufficiently open to permit of this examination. Nature, it would appear, tends to expel the substance,53 and we ought to co-operate, if necessary, with this tendency. We must also relieve suppression of urine,* or any other urgent symp- tom which may be present. $ 32. POLYPI. Polypous tumours are not uncommon, and may take place at any age; they are not, however, often met with in very young women. They always affect the health, producing want of appetite, dyspeptic symptoms, uneasiness in the ute- rine region, a variable swelling of the abdomen, aching pain in the back, bearing-down pains, tenesmus, and a dragging sensation at the groins. When these symptoms have con- tinued some time, the strength is impaired, and the pulse be- comes more frequent. At first, there is generally a mucous discharge; but at length blood is discharged, owing to the rupture of some of the veins of the tumour, or sometimes from the uterine vessels themselves and the permanent dis- charge not unfrequently becomes foetid. Mr. Clark, in his late work, very properly notices, that the blood often coagu- lates over the polypus, and comes off like a ring. Thepe symptoms, however, cannot point out, to a certainty* the existence of a polypus: we must have recourse to examina- tion, by which we discover that the uterus is enlarged, its mouth open, and a firm, but generally, moveable body within it. If the os uteri have not yet opened so as to admit the finger, the diagnosis must be incomplete. By degrees the polypus descends from the uterus, or pain- ful efforts are made more quickly to expel the tumour, the * This proved fatal in a child of five years old. 91 body of which passes into the vagina53, and sometimes occasions retention of urine." The pedicle remains in utero, and the bad consequences formerly produced still continue, except in a few cases, where the tumour has dropped off,* and the patient got well. In such cases, it has been sup- posed that the os uteri acted as a ligature; and to the same cause is attributed the bursting of the veins, which produce, in many instances, copious hemorrhage. But although hemorrhage he most frequent after the polypus has descend- ed, yet it may take place whilst it remains entirely in utero. It sometimes happens that the uterus becomes partially inverted,! before or after the polypus is expelled into the vagina; and this circumstance does not seem to depend al- together on^the size of the polypus, or its weight. Polypus may also be accompanied with prolapsus uteri4 Polypi may be attached to any part of the womb, to its fundus, cervix, or mouth ; and it has been observed, that there is less tendency to hemorrhage, when they are attach- ed to the cervix, than either higher up, or to the os uteri it- self. If there be an union betwixt the os uteri and the tu- mour,§ or if they be in intimate contact, polypus, may pass for inversio uteri; but the history of the case, and attentive examination, will point out the difference, which will be no- ticed when I come to consider inversion and prolapsus of the uterus. Here I may only remark, that the womb is sensi- ble, but the polypus is insensible to the touch, or to irrita- tion ; but it should be recollected, that if the polypus be moved, sensation can be produced by the effect on the womb. Polypi are of different kinds. The most frequent kind is of a firm semicartilaginous structure, covered with a produc- tion of the inner membrane of the womb ; and indeed it seems to proceed chiefly from a morbid change of that mem- » Mem. de 1'Acad, de Chir. Tom. III. p. 552 f Vide case by Goulard, in Hist, de l'Acad. de Sciences, 1732. p. 42.—Dr. Denman, in his engravings, gives two plates of inversion, one from Dr. Hun- ter's Museum, the other from Mr. Hamilton. * Med. Comment. Vol. IV. p. 228. § Mem, of Med. Society in London, VoL V. p. 12. 92 brane, and a slovy subsequent enlargement of the diseased portion; for the substance of the uterus itself is not neces- sarily affected. The enlargement is generally greatest at the farthest extremity of the tumour, and least near the womb; so that there is a kind of pedicle formed, which some- times contains pretty large blood vessels, and the tumour is pyriform. But if the membrane of the uterus be affected to a considerable extent, and especially if the substance of the uterus be diseased, then the base, or the attachment of the polypus, is broad. The vessels are considerable, especially the veins, which sometimes burst. In every instance, I believe, if the patient live long, the tumour is disposed to ulcerate. The ulcer is either superficial and watery, or it is hollowed out, glossy, and has hard margins, or it is fungous. The two last varie- ties are most frequent. Some polypi are soft and lymphatic, but these are rare in the uterus. Some are firm without, but contain gelatinous fluid, or substance like axunge within. Some are solid, others cellular, with considerable cavities. Polypi are hurtful at first, by the irritation they give the uterus, and by sympathetic derangement of the abdominal viscera. In a more advanced stage, they are attended with debilitating and fatal hemorrhage, and often with febrile symptoms, especially if the discharge be offensive, or the surface ulcerated. Notwithstanding the existence of polypus, however, it is possible for a woman to conceive.* Various means have been proposed for the removal <£ polypi, such as excision, caustic, or tearing them away; but all of these are dangerous and uncertain; and therefore the only method now practised, is to pass a ligature round the base or footstalk of the polypus, and tighten it so firmly as to kill the part. The ligature consists of a firm silk cord, or a well twisted hemp string, properly rubbed with wax, or covered with a varnish of elastic gum. This is better than * In M. Guiot's case, the polypus was expelled,—M. Levret adds other case.9, Mem. de PAcad.de Chir. Tom. III. p. 543. 93 a silver wire, which is apt to twist or form little spiral turns, which impede the operation, and may cut the tumour. It is difficult to pass the ligature properly, if the polypus be alto- gether in utero ; and it ought not even to be attempted, if the os uteri be not fully dilated. On this account, if the symp- toms be not extremely urgent, it is proper to delay until the polypus have wholly, or in part, descended into the vagina; and when 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 uterus.* 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 assist- ance of a silver probe with a small fork at the extremity. By practice and dexterity, this instrument may doubtless be adequate to the object in view; but without these requisites, the operator will be foiled, the ligature twisting or going past the tumour, every attempt giving much uneasiness to the patient, and not unfrequently, after many trials and much irritation, the patient is left exhausted with fatigue, vexation, and loss of blood. This is very apt to happen, if the polypus be so large as to fill the vagina. The process may be facili- tated by employing a double canula, but the tubes made to separate and unite at pleasure,! by means of a connecting base, or third piece, which can be adapted to them like a sheath. The ligature is passed through the tubes, which are to be placed close together, and no loop is to be left at the mid- dle. They are then to be carried up along the tumour, gene- • M. Baudelocque observes, " Nous regardions ce renversement neces- saire pour obtenir la guerison de la malade." Recueil Period. Tome IV. p. 137. f An instrument of this kind is proposed by M. Cullerier, and is described by M. Lefaucheux in his Dissert, sur les Tumeurs circonscrites et indolentsdu tissu cellulaire de lamatrice et du vagin.(*) (t) For a plate and description of this instrument, the reader is referred to Cooper's Surgery, Philadelphia edition 94 rally betwixt it and the pubis. Being slid up along the finger to the neck of the polypus, one of them is to be firmly retained in its situation by an assistant, and the other carried com- pletely round the tumour, and brought again to meet its Fel- low. The two tubes are then to be united by means of the common base. The ligature is thus made to encircle the polypus, and, if necessary, it may afterwards be raised higher up with the finger alone, or with the assistance of a forked probe. When the ligature is placed in its proper situation, it is tg be gradually and cautiously tightened, lest any part of the uterus which may be inverted be included. If so, the patient complains of pain, and sometimes vomits; and if these symp- toms were neglected, and the ligature kept tight, pain and tension of the hypogastrium, fever and convulsions would take place, and in all probability the woman would die.'5 In some instances, however, the womb has been included with- out a fatal effect.5* 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 wlien the ligature is first applied. If the first tightening of the ligature, by way of trial, give no pain, it is to be drawn firmly, so as to compress the neck of the tumour sufficiently to stop the circulation. It is then to be secured at the extremity of the canula; and as the part will become less in some time, or may not have been very tightly acted on at first, the ligature is to be daily drawn tighter, and in a few days will make its way through. After the polypus is tied, it is felt to be more turgid, and harder; and if visible, it is found of a livid colour, and presently exhales a foetid smell. These are favourable signs. The diet is to be light, and all irritation avoided duringthe cure. The bowels and bladder must be attended to, and if there be sympathetic irritation of the stomach, soda water is useful, with small doses of laudanum.(V) (u) The reader is referred to the following interesting paper on the subject •fib: preceding article, viz. « Memoir sur I'organization des Polypes Uteriifl 85 § 33. MALIGNANT POLYPE. There are other tumours still more dangerous,* as they end in incurable ulceration, and are so connected with the womb, that the whole of the diseased substance cannot be removed. These always adhere by a very broad base,*7 and cannot be moved freely, or turned round like the mild polypus. They are sometimes pretty firm, but generally they are soft and fungous, or may resemble cords of clotted blood. When dissected, they are found to be very spongy, with cells or cavities of various sizes; sometimes they are laminated. These, which have been called vivaces by M. Levret, are always the consequenee of a diseased state of the womb; but they are not always, as that author supposes, vegetations from an ulcerated surface. They do, however, very frequently spring from that source, being generally of the spongoid nature. Occasionally they have been mistaken for a piece of a retained placenta, and portions of foetid fungi have been torn away, in attempts to extract the supposed placenta, or ovum. The hypogastric region is tumid, and painful to the touch, even more so than the tumour itself, which, felt per vaginam, is less sensible than the womb. Sometimes little pain is felt in this disease, except when the womb is pressed. The tu- mour often bleeds, discharges a sanious matter, and may shoot into the vagina: but in this it differs from polypus, that it comes into the vagina generally by growth, and not by ex- pulsion from the womb, which does not decrease or become empty as the vagina fills. The treatment must be palliative, for extirpation does not succeed, the growth being rapidly renewed. Opiates and cleanliness are most useful. et 1'appUcation de cette connoisance 4 la pratique chirurgicale, par P. J. Uoux in tome Sieme des (Euvres chirurgicales de P. J. Default par Xav. Bichat. p 370. * Vide Mem.de PAcad.de Chir. Tome IH. p. 588.—Herbiniaux Observa- tions, Tome I. ob. 39.—Baillie's Morbid Anatomy, chap, xix.—Vigarous de Malad. des Feromes, Tome I. p. 425. 06 $ 34. MOLES. Moles* are fleshy or bloody substances contained within the cavity of the uterus. They acquire different degrees of magnitude, and are found of various density and structure." They may form in women who have not borne children,! or they may succeed a natural delivery^ or follow an abortion, or take place in a diseased state of the uterus.§ It is the opinion of many, that these substances are never formed in the virgin state, and no case that I have yet met with contradicts the supposition. The symptoms produced by moles are at first very much the same with those of pregnancy, such as nausea, fastidious appetite, enlargement of the breasts, &c; but the belly enlarges much faster, is softer, and more variable in size than in pregnancy, being sometimes as large in the se- cond month of the supposed, as it is in the fifth of the true pregnancy. Pressure occasionally gives pain. Petit ob- serves, that the tumour seems to fall down when the woman stands erect, but this is not always the case. It must be con- fessed, that the symptoms are at first, in most cases, ambigu. ous, nor can we for some time arrive at certainty. In ge- neral, the mass is expelled within three months, or before the usual time of quickening in pregnancy; and more or less hemorrhage accompanies the process, which is very si- milar to that of abortion, and requires the same manage- ment.|| Sometimes the expulsion may be advantageously hastened, by extracting the substance with the finger; but we must be careful not to lacerate it, and leave part behind. If the mole be retained beyond the usual time of quickening, * Sandifort Obs. Path. Anat. lib. II. p. 78.—Schmid. de Concrcment. Uteri, in Haller's Disp. Med. Tomus IV. p. 746. ■J- 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. Ixmp- 797. § With scirrhus of the uterus, Haller's Disp. Med. IV. p. 751 et 753. || Puzos advises blood letting, Traite, p. 211.—.Vigarous recommends erne"- tics and purgatives, to favour the expulsion, Tome I. p. 115. 07 we find that the belly does not increase in the same propor- tion as formerly, and the womb does not acquire the magni- tude it possesses in a pregnancy of so many months stand- ing. There is also no motion perceived. Many of the symp- toms of mole may proceed from polypus; but in that case, the breasts are flaccid and the symptoms indicating preg- nancy are much more obscure. The os uteri is not neces- sarily closed in a case of polypus; whereas in that of a mole, if there have been no expulsive pains, it is generally shut. When a woman is subject to the repeated formation of moles, I know of no other preventive, than such means as im- prove and invigorate the constitution in general, and the ute- rus in consequence thereof. This is of no small importance, as a weak state of the uterine system predisposes to more for- midable diseases, and may be followed by scirrhus of the womb or of the breast. $ 35. HYDATIDS. Hydatids may also enlarge the womb, and these frequently are formed in consequence of the destruction of the ovum at an early period," or of the retention of some part of the pla- centa, after delivery or abortion. We possess no certain di- agnostic : when they are formed in consequence of coagula, or part of the placenta remaining in utero, the symptoms must be such as proceed from the bulk of the womb, or from its irritation, as if by a polypus or mole. The remarks in the? preceding section are therefore applicable here; but in a great majority of cases, hydatids are formed in consequence of the destruction of an ovum; and accordingly, the symp- toms at first are exactly the same with those of pregnancy. These cease when the ovum is blighted, and the time when this happens is marked by the breasts becoming flaccid, and the sickness and the sympathetic effects of pregnancy going off. The conception remains, and the belly either continues nearly of the same size, or, if it increase, it is very slowly. Menstruation does not take place; but there may occasion- ally be discharges of blood in different degrees, and there VOL. I. „ 98 always is at one period or other, a very troublesome discharge of water, so that cloths are required, and even with these, the patient is uncomfortable. No motion is perceived by the woman, and the size of the belly and state of the womb do not correspond to the supposed period of pregnancy. In some instances, the health docs not suffer; in others, feverishneai and irritation are produced. After an uncertain lapse of time, pains come on, and the mass is discharged, often with very considerable hemorrhage. This expelling process may some times be advantageously assisted by introducing the hand to remove the hydatids, or to excite the contraction of the womb; but this must be done cautiously, and only when hemorrhage or some other urgent symptoms occur. These must be treat- ed on general principles. In some cases, milk is secreted after the hydatids are ex- pelled. In others, a smart fever, with pain in the hypogas- trium, follows. It requires laxatives and fomentations. When hydatids form in a blighted ovum, their number varies greatly in different cases. In some, I have seen only a little bit con- taining vesicles, often only the under part which had been for some time detached in a threatened abortion. In others, al- niist the whole is changed, and the mass much enlarged. This, I presume, is connected with the womb, by the un- changed portions alone; and therefore, in examining the in- ner surface of such a uterus after the mass was expelled, we should expect to find it more or less similar to the gravid state, according to the greater or less change in the ovum. The re- lative magnitude of the vessels in the two states has not been ascertained, few opportunities being afforded of dissection in this disease, (a:) (x) Ruysch in the first volume of his valuable works, has given two very curious and accurate plates of these hydatids of the placenta or uten» 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. BailUe has observed, although there may be some difference between them in simplicity of organization, this need be no considerable objection to the opinion, as life may be conceived to be at- tached to the most simple form of organization. 99 Sometimes there is only one large hydatid, or, at most, a very few in the womb, and the preceding remarks will also be applicable, 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 discov ered in utero, nor does the woman perceive any motion. There maybe pain in the abdomen, and obscure fluctuation is discernible. The neck of the womb is small, and the case much resembles ovarian dropsy, except that the tumour occupies the region of the uterus. The duration of this complaint is uncertain; but the water is at last discharged suddenly, and after making some exertion. The bag afterwards comes away, and the process is not attended with much pain.* It is most prudent to be patient; but if the symptoms be troublesome, the fluid can be drawn off by the os uteri. This disease, a solitary hydatid, is oftener combined with pregnancy, or with a mole, than met with alone. The first combination60 is not uncom- mon, and I have seen the hydatid expelled some weeks before labour. Hildanus gives an instance of the second, where the ovum was converted into a mole intimately connected to the uterus, and complicated with a collection of fluid to the extent of six pounds. In this case, so much irritation was given, as to exhaust the strength, and produce local inflam- mation. § 36. AQUEOUS SECRETION. ■r A different disease from that described in the last section, is an increased secretion from the uterus itself, accompanied generally with symptoms of uterine irritation; and if the wo- man menstruate, the menses are pale and watery. There may For further information on the subject of hydatids, particularly those of the uterus, the student is referred to a paper by the editor, inserted in the Eclectic Repertory, Vol. I. p. 499, and seq. Also to Monro's Morbid Anato- my of the human gullet, stomach and intestines. Edin. 1811. p. 255. • Hildanus, I think, relates the history of a woman who was supposed to be pregnant, but, dum noctu cum marito rem haberet, a sudden inundation swept away her hopes, 100 be a constant stillicidium of water,* or from some obstructing cause the fluid may be for a time retained,81 and repeatedly discharged in gushes; I do not know to a certainty, that this can take place without some organic affection of the womb, or some substance within its cavity. At the same time, I have met with this where no hydatids were discharged, where the womb felt sound, and a cure was at last accomplished. We must always examine carefully, for it may proceed from hyda- tids, or from disease, or excrescences about the os uteri. If nothing can be discovered, we must proceed upon the general principle of improving the health, and injecting mild astrin- gents. I need scarcely caution the practitioner not to con- found a discharge of urine from an injury of the bladder, with this complaint.f § 37. WORMS. Worms:}: have been found in the uterus, producing consi- derable irritation; and generally, in this case, there is a foe- tid discharge. We can know this disease only by seeing the worms come away. It is cured by injecting strong bitter in- fusions. § 38. TYMPANITES. Sometimes^ air is secreted by the uterine vessels, and comes away involuntarily, but not always quietly. Tonics, and astringent injections, occasionally do good; and as this * Hoffman mentions a woman who had a constant stillicidium, a pint being discharged daily. It at last proved fatal. Opera, Tom. III. p. 326, and Tom. I. p. 330. f Vesalius, Tom. I. p. 438, says, that he found an uterus containing 180 pints of fluid, and its sides in many places scin-hous. I wish he may not have mistaken the ovarium for the womb. * Vigarous Malad. Tome I. p. 412.—Mr. Cockson mentions a case, where maggots were discharged before the menstrual fluid. The woman was cured, by injecting oil, and infusion of camomile flowers. Me-J. Comment VoL nr. p. 86. §Vide Vigarous' Maladies, Tome I. p. 401. 101 disease rarely causes sterility, it is sometimes cured perma- nently by pregnancy. It is said, that the air is, in certain cases, retained, and the uterus distended with it, producing a tympanites of the uterus. § 39. PROLAPSUS UTERI. The prolapsus, or descent of the uterus, takes place in va- rious degrees.* The slighest degree, or first stage has been called a relaxation; a greater degree, a prolapsus; and the protrusion from the external parts, a procidentia. It is ne- cessary to attend carefully to this disease, to ascertain its existence, as it may, if neglected, occasion bad health, and many uneasy sensations. The symptoms at first, if it do not succeed parturition are ambiguous, as some of them may proceed from other causes. They are principally pain in the back, groins, and about the pubis, increased by walking, and accompanied with a sensation of bearing-down. There is a leucorrhseal discharge, and sometimes the menses are increas- ed in quantity. In a more advanced state, there is stran- gury, or the urine is obstructed, and the patient feels a tumour or fulness toward the orifice of the vagina, with a sensation as if her bowels were falling out, which obliges her instantly to sit down, or to cross her legs as if to prevent the protrusion. This is accompanied with a feeling of weakness. There are also, during the whole course of the complaint, but especially after it has continued for some time, added many symptoms, proceeding from deranged action of the stomach and bowels, together with a variety of those called nervous. On this account, an inattentive practitioner may obstinately consider the case as altogether hysterical, until emaciation and great debility are induced. But if the woman have been recently delivered, there is less likelihood of the practitioner being misled. She feels a weight and uneasiness about the pubis and hypogastric re- gion, with an irritation about the urethra and bladder; and • Vide Memoir by Sabatier, in 3d. Vql. of the Memoirs of the Academy of Surgery. 103 sometimes a tenderness in the course of the uretfira, or about the vulva. A dull dragging pain is felt at the groins, and when she stands or walks, she says she feels exactly as she did before the child was born, or as if there were something full and pressing. Pains are felt in the thighs, and the back is generally either hot, or aches. These symptoms go off in a great measure, when she lies down, though, in some cases, they are at first so troublesome, as to prevent rest. In some instances, no pain is felt in the back; but whenever the pa- tient stands, she complains of a painful bearing-down sensa- tion, or sometimes of pressure about the urethra, or orifice of the vagina. By examination, the uterus is felt to be lower down than usual, and the vagina always relaxed. In certain circum- stances, it prolapses, forming a circular protrusion at the vulva. Next, the os uteri descends so low as to project out of the vagina. In the greatest degree, or procidentia, the uterus is forced altogether out, inverting completely the vagina, and forming a large tumour betwixt the thighs. The intestines descend62 lower into the pelvis, and even may form part of the tumour, being lodged in the inverted vagina, giv- ing it an elastic feel. In some instances, this unnatural situation of the bowels gives rise to inflammation. The uterus is partially retroverted, for the fundus projects immediately under the perinseum, and the os uteri is directed to the an- terior part of the tumour. The orifice of the urethra is sometimes hid by the tumour, and the direction of the canal is changed; for the bladder, if it be not scirrhous, or distend- ed with a calculus of large size, is carried down into the pro- truded parts63; and a catheter passed into it, must be direct- ed downwards and backwards. The procidentia is attended with the usual symptoms of prolapsus uteri, and also with difficulty in voiding the urine, tenesmus, and pain in the tumour. If it have been long or frequently down, the skin of the vagina becomes hard, like the common integuments, and it very rapidly ceases to secrete. Sometimes the tumour inflames, indurates, and then ulceration or sloughing take* place. This procidentia may occur in consequence of ne- 103 glecting the first stage, and the uterus is propelled with bearing-down pains; or it may take place all at once, in consequence of exertion, or of getting up too soon after de- livery. It may also occur during pregnancy, and even dur- ing parturition. Sometimes it is complicated with stone in the bladder,64 or with polypus in the uterus.* Some have, from theory, denied, the existence of prolap- sus,65 and others have disputed whether the ligaments were torn or relaxed. There can be little doubt, that when it oc- curs speedily after delivery, it is owing to the weight of the womb, aud the relaxed state of the ligaments and vagina. From these causes, getting up too soon into an erect posture, or walking, may occasion prolapsus, particularly in those who are weak or phthisical. When it occurs gradually in the un- impregnated state, it is rather owing to a relaxation of the va- gina, and parts in the pelvis, than elongation of the round ligaments. By experiments made on the dead subject, we find, that more resistance is afforded to the protrusion, by the connection of the uterus and vagina to the neighbouring parts, than by the agency of the ligaments; for although the ligaments be cut, we cannot, without much force, make the uterus protrude. Frequent parturition, fluor albus, dancing during menstruation, and whatever tends to weaken or relax the parts, may occasion prolapsus. Sometimes a fall brings it on. No age is exempt from it.66 When symptoms indi- cating prolapsus uteri manifest themselves, we ought to ex- amine the state of the womb, the patient having lately been, or rather being, in an erect posture. The symptoms some- times at first turn the attention rather to the bladder or pubis, than the womb; but a practitioner of experience will think it incumbent on him to ascertain the real situation of that viscus. If we find that there is a slight degree of uterine descent, we must immediately use means to remove the relax- ation. These consist in the frequent injection of solution of sulphate of alumin, either in water, or decoction of oak bark, repeated ablution with cold water, tonics, and the use of the * Vide the case of a girl aged twenty-one years, related by Mr. Fynney. The polypous excrescence was extirpated from the os uteri, and t'hen apes eary was employed. Med. Comment. Vol. IV. p. 228. 104) cold bath, at the same time that the bowels are kept regular, all exertion avoided, and a recumbent posture much observed. If these things fail, or if the disease exist to a considerable de- gree, then, besides persisting in them, we must have recourse to the assistance of mechanical means. These consist of sup- porting substances called pessaries, which are placed in the vagina, and resting on the perinseum, keep up the womb. They always give immediate relief, but where the relaxation is considerable, they only mitigate, but do not entirely re- move the sensation, which must continue more or less, as long as the relaxation remains. In recent cases, or where the relaxation is not great, a perseverance in the use of the pessary, topical astringents and general tonics may accom- plish a cure. Fatigue or exertion must always be avoided. Pessaries are made of wood, and are of different shapes, some oval, some flat and circular, some like spindles, or the figure of eight, others globular. Of all these, the globular(i/) pessary is the best, and it ought to be of such size as to re- quire a little force to introduce it into the vagina; that is to say, it must be so large as not to fall through the orifice, when the woman moves or walks. Whatever be employed, it ought to be taken out frequently, and cleaned.67 By di- minishing gradually the size of the pessary, and using astrin- gents, we may often be able at last to dispense with it. In all the stages, a firm broad bandage applied round the abdomen, frequently relieves the uneasy sensations about the bowels, back, and pubis. The cold bath is also useful. It is farther necessary to mention, that the symptoms and treatment pf prolapsus may be modified by circumstances which precede it, but with which, it is not essentially connected. For in- stance, a tender or inflamed state of the uterus, and the ap- pendages, may take place after delivery, and when convales- cent, the patient may rise too soon, or sit up, striving to make the child suck, and thus bring on a degree of prolapsus. In this case, it is evident that the symptoms may be more acuta or painful, and they will not be removed by a pessary, until (y) The oval form is nevertheless preferred by many, and apparently not without reason. 105 by continued rest, laxatives, and occasional fomentations, the morbid sensibility of the parts within the pelvis be got rid of. When the relaxation is great, it has been proposed to use a hollow elliptical pessary, so large, as that by pressing against the sides of the vagina, it may support both itself and the womb, but it generally gives pain, and the relaxed vagina, turns up within it, and becomes irritated. I am therefore, clearly of opinion, that the oval pessary should, though hollow, ha ye no large aperture. The long diameter must vary from 2| to SJ inches, according to the degree of relaxation. In such cases of relaxation, if the oval pessary do not succeed in removing the distressing sensation of the abdominal viscera being about to fall out, then, in addition to it or the globe pessary, benefit may be derived from sup- porting the perineum itself, with a soft pad, with a spring on a similar principle with that used for prolapsus ani. A contrivance of this kind, or a firm T-bandage must be em- ployed with a globe pessary, where the perineum is greatly lacerated. («) If a procidentia be large, and have been of long duration, the reduction of the uterus may disorder the contents of the abdomen, producing both pain and sickness. In this case, we must enjoin strict rest in a horizontal posture. The belly should be fomented, and an anodyne administered. Sometimes it is necessary to take away a little blood; and we must always attend to the state of the bladder, preventing an accumulation of urine. When the symptoms are abated, (z) In my own practice, I have generally preferred the oval pessary of elastic gum, by being applied transversely; as regards the vagina, there is , less danger of impeding the evacuation of the fxoetand urine, by pressure on the rectum and neck of the bladder, or urethra. Where this cannot be procured, pessaries maybe made of silver, of the oval form and hollow, and with care may be found to answer. But it is probable, that the sponge pessary, under proper management, will be found to answer every intention. This kind of pessary, appears first to have been publicly recommended by Dr. Haighton, of London, and has since been approved and adopted by several practitionere of respectability. See a paper on thia subject, by Mr. Dawson, in the 13th Vol of Land. Med Physl Journal. VOL. I. p r 106 a pessary must be introduced,* and the woman may rise for a little, to ascertain how it fits ; but, as in other cases, she ought for some time to keep much in a horizontal posture, and avoid for a still longer period every exertion. If there have existed inflammation of the displaced bowels, during the continuance of the procidentia, serious consequences may result from the reduction, owing to the adhesions which have formed. Should there be much difficulty and pain at- tending the attempt to reduce, it ought not to be persisted in. If the tumour, from having been much irritated, or long protruded, be large, hard, inflamed, and perhaps ulcerated, it will be impossible to reduce it until the swelling and in- flammation are abated, by a recumbent posture, fomenta- tions, saturnine applications, laxatives, and perhaps even blood-letting, f After some days we may attempt the re- duction, and will find it useful previously to empty the blad- der. The reduction, in general, causes for a time, abdomi- nal uneasiness. If the uterus cannot be reduced, and is much diseased, it has been proposed to extirpate the tumour. This has been done, it is true, with success,68 but it is ex- tremely dangerous ; for the bladder is apt to be tied:}: by the ligature, which is put round the part; and as the intestines fall down above the uterus into the sac, formed by the invert- ed vagina, they also are apt to be cut§ or constricted. A prolapsus uteri does not prevent the woman from becom- ing pregnant ;69 and it is even of advantage that she should become so, as we thus, at least for a time, generally cure the prolapsus. But we must take care, lest premature Ja- bour|| be excited; for the uterus may not rise properij^or may again prolapse, if exertion be used. * Dr. Denman very properly advises, that a pessary should not be intro- duced immediately after the uterus is reduced. Lond. Med. Journal, Vol VII. p. 56. f M. Hoin succeeded in reducing a very large, hard and even ulcerated procidentia, by fomentations, rest, and low diet. Mem. de I'Acad. de Chir. Tome m. p. 365. $ This happened in Ruysch's case. Obs. Anat. vii. § This occurred in a case related by Henry, ab Heers. Obs. Med. p. 192 D Vide Mr. Hill's case, in .vied. Comment. Vol. IV. p. 88. 107 Sometimes, especially if the person receive a fall,70 or have a wide pelvis, the uterus may prolapse during pregnancy, although the woman have not formerly had this disease. Our first care ought to be directed to the bladder,71 lest fa- tal suppression of urine73 take place. Our next object is to replace the uterus, and retain it by rest, and a pessary. If it cannot be reduced,* the uterus must be supported by a ban- dage,! until, by delivery, it be emptied of its contents. It is then to be reduced. The management of prolapsus during labour, will be afterwards considered. If prolapsus be threatened, or have taken place after deli- very, in consequence, for instance, of getting up too soon, we must confine the woman to a horizontal posture, till it have regained its proper size and weight; and this diminu- tion is to be assisted by gentle laxatives, particularly the daily use of the sulphas potassa? cum sulphure, in doses of from two to three drachms. The bandage formerly noticed, is also useful and comfortable. In some cases, the cervix uteri lengthens and descends lower in the vagina, though the body of the womb remains in situ. This is not to be confounded with prolapsus, for it is really a preternatural growth of part of the uterus; and this portion, or elongation, has been removed by liga- ture. § 40. HERNIA. - Inguinal hernia? of the uterus have been long ago described by Sennert, Hildanus, and Ruysch, and very lately by Lal- lement. This species of displacement may occur in the unimpregnated state, and the woman afterwards conceive; or it may take place when pregnancy is somewhat advanced. If it be possible to reduce the uterus, this must be done; and * See a remarkable case in prolapsus in the gravid state, where the whole uterus protruded, and reduction was not accomplished till after deli- very. By P. C. Fabricius, in Haller. Disp. Chir. Tomus HI. p. 434. f Vide Memoirs by M. Sabatier, in Mem. de I'Acad. de Chir. T©me IH. p. 370. 10S in one stage, an artificial enlargement of the foramen, through which the uterus has protruded, may assist the re- duction. If however, gestation be far advanced, then the in- cision must be made into the uterus whenever pains come on, and the child must be thus extracted. § 41. DROPSY OF THE OVARIUM. The ovarium is subject to several diseases, of which the most frequent is that called dropsy. The appellation, how- ever, is not proper, for the affection is not dependent on an increased effusion of a natural serous secretion or exhalation, but is more akin to encysted tumours, and consists in a pe- culiar change of structure,* and the formation of many cysts, containing sometimes watery, but generally viscid fluid, and having cellular, fleshy,f or indurated substance interposed between them, frequently in considerable masses. They vary in number and in magnitude. There is rarely only one large cyst containing serous fluid; most frequently we have a great many in a state of progressive enlargement; the small ones are perhaps not larger than peas, others are as large as a child's head, whilst the one which has made most pro- gress may surpass in size the gravid uterus at the full time. The inner surface of the cysts may either be smooth, or co- vered with eminences like the papilla? of a cow's uterus.! Their thickness is various, for sometimes they are as thin as bladders, sometimes fleshy, and an inch thick. The fluid they contain is generally thick and coloured, and frequently foetid, and in some instances, mixed with flakes of fleshy matter, or tufts of hair; occasionally, it is altogether gela- tinous, and cannot be brought through a small opening. The * Le Dran says, this dropsy always begins with a scirrhus, and is only a Symptom of it.—Dr. Hunter says he never found any part of a dropsical ova- rium in a truly scirrhous state. f Dr. Johnson's patient had the right ovarium converted into a fleshy mass, weighing nine pounds, and full of cysts. Med. Comment. Vol. VII. p. 265. * I have seen the inner surface of the ovarium studded over with nearly two dozen of large tumours. 31. Morand notices two cases, in wliich a similar structure obtained. 109 tumour has been seen made up entirely, or in part, of hydatids.73 The effects or symptoms of this disease of the ovarium, may all be referred to three sources, pressure, sympathetic ir- ritation, and action carried on in the ovarium itself. It some- times, though not often, begins with pretty acute pain about the groins, thighs, and side of the lower belly, with disturbance of the stomach and intestines, and occasionally syncope. A few patients feel pain very early in the mamma?; and M. Ro- bert affirms, that it is felt most frequently in the same side with the affected ovarium. In some cases milk is secreted.74 But generally the symptoms are at first slight, or chiefly de- pendent on the pressure of the parts within the pelvis. The patient is costive, and subject to piles, has a degree of stran- gury, which in a few instances, may end in a complete re- tention of urine; and sometimes one of the feet swells. By examining per vaginam, a tumour may often be felt betwixt the vagina and rectum, and the os uteri is thrown forward near the pubis; so that, without some attention, the disease may be taken for retroversion of the womb.* In some time after this, the tumour, in general, rises out of the pelvis,75 and these symptoms go off. A moveable mass can be felt in the hypogastric, or one of the iliac regions. This gradually enlarges, and can be ascertained to have an obscure fluctua- tion. The tumour is moveable, until it acquire a size so great, as to fill and render tense the abdominal cavity. It then resembles ascites, with which it in general comes to be ultimately combined76. Little inconvenience is produced, except from the weight of the tumour, and the patient may enjoy tolerable health for years. But it is not always so, for the tumour sometimes presses on the fundus vesica?, produc- ing incontinence of urine, $r on the kidney, making part of it to be absorbed; and it often irritates the bowels, causing uneasy sensations, and sometimes hysterical affections.f It * Mr. Home's case related by Dr. Demnan, Vol. I. p. 130, had very much the appearance of retroversion. f Case by Sir Hans Sloane, in Phil. Trans. No. 252.~Dr, Pulteny's patient, no augments in size, and carries up the uterus with it ;* so that the vagina is elongated: and this is especially the case, if both ovaria be enlarged,77 The urine is not in the com- mencement much diminished in quantity, unless this disease be conjoined with ascites; and the thirst at first, is not greatly increased. But when the tumour has acquired a great size, the urine is generally much diminished or ob- structed. If, however, the bulk be lessened artificially, it is often, for a time, increased in quantity, and the health im- proved. This is well illustrated by the case of Madame de Rosney,f who in the space of four years, was tapped twenty- eight times: for several days after each puncture, she made water freely, and in sufficient quantity; the appetite was good, and all the functions well performed : but in proportion as the tumour increased, the urine, in spite of diureticsj diminished, and at last came only in drops. The woman ge- nerally continues to be regular for a considerable time, and may even become pregnant. In the course of the disease, the patient may have attacks of pain in the belly, with fever, indicating inflammation of part of the tumour, which may terminate in suppuration, and produce hectic fever; but in many cases, these symptoms are absent, and little distress is felt, until the tumour acquire I size so great as to obstruct respiration, and cause a painful sense of distention. By this time, the constitution becomes broken and dropsical effusions are produced. Then the ab- dominal coverings are often so tender, that they cannot bear pressure; and the emaciated patient, worn out with restless nights, feverishness, want of appetite, pain, and dyspnoea, expires. The symptoms of this disease all arising, either from pres- sure or irritation, must vary according to the nature of the whose ovarium weighed fifty-six pounds, had excruciating pain in the left side, spasms, and hysterical fits. Mem. of Medical Society, Vol. II. p. 265. * This point is well considered by M. Voisin, in the Recueil Period. Tome XVII. p. 371, et seq.—The bladder may also be displaced, as in the case of Mademoiselle Argant, related by Portal. Cours d'Anat. Tome V. p. 549. j- Portal. Cours d'Anat. Tome V. p. 549. Ill parts most acted on, and the peculiar sympathies which exist in the individual. When we consider that, in many in- stances, the whole constitution, as well as different organs, may bear without injury, a great, but very gradual irritation, it is not surprising that this disease, which, for a long time, operates only mechanically, should often exist for years with- out affecting the health materially, whilst in more irritable habits, or under a different modification of pressure, much distress, too often referred to hysteria, may be produced. This disease has sometimes appeared to be occasioned by injury done to the uterus in parturition, as, for instance, by hasty extraction of the placenta; or by blows, falls, violent passions, frights, or the application of cold; but very often, no evident exciting cause can be assigned. In the first stage of this complaint, we must attend to the effects produced by pressure. The bladder is to be emptied by the catheter, when this is necessary; and stools are to be procured. It may be considered, how far, at this period, it is proper to tap the tumour from the vagina, and by injections or other means, endeavour to promote a radical cure. When the woman is pregnant, and the tumour opposes delivery, there can be no doubt of the propriety of making a puncture,78 which is preferable to the use of the crotchet.(a) But this has only been resorted to, in order to obviate particular in- conveniences, and affords no rule of conduct in other cases, where no such urgent reason exists. I am inclined to dissuade strongly from any operation at this period, because in a short Jime the tumour rises out of the pelvis; and then the patient may remain tolerably easy for many years. Besides the ova- rium in this disease contains,in general, numerous cysts; and as these, in the first stage, are small, we can only hope to empty the largest. Perhaps we may not open even that; and although it could be opened and healed, still there are others coming forward, which will soon require the same treat- fa) Where the tumour in the vagina occupies a large space, Dr. Merriman thinks it a warrantable practice to remove it by excision if it consisted of a solid substance, and certainly to puncture it if it contained a fluid. Vide Me- dico?Chirurgical Transactions,, Vol. HI. p. 47. 11*2 ment. Puncturing, then, can only retard the growth of the tumour, and keep it longer in the pelvis, where its presence is dangerous. When the tumour has risen out of the pelvis, we must, in our treatment, be much regulated by the symptoms. The bowels should be kept open, but not loose, by rhubarb and magnesia, aloetic pills, cream of tartar, or Cheltenham salt Dyspeptic symptoms may sometimes be relieved by prepara- tions of steel, combined with supercarbonate of soda, or other appropriate medicines, though their complete removal cannot be expected as long as the exciting cause remains. General uneasiness or restlessness, occasionally produced by abdomi- nal irritation, may be lessened by the warm bath, saline ju- lap, and laxatives; whilst spasmodic affections are to be re. lieved by foetids; and if these fail, by opiates. If, at any time, much pain be felt, we may apply leeches, and use fomen- tations, or put a blister over the part. Upon the supposition of this disease being a dropsy, diuretics have been prescribed, but not with much success,79 and often with detriment. Some have supposed, that diuretics do no good whilst the disease is on the increase; but that, when it arrives at its acme, they are of service. But this disease is never at a stand; it goes on increasing, till the patient is destroyed. When they pro- duce any effect, it is chiefly that of removing dropsical affec- tions combined with this disease; and in this respect, they are most powerful immediately after paracentesis. With regard to the power of diminishing the size of the ovarium, my opinion is, that they have no more influence on it, thaji they have over a mellicerous tumour on the shoulder. In oue ease, fomentations and poultices appear to have discussed a tumefied ovarium.* Having palliated symptoms until the distension becomes troublesome, we must then tap the tumour, which gives very great relief; and, by being repeated according to circumstan- ces, may contribute to prolong life for a length of time.80 As the uterus may be carried up by the tumour, it is proper to * Vide Dr. Monro's fourth case, in Med- Essays, Vol. V. 113 ascertain, whether it be the right ovarium or the left whicli is enlarged; and we should always tap the right ovarium on the right side, and vice versa: by a contrary practice, the uterus has been wounded.* When the disease is combined with ascites, it is sometimes necessary to introduce the trocar twice, and the difference between the two fluids drawn off is often very great. We must neither delay tapping so long as to injure by great irritation and distention, nor have recourse to it too early, or too frequently, for the vessels of the cavity excrete much faster and more copiously after each operation, and it is to be remembered, that this is a cause of increasing weakness, not only from the expenditure of gelatinous fluid, but also from the increased action performed by the vessels, whicli must exhaust as much as any other species of exer* tion. Finally, it has been proposed, to procure a radical cure, by laying open the tumour, evacuating the matter, and prevent- ing the wound from healing, by which a fistulous sore is pro- duced ; or by introducing a tent, or throwing in a stimulating injection. Some of these methods have, it is true, been suc- cessful,81 but occasionally they have been fatal ;82 and in no case, which I have seen, have they been attended with benefit. There are two powerful objections to all these practices, be- sides the risk of exciting fatal inflammation: the first is, that the cyst is often irregular on its interior surface, and therefore cannot be expected to adhere: the second is, that as the ova- rium, when dropsical, seldom consists of one single cavity, so, although one cyst be destroyed, others will enlarge, and renew the swelling; and, indeed, the swelling is seldom or never completely removed, nor the tumour emptied, by one operation. Hence even as a palliative, the trocar must some- times be introduced into two or more places. It has happened, that a cyst has adhered to the intestine,83 and burst into it, the patient discharging glary or foetid mat- ter by stool.84 Such instances as 1 have known, have only * In a case of this kind related by M. Voisin, the uterus was wounded, and the patient felt great pain, and fainted. She died on the third day after the operation. Recueil Period. Tome VII. p. 372, &c. vol. I. 0. 114 been palliated, but not cured, by this circumstance. Some- times the fluid has been evacuated per vaginam,85 or the ova- rium has opened into the general cavity of the abdomen, and the fluid been effused there. There is another disease, or a variety of the former dis- ease, in which bones, hair, and teeth, are found in the ova- rium.80 The sac, in which these are contained, is sometimes large, and generally is filled with watery or gelatinous fluid. The bony substance, and teeth, usually adhere to the inner surface of the cyst. This disease produces no inconvenience, except from pressure. It has been deemed by some, to be merely an ovarian conception; but it may undoubtedly take place without impregnation, nay similar tumours have been found in the male sex.87 It is to be treated as the former disease. § 42. OTHER DISEASES OF THE OVARIUM. The ovaria are sometimes affected with scrophula, and the tumour may prove fatal by producing retention of urine. When it rises out of the pelvis, it is often productive of hypochondriasis, and very much resembles the ovarian dis- ease, formerly mentioned, but is firmer, seldom gives a sen- sation of fluctuation, and sometimes is very painful when pressed. It rarely terminates in suppuration ; but when it does, the fluid, as Portal observes, is blanclmtre, JUamenteiix, grumeleux, mal digere. The substance of the ovarium is soft, and similar to that of other scrophulous glands. Occasion- ally it contains a cheesy substance, which is found, at the same time, in the mesenteric and other glands. Burnt sponge, cicuta, mercury, electricity, laxatives, &c. have been employed, but seldom with benefit. The most we can do, is to palliate symptoms, such as retention of urine, cos- tiveness, dyspepsia, or pain. The ovarium may also be enlarged, and become hard and stony,88 or converted into a fatty substance.89 Sometimes it is affected with the spongoid disease, and is changed into a substance like brain, with cysts containing bloody serum. 115 The tumour in this disease, feels tense and clastic. It may burst through the abdominal parietes, and throw out large fungous excrescences. Frequently we find, on cutting an enlarged ovarium, that part of it resembles the spongoid structure, having bloody fungous cysts; part is like firm jelly, and part like cartilage, or dense fat. Often the uterus participates in the disease. I have seen a mass of this kind weigh thirteen pounds. I have never found the ovarium cancerous. § 43. DEFICIENCY. The ovaria may be wanting on one or both sides, (6) or may be unusually small. In such cases, it sometimes hap- pens, that the growth of the external parts stops early, anil the marks of puberty arc not exhibited. The ovarium may form part of a herniary tumour. § 44. DISEASES OF THE TUBES AND LIGAMENTS. The tubes may be wanting, or impervious, and are sub- ject to many of the diseases of the ovaria. The round ligaments may partake of the diseases of the uterus, or may have similar diseases, originally appearing in them. When they are affected, pain is felt at the ring of the oblique muscle, and sometimes a swelling can be per- ceived there. (6) See a case of deficiency of the ovaria, by Charles Pears, F. L. S. in the Phil. Trans, for 1805. This woman died at the age of twenty-nine. She had never menstruated. She ceased to grow at the aga often years. U6 CHAP. XI. Of Menstruation. The periodical discharge of sanguineous fluid which takes place every month from the uterus, is termed the menses; and whilst the discharge continues, the woman is said to be out of order, or unwell. In some instances, the discharge takes place at puberty, without any previous or attendant indisposition; but in most cases, it is preceded by uneasy feelings, very often by affec- tions of the stomach and bowels, pain about the back and pel- vis, and various hysterical symptoms. These affections, which are more or less urgent in different individuals, gra- dually abate; but at the end of a month, return with more severity, attended with colic pains, quick pulse, sometimes hot skin, and a desire to vomit. There now takes place from the vagina, a discharge of a serous fluid, slightly red, but it does not in general become perfectly sanguineous for several periods. When the discharge flows, the symptoms abate; but frequently a considerable degree of weakness remains, and a dark circle surrounds the eye. In a short time the girl menstruates, often without any other inconvenience than a slight pain in the back, though sometimes, during the whole of her life, she suffers from many of the former symp- toms every time she is unwell; and all women, at the men- strual period, are more subject than at other times to spas- modic and hysterical complaints. When a girl begins to menstruate, certain changes take place, denoting the age of puberty. The uterus becomes more expanded, and receives its adult form; the vagina en- larges ; the mons veneris swells up, and is covered with hair; the pelvis is enlarged; the glandular substance of the breasts is unfolded, and the cellular part increased ; at the same time the mental powers become stronger, and new passions begin to operate on the female heart. The age at which menstruation begins, varies in indm- 117 duals, and also in different climates. It is a general law, that the warmer the climate, the earlier does the discharge take place, and the sooner does it cease. In Asia, for instance, the menses begin about nine years of age; whilst in the North, a woman does not arrive at puberty until she is eigh- teen or twenty years old; nay, if we may credit authors, in very cold countries, women only menstruate in the summer seasons.* In the temperate parts of Europe, the most com- mon age at which the menses appear, is thirteen or fourteen ycars.f * The quantity of the discharge varies, also, according to the climate and constitution of the woman. In this country from six to eight ounces are lost at each menstrual period; hut this does not flow suddenly; it comes away slowly for the space of three or four days. Some women discharge less than this, and are unwell for a shorter space of time: others, especially those who live luxuriously, and are confined in warm apartments, menstruate more copiously, and continue to do so for a week. In this country, menstruation ceases about the forty-fourth year, lasting for a period of about thirty years. In the East, the menses begin soon, flow copiously, and end early; the women in Asia, for example, being old, whilst the Europeans are still in their prime. In the north, the menses begin late, flow sparingly, and continue long. . The menses are obstructed during pregnancy,:}: and the giving of suck; but if lactation be very long continued, the menses return, and the milk disappears or becomes bad. * Linnaeus and others have said that the women of Lapland do not men- struate more than once or twice in the year. C. f Menstruation commences about the same age in the United States, and continues to the fortieth or forty-fifth year. C. t This is a point still debated. The weight of authority is, however, de- cidedly against menstruation continuing during pregnancy. By Baudelocque, Denman, and almost all the modern writers, it is denied. Those who main- tain the contrary opinion, have very probably mistaken a hemorrhage from the vagina, which sometimes recurs with considerable periodical regularity, for the menstrual flux. Several cases of this kind have come under my own observation, where I had an opportunity of examining the discharge accu- rately, fn every instance, I found it pure coagulable blood. 118 The discharge appears to be yielded by the uterine arte- ries, but is not an extravasation or hemorrhage, for when collected, it does not separate into the same parts with blood, neither does it coagulate.(c) In many instances, a great quan- tity has been retained for some months in the uterus and vagina, but it has never been found clotted when it was eva- cuated. Menstruation has been attributed to the influence of the moon, to the operation of a ferment in the blood, or in the uterus, to the agency of a general or local plethora, or to the By adverting to the state of the pregnant uterus, this is exactly what we should be led to expect. Contemporary with conception, we know that the uterine cavity is lined with the membrana, decidua, and that soon after- wards the os tincae is completely sealed with impacted mucus. Were an effusion therefore to take place, especially in the early months of gestation, it would destroy the attachment of the membrane, and produce all the con- sequences of uterine hemorrhage. It would seem, moreover, that the action which the vessels of the uterus take on to fabricate and support this membrane, is totally incompatible with the menstrual secretion. The two actions cannot co-exist. This is prorfel not only by the alleged cessation of the menses during pregnancy, but still more clearly by the fact which has not been sufficiently attended to, that in a large proportion of cases of obstinate amenorrhoea, the membrana decidu* exists, and that the first symptom of the return of the discharge is the com- ing away of the membrane. Of the identity of the two membranes there can be no doubt. It has been ascertained by Dr. Baillie and many other competent judges. C. (c) The celebrated John Hunter was, perhaps, the first physiologist who took notice publicly of this fact, at least in Great Britain. In his Lectures on the Theory and Practice of Surgery, (as quoted by Dr. It. W. Johnson, Sys- tem of Midwifery, 2d edition, 4to, p. 34 and 35) he observes, that "die blood discharged in menstruation, is neither similar to blood taken from a vein of the same person, nor to that extravasated by an accident in any other part of the body; but is a species of blood changed, separated, or thrown ofi' from the common mass, by an action of the vessels of the uterus, in a pro- cess similar to secretion; by which action the blood having lost its living prin- ciple, it does not afterwards coagulate.'* In his Treatise on the Blood, voL T p. 24, Philadelphia edition, he says, " in healthy menstruation, the blood which is discharged does not coagulate: in the irregular, or unhealthy it does. The healthy menses, therefore, (he continues) shew v. peculiar action of the constitution; and it is most probably yi this action, that its wlubimit purposes consist." 119 existence of a secretory action in the uterus.* The last of these is the most probable opinion; but as this work is meant to be practical, I think it wrong to devote more time to the • I am too, very much inclined to believe, that menstruation results from a secretory action of the uterus. Every other theory on the subject is in- deed totally irreconcileable with facts. I will briefly enumerate the leading arguments by which the doctrine may be defended. 1. That the uterus in its villous and vascular structure resembles in some degree a gland, and also, in its diseases, being equally liable to scirrhus, cancer, &c. &c. 2. That, like other secretory organs, blood is very copiously diffused through it. 3. That by the arrangement of its vessels, it is evidently designed that the circulation should be retarded for the purpose of secretion. The arte- ries are not only exceedingly convoluted, but they are larger and with thin- ner coats than their corresponding veins. Thus, Haller says, " the blood is brought to the womb in greater quantity, and more quickly through its lax and ample arteries, and on account of the rigidity and narrowness of the veins, it returns with difficulty." 4. That, in common with other secretions, menstruation is often, at first, imperfectly done, and is subject afterwards to vitiation and derangement At is commencement the discharge is commonly thin, colourless, and defi- cient, and recurs at protracted and irregular intervals with pain and difficulty. 5. That, in many of the inferior animals, during the season of venereal in- calescence, there is an uterine discharge which is undoubtedly a secretion. This answers seemingly the same end as menstruation, namely, giving to the Uterus an aptitude to conception. Though this fluid generally differs from the menses in complexion, yet in some instances they are precisely similar. Whenever the venereal desire suffers a violent exacerbation from restraint, Qr other causes, the discharge in these animals becomes red. This has been more especially remarked in bitches kept from the male. 6. That the menses are a fluid sui generis, or at least, varying very essen- tially from the blood, having neither its colour nor odour, nor coagulability, and on chemical analysis present different results. These last circumstances are enough alone to establish the theory. 7. To the objection that the uterus is not sufficiently glandular for the function of secretion, it has been, I think, very satisfactorily replied, that there is hardly a viscus pr surface of the body which is not competent to the secretion of a fluid. It would really seem that no operation of the animal economy requires a less complex apparatus. Of what indeed does a gland consist, except a congeries of vessels? Even the most perfect of the secre- tions are affected by this simple contrivance. If a few vessels, " creeping over the coats of the stomach," can secrete the gastric liquor, why may not the infinitely more glandular organization of the uterus elaborate the men- strual fluid ?(d) C, (. Magnesia ustae 3j- Aquae purx ?vss. Sp. Cinnamon ziij. Aquae Ammonix purae Zj m. Two or three spoonsful to be taken either occasionally, or when the symp- toms are more continual, immediately after every meal. 184 not formerly like. This desire is common in cases of abdo- minal irritation, as we see in those who are afflicted with worms, or have indurated or morbid faeces in the intestines. These longings, it has been thought dangerous to deny ; for as it was supposed, that they depend upon some peculiar state of the child affecting the mother, it was imagined, that if this was not removed, the infant would sustain an injury, or might even bear the mark of the thing longed for. Into this doctrine, it is now unnecessary to enter, and it will be sufficient to add, that when the desire is placed upon any article of diet, it may be safely gratified, and, indeed, gene- rally the inclination leads to some light and cooling regimen. § 6. SPASM OF THE STOMACH AND DUODENUM. Spasm of the stomach, or duodenum, may often be attri- buted to some irregularity of diet, to the action of cold, or to the influence of the mind. It is necessary to interfere promp- ly, not only because the pain is severe, but also because it may excite abortion, or kill the child. A full dose of lauda- num, with ether, followed immediately by a saline clyster, is almost always successful; but when the attacks are re- newed, then we must endeavour to prevent them by tonics, such as colomba, oxyde of bismuth, or preparations of steel. It is at the same time, essential that the bowels be kept open. Blood-letting is of service. When spasm of the stomach takes place in the end of preg- nancy, or about the commencement of parturition, with a sense of fulness or uneasiness in the head, it is necessary to detract blood, lest the patient be seized with convulsions. This re- medy is likewise proper, when the pain is accompanied with tenderness about the epigastric region, heat of the skin, full pulse, and ruddy face. When pain proceeds from the pas- sage of a biliary calculus, it is to be treated more solito. § 7. COSTIVENESS. Costiveness is a general attendant on pregnancy, partly owing to the pressure**)!' the uterus on the rectum, and partly 185 owing to the increased activity of the womb producing a slug- gish motion of the bowels. We must not, however, neglect this state, because it naturally attends gestation, for it may occasion many and serious evils. It certainly increases the irritability of the system, as well as some of the stomachic ailments; and is apt to cause irritation of the bowels, which may either excite premature labour, or give rise to much inconvenience after delivery, and not unfrequently occasions convulsions. Magnesia is a very common remedy, because it at the same time relieves heartburn; but, when it fails, or is not required for curing acidity in the stomach, tlie common aloetic pill, or a combination of aloes with extract of hyoscyamus, should the former gripe, may be employed. Castor oil is also given, either alone, or made into an emulsion with mucilage. It sometimes happens that indurated faeces are accumu- lated in the rectum or colon, producing considerable irrita- tion. This causes not only pain, but also an increased secre- tion of the intestinal mucus, which is passed either alone, or with blood, together with pieces of hard faeces. This state, like dysentery, is often accompanied with great tenesmus ; but it may be readily distinguished, by examining per vagi- nam, for the rectum is found to be filled with faeces. Our first object ought to be to remove the irritating cause, which might ultimately produce abortion. Clysters are of great efficacy, because they soften the faeces, and assist in emptying {hat part of the intestine which is most distended. These are to be, at first, of a very mild nature, and must be frequently repeated. It may even be requisite to break down the fecu- lent mass, with the shank of a spoon, or some such instru- ment.^) After the rectum is emptied, laxatives, such as castor oil, or small doses of sulphate of magnesia must be given to evacuate the colon; and when the faeces are brought (y) The reader is referred, for a very interesting case of alvine concre- tion, where it became necessary to introduce a long flexible catheter through the hardened and impacted faeces, occupying the superior part of the pelvis, for the purpose of injecting an enema, to Hoy's Practical Oservations on Surgery, chap. XVIII. case 3. VOL. I. « B 186 into the rectum, clysters must be again employed. After the bowels are emptied, hyoscyamus should be given, to allay the irritation; or if this be not sufficient, and the pain and secre- tion of mucus, with tenesmus, still continue, an opiate must be administered, but next day it is to be followed by a mild laxative. And if there be fever or considerable pain in the abdomen blood-letting will be necessary. If this costive state be neglected near the time of delivery, the labour is often protracted ; and after delivery masses of indurated faeces come down from the colon, producing considerable pain and frequency of pulse. When there is much irritation and sen- sibility, upon pressing on the abdomen, either before or after delivery, it will be proper to detract blood, at the same time that we use the remedies already pointed out. § 8. DIARRHCEA. The bowels, instead of being bound, may be very open ; or costiveness and diarrhoea may alternate with each other. The diarrhoea is of two kinds; a simple increase of the peristaltic motion, and increased serous secretion; or a more obstinate disease, depending on debilitated and deranged action of the bowels. In the first kind, the discharge is not altered from the natural state, except in being thinner; the appetite is pretty good, and the tongue clean, or only slightly white. This is not to be checked, unless it go to a consider- able extent, or continue long, or the patient be weakened by it, or be previously of a debilitated habit. Anodyne clysters, or the confectio catechu, will then be of service. Should the pulse be frequent, and any degree of heat or tension be felt in the abdomen, venesection will be useful. In the second kind, the appetite is lost or diminished, the tongue is foul, and the patient has a bitter or bad taste, and occasionally vomits ill tasted or bilious matter; the breath is offensive, and often the head aches. The stools are very offensive, and generally dark coloured. In this case, small doses of rhu- barb give great relief, and one grain of ipecacuanha may oc- casionally be added to each dose of rhubarb. A light bitter 187 infusion is also a useful remedy. Attention must be paid to the diet, which is to be light, and the food taken in a small quantity at a time. Considerable benefit is derived from soda water, which generally abates the sickness. When the tongue becomes cleaner and the stools more natural, anodyne clysters may be administered. In all cases of continued diarrhoea, it is useful to have the surface kept warm with flannel; and sometimes a flannel roller, bound gently round the abdomen, gives great relief. § 9. PILES. Pregnant 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 costive- ness, the disease has been considered as dependent on the mechanical action of the faeces; but whatever truth may be in this opinion in some cases, yet generally it is without foundation ; and it is no unusual thing for those who are subject to piles, to be able to foretell an attack, by the ap- pearance of peculiar symptoms, indicating diminished action of the alimentary canal. The treatment of this disease is two-fold. We are to remove the cause by such means as give a brisker action to the bowels such as bitters and laxatives ; which last are also of great service by removing the irrita- tion of the faeces from the rectum, and rendering them softer, by which the expulsion gives less pain. For this purpose, cream of tartar alone, 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 lessen the effect by such local means as abate irritation and sensibility. When the pain, inflammation, and swelling, are great, it is of service to de- tract blood topically, by the application of leeches, or, espe- cially if there be considerable fever, blood-letting may be 188 necessary, as in other cases of local inflammation. The diet should be spare; all stimulants and cordials must bo avoided ; cooling and anodyne applications to the tumour are also very proper, such as an ointment containing a small quantity of acetate of lead, or a weak solution of the acetate of lead in rose water, or a mixture of the acetum lithargyri and cream. Sometimes astringents are of service, such as the gall ointment; or narcotics, such as opium* or belladona. If these means fail, it will be proper to give an anodyne clyster, and apply fomentations or emollient poultices to the tumour, but every practitioner can tell how often all topical applica- tions have disappointed him. In some cases, the tumour be- comes slack, and subsides gradually ; in other instances it bursts, and more or less blood is discharged. If the hemorr- hage be moderate, it gives relief; but if profuse, it causes weakness, and must be restrained by pressure and astrin- gents. Great pain, or much hemorrhage, are both apt to excite abortion. § 10. AFFECTIONS OF THE BLADDER. The bladder is often affected by pregnancy. In some in- stances like the intestines, it becomes more torpid than for- merly ; so that the woman retains her water long, and expels it with some difficulty, and in considerable quantity at a time. This state requires great attention, for retroversion of the uterus may, at a certain stage of gestation, be readily occa- sioned. There is not much to be done with medicines in this case; for, although soda, and similar remedies, sometimes give relief, yet more reliance must be placed on the regular efforts of the patient. Should these he delayed too long, then the catheter must be employed. More frequently the bladder is rendered unusually irritable, especially about its neck, and the urethra participates in this * Dr. Johnson advises the following ointment to be applied, and then a poultice to be laid over the tumour. R. 01. Amygd. 5i Ol Succini ^38. Tr. Opii. 3h\ M. System p. 125. P 189 state. There is also, in many instances, an uneasiness felt in the region of the bladder itself. This state requires a very different treatment from the former, for here it is our object to avoid every saline medicine which might render the urine more stimulating. Relief is to be expected by taking away blood, giving small doses of castor oil, and, occasionally, the extract or tincture of hyoscyamus, and encouraging the pa- tient to drink mucilaginous fluids, which, if they do not reach the bladder as mucilage, at least afford a bland addition to the blood, from which the urine is secreted. This state of the bladder is sometimes productive of a light irritation about the symphysis of the pubis, rendering the articulation less firm and more easily separated. In such circumstances, when the pubis is tender, blood-letting and rest are the two principal remedies. A very distressing affection, which is often conjoined with this state of the bladder and urethra, but which may also take place without it, is a tender and irritable state of the vulva, producing great itching about the pudendum, especially dur- ing the night, and generally the urine is felt very hot. This distressing condition is often alleviated by blood-letting and laxatives; and when the itching is great, a sponge, dipped in cold water, or in cold solution of cerussa acetata, should be applied. If much fever exist, the saline julap, combined with a little tincture of opium, is useful. Incontinence of urine is not uncommon, in the end of ges- tation, and is produced by the pressure of the uterus on the bladder, by which the urine is forced off involuntarily, when- ever the woman coughs or moves quickly; or at least she can- not retain much of it, being obliged to void it frequently, but without strangury. For this complaint there is no cure; and many consider it as a favourable omen, that the child's head is resting on the os uteri. When the uterus is very pendulous, some advantage may be obtained, by supporting the belly with a proper bandage attached to the shoulders. 190 § 11. JAUNDICE. Connected with the state of the alimentary canal, is the jaundice of pregnant women. This disease appears at an early period, and is preceded by dyspeptic symptoms, whicli generally increase after the yellowness comes on. In some instances, the tinge is very slight, and soon disappears. In other cases, the yellow colour is deep and long continued, and the derangement of the stomach and bowels considerable. Emetics, and other violent remedies, which are sometimes used in the cure of the jaundice, are not allowable in this case, and in every instance, when young married women are seized with jaundice, we should be very cautious in our pre- scriptions. Gentle doses of calomel, or of other laxatives, with some light bitter infusion, are the most proper remedies; and generally the complaint soon goes off. Jaundice may also take place in the end of gestation; and in this case, it proceeds most frequently from pressure on the gall duct. Sometimes, however, it is dependent on a disease of the liver itself, which may occur at any period of gestation, and is marked by the usual symptoms. In this case the danger is very great, and can only be averted by taking cautious mea- sures for removing the hepatic disease. § 12. COLOURED SPOTS. In some cases, the skin is partially coloured; the mouth, for instance, being surrounded with a yellow or brown circle, or irregular patches of these colours appearing on different parts of the body. This is an affection quite independent of the state of the bile, and seems rather to be connected with certain conditions of the alimentary canal. It goes off after delivery, and does not require any peculiar treatment. § 13. PALPITATION. The thoracic viscera not unfrequently suffer during preg- 191 nancy. Palpitation of the heart is a very common affection, and extremely distressing. It is a disease so well known, that it is needless here to describe it; but it may not be improper to observe, that women themselves sometimes mistake for it a strong pulsation of the arteries, at the upper part of the abdo- men. It may make its attack repeatedly in the course of the day; or only at night, before falling asleep; or at the interval of two or three days; and is very readily excited by the slighest agitation of the mind. It is generally void of danger; but in delicate women, and in those who arc disposed to abortion, it sometimes occasions that event; and if long con- tinued, it may excite pulmonic disease in those who are pre- disposed to it. Absolute rest, with antispasmodics, are re- quisite during the paroxysm. Hartshorn, ether, and tinc- ture of opium, may be given, separately or combined. Ro- deric a Castro prescribes a draught of hot water. The attacks are to be prevented by the administration of tonics, such as tincture of muriated iron; and of foetids, such as valerian and asafcetida. Fatigue and exertion must be avoid- ed, and the mind kept tranquil. If the person be plethoric, it is sometimes useful to take away a little blood. The bowels are to be carefully kept open. The diet must be at- tended to ; for it is often produced by a disordered stomach. A tendency to nervous or hysterical diseases is to be pre- vented, in those who are liable to them, by occasional blood- letting, the use of laxatives, and camphor, or foetids. Opiates are only to be given for the immediate relief of urgent symp- toms. § 14. SYNCOPE. Another distressing affection of the heart, attendant on pregnancy, is syncope. This may take place at any period of gestation, but is most frequent in the three first months, or about the time of quickening. It often occurs in those who are otherwise healthy, but it also may occur daiiy for sometime in those who are weakened by a loose state of the bowels, alternating with costiveness, or by want of sleep oc- 193 easioned by tooth-ach. It may succeed some little exertiou, or speedy motion, or exposure to heat; but it may also conic on when the person is at perfect rest. The paroxysm is sometimes complete, and of long duration; at other times, the person does not lose her knowledge of what is going on, and soon recovers. A recumbent posture, the admission of cold air, or application of cold water to the face, the use of volatile salt, and the cautious administration of cordials, con- stitute the practice during the attack. Should the fit remain long, we must preserve the heat of the body, otherwise a protracted syncope may end in death. Those who are sub- ject to fainting fits, must avoid fatigue, crovvded or warm rooms, fasting, quick motion, and agitation of the mind. Tonics are useful when the system is weak, and the bowels must be regulated. There is a species of syncope, that I have oftener than once found to prove fatal in the early stage of pregnancy, which is dependent, I apprehend, on organic affections of the heart, that viscus being enlarged, or otherwise diseased, though perhaps so slightly as not previously to give rise to any troublesome, far less any pathognomonic symptoms. Although I have met with this fatal termination most fre- quently in the early stage, I have also seen it take place so late as the sixth month of pregnancy. § 15. DYSPNCEA AND COUGH. Sudden attacks of dyspnoea in those who were previously healthy, are generally to be considered as hysterical, and are readily removed by antispasmodics. There is, however, a more obstinate and protracted symptom, not unfrequently connected with pregnancy, namely cough. This may come in paroxysms, which are generally severe, or it may be al- most constant, in which case it is short and teasing. Some- times a viscid fluid is expectorated, but more frequently the cough is dry. During the attack, the head is generally pain- ful, and the woman complains much of the shaking of her body, especially of the belly. All practical writers are 193 agreed with respect to the danger of this disease, for it is ex- tremely apt to induce abortion; and it is worthy of remark, that after the child is expelled, the cough often suddenly eeases. 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 he 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. HAEMOPTYSIS AND H.KMATEMESIS. In some instances, haemoptysis or haematemesis take place in pregnancy, especially in the last months, and these are very dangerous affections. Blood-letting is the remedy chiefly to be depended on; and afterwards purgatives should be given; acids and hyoscyanris may be employed to allay irritation. If these means do not succeed, the patient dies. Should the hemorrhage take place during labour, or should pains come on prematurely, and the os uteri dilate, as sometimes happens, it will be prudent to accelerate the delivery. § 17. HEAD-ACHE AND CONVULSIONS. Head-ache is a very alarming symptom, when it is severe, constant, and accompanied with symptoms of plethora. If the eye be dull or suffused, and the head giddy, especially when the person stoops or lies down, with a sense of heavi- ness over the eyes, or within the skull, great danger is to be apprehended, particularly if the woman be far advanced in her pregnancy. This is still more the case, if she complain of ringing in the ears, and flashing of fire in the eyes, or in- distinct vision. In such circumstances, she is seized either with apoplexy or epilepsy. These diseases are to be prevent- ed by having immediate recourse to blood-letting and purga- VOIu I. CE 194 tives; and the same remedies are useful, if either one or other of these diseases have already taken place. The quan- tity of blood which is to be detracted, must be determined by the severity of the symptoms, the habit of the patient, and the effect of the evacuations; but, generally, moderate evacuation will prevent, whilst very copious depletion is re- quisite to cure these diseases. If the head-ache be accompanied with oedema, the digitalis is a useful addition to the practice. I shall not at present enter more minutely into the treatment of epilepsy. I shall only remark, that the first thing to be done is to detract blood from a vein; next, the bowels are to be immediately opened by a clyster, and then a purgative is to be administered. If the patient is seized with apoplexy, there is seldom any attempt made to expel the child,* and, in my own practice, I have never known that event take place. In epilepsy, on the contrary, if the paroxysm be protracted there is gene- rally an effect produced on the uterus; its mouth opens, and the child may be expelled, if the patient be not early cut off by a fatal coma. Whenever expulsive effects come on, we must conduct the labour according to rules hereafter to be noticed. In some instances, palsy either succeeds an apoplec- tic attack, or follows head-ache and vertigo. This disease does not commonly go off until delivery have taken place; but it may be -prevented from becoming severe, by mild laxatives and light diet; and, after the woman recovers from her la- bour, the disease gradually abates, or yields to appropriate remedies. All head-aches, however, do not forbode these dismal events, for often they proceed from the stomach, and evidently de- pend on costiveness, dyspepsia, or nervous irritation. These are generally periodical, accompanied with a pale visage, they feel more external than the former, and are often con- fined to one side of the head. They are attended with aci- dity in the stomach, eructations, and sometimes considerable giddiness or slight sickness, with bitter taste in the mouth. * Mr. Wilson's case is an exception to this. Vide Med. Facts, vol. v. p. 96. 195 They are relieved by the regular exhibition of laxatives, by sleep, the moderate use of volatiles, and the application of ether externally. Hysterical convulsions are not uncommon during gestation, and more especially during the first four months. They occur in irritable habits, or in those who are naturally dis- posed to syncope, or who have been exhausted by any pain, depriving them of rest, or by alvine discharges. They are distinguished by the face usually being pale during the at- tack, the countenance is very little distorted, there is no foam issuing from the mouth, the patient for a time lies as in a faint, and then has convulsive motions, or screams and sobs, and the fit generally is terminated by shedding tears. The treatment, in the first instance, consists in administering antispasmodics, particularly opiates and volatile foetids. Af- terwards, the returns are to be prevented by bringing the bowels into a correct state, and keeping them so. The ex- ercise is to be gentle, but taken regularly. The diet mild but nourishing. Sleep is to be procured, if necessary, by opiates; and tonic medicines, with the assistance of ammoniated tinG- ture of valerian, must complete the cure, § 18. TOOTH-ACHE. Tooth-ache not unfrequently attends pregnancy, and, some- times, is a very early symptom of that state. The tooth may be sound or diseased, but in neither case, ought we to extract it, in the early months, if it be possible to avoid the opera- tion. I have known the extraction followed in a few minutes by abortion. Blood-letting frequently gives relief, and, sometimes, a little cold water taken into the mouth abates the pain. In other cases, warm water gives more relief. § 19. SALIVATION. Salivation is, with some women, a mark of pregnancy. It has been supposed that there is a sympathy existing between the pancreas and salivary glands, and that the phlegm re- 196 jected by vomiting proceeded from the former, whilst, in many instances, the latter yielded an increased quantity of viscid saliva. This is a symptom which scarcely demands any medicine, but, when it does, mild laxatives are the most efficacious. § 20. MASTODYNIA. Pain and tension of the mammae frequently attend gesta- tion, and these symptoms 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, Chanibon 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. (EDEMA. In the course of gestation, the feet and legs very generally become oedematous; and sometimes the thighs, and labia pudendi participate in the swelling. The swelling is by no means proportioned always to the size of the womb, for, as has been remarked by Puzos, those who have the womb un- usually distended with water, and those who have twins, have 197 frequently very little oedema of the feet. This disease is partly owing to the pressure of the uterus, but it also seems to be somewhat connected with the pregnant state, inde- pendent of pressure; for in some instances, the oedema is not confined to the inferior extremities, but affects the whole body. A moderate degree of oedema going off in a recumbent pos- ture is so far from being injurious, that it is occasionally re- marked, that many uneasy feelings are removed by its acces- sion ; but a greater and more universal effusion indicates a dangerous degree of irritation, and may be followed by epi- lepsy. In ordinary cases, no medicine is necessary except aperients; but, when the oedema is extensive or permanent, remaining even after the patient has been for several hours in bed, it may be attended with unpleasant or dangerous effects, such as convulsions; or, it may predispose to puerpe- ral diseases; we must therefore lessen it by means of those agents which alleviate the other diseases of pregnancy, namely, blood-letting and purgatives. These means are always proper, unless the strength be much reduced; in which case, we only employ the purgatives and cordials prudently, with acetate of potash, or sweet spirit of nitre. Diuretics, generally, are not successful, and many of them, if given liberally, tend to excite abortion. Friction relieves the feel- ing of tension. § 22. ASCITES. Ascites may, like oedema, be excited, in consequence of some condition connected with gestation, or may be inde- pendent of it, arising from some of the ordinary causes of dropsy, especially from a disease of the liver. In the last case, medicine has seldom much effect in palliating or re- moving the disease ; and the woman usually dies, within a week or two after her delivery, whether that have been pre- mature, or delayed till the full time. When ascites is not occasioned by hepatic disease, and appears for the first time during gestation, it is generally connected with the oedema- tous state above-mentioned, and seldom comes on until the 198 woman has been at least three months pregnant. If it be not attended with other bad symptoms, such as head-ache, lev erish- ness, drowsiness, &c. it abates and goes off, a little before, or soon after delivery, which is often premature. I ha\e seen diuretics given very freely in these cases, but most frequently without any benefit. On this account, and also from the danger of these exciting abortion, or premature labour, I am inclined to dissuade from their use, except in urgent cases. Then the mildest ought to be employed, such as cream of tar- tar, juniper tea, acetate of pot-ash, &c. If any of these produce much irritation of the urinary organs, they must be exchanged for others. Purgatives and blood-letting are more useful. Ascites may have existed previously to pregnancy, and the two causes combined, may produce a very great enlargement of the belly. In this case, the uterus may be felt through the teguments, sometimes very much compressed, as if the child lay across. Mild diuretics tend to keep the disease at bay; and if the distension be very great, especially at an early stage, my experience leads me to conclude, that after quick- ening, a great part of the fluid may be drawn off safely, pro- vided, during the operation and afterwards, the abdomen be carefully and uniformly supported by a bandage. It is useful to know this, as the distension is sometimes so great, that life could not go on, without much distress, till the end of gesta- tion. The operation, I think, is more apt to be succeeded by labour, if performed in the last month, than earlier.(a) (z) Instances have occurred, where in cases of ascites combined with pregnancy, the operation of paracentesis has been performed, although this is a practice by no means to be commended. In the eighth Vol. of the Lon- don Med. Facts and Observations, there is a case related by Mr. Simmons, of a pregnant woman with symptoms of ascites being twice tapped, first, in the second month of pregnancy, wheh 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 f»f pregnancy was tapped, but it appears that the consequence of this opera- 199 * 33. REDUNDANCE OF LIQUOR AMNII. When the liquor amnii is in too great quantity, much in- convenience is produced, and not unfrequently the child perishes. This disease is known, by the woman being un- usually large at an early period of gestation, for generally by the seventh month, she is as big as she ought to be in the ninth. It is distinguished from ascites, by the motion of the child being felt, though obscurely, by the mother, and the breasts enlarging. Per vaginam we can ascertain, that the uterus contains a substance, which alternately recedes and descends as the finger strikes on the lower part of the womb. This is to be considered as a dropsical affection of the ovum, but the health of the woman seldom suffers so much as in dropsy; the tongue, how ever, is white, and the urine is di- minished in quantity. The legs are less apt to swell than in a common pregnancy. The distension may, in the advanced stage, prove troublesome. When the quantity of water is greatly increased, the child is seldom kept till the full time, but is generally expelled in the eighth month, or sooner, and the labour is apt to be accompained or succeeded by uterine hemorrhage. In some instances, the child occupies the upper part of the uterus, and the water the under, at least during tion was an abortion, although the patient soon recovered. Both these cases are related by the gentlemen under whose observation they fell, to prove that the paracentesis has been performed, and even the uterus perforated, [which they suppose was the case in both these instances,] without material injury to the patient. In the same work is related a case of a woman, who was tapped no less than five times during pregnancy : at the full period she was, notwithstand- ing, delivered of a fine child, and recovered completely from the puerperal These cases prove, how much the system will sometimes suffer with im- punity, but at the same time we must acknowledge, that it is best not to pre. sume too far on the preservative energies of nature. Sometimes pregnancy has been, from gross inaccuracy, mistaken for drop- sy, and the paracentesis been performed with a fatal effect; the patient in 'one instance fainting, and expiring almost instantaneously. Upon examinar tion after death, it was found that the trocar had not only perforated the uterus, but had also penetrated the foetus! 300 labour. Twice in the same woman, in succeeding pregnan- cies, I found the child contained in the upper part of the uterus, and embraced by it as if it were in a cyst, whilst se- veral pints of water lay between it and the os uteri. When the water came away, filling some basons, then the child de- scended to the os uteri, but was born dead, with the thighs turned firmly up over the abdomen, and other marks of de- formity. This is a disease of the ovum and not of the mother, for even the foetus itself is often malformed, or at least blighted. The affection in toto, may be considered as a species of monstrous conception. Some particular condition of the parent may, however, in certain cases, occasion it. For in- stance, it may be connected with a syphilitic taint in either the father or mother; or with some less obvious cause im- pairing the action of the womb, but not directly producing a miscarriage; with lunacy or idiotism; or with a state of ge- neral or uterine debility; or with an original imperfection of the ova in the ovarium : for a woman may, without any ap- parent cause, have repeatedly this kind of pregnancy. All of these causes do not operate uniformly to the same extent, but the foetus suffers in proportion to their operation. It is either born very feeble and languid, and is reared with difficulty or it dies almost immediately, or it perishes before labour com- mences ; and this is generally the case when the diseased state exists to any great degree. The period of the child's death is usually marked by a shivering fit, and cessation of motion in utero, at the same time that the breasts become flaccid. Af- terwards irregular pains come on, with or without a watery discharge. Sometimes the woman is sick or feverish for a few days before labour begins. If the liquor amnii be not increased greatly beyond the usual quantity, the woman may go the full time, but, from the distension of the uterus, is apt to have a lingering labour. Tonics, the cold bath, dry diet, with occasional venesec- tion, and the use of laxatives, during pregnancy, may be of service, hut frequently fail. Diuretics do no good. A course of mercury conducted prudently, previous to conception, is 201 the only remedy, when we suspect a syphilitic taint. It may be necessary to prescribe it to both parents. When it pro- ceeds from some more latent cause, I think it is useful, for preventing a repetition of the disease, to make the mother nurse, even although her child be dead. Mercury ought also to be tried. When the distension produces much distress, it has been proposed to draw off the water by the os uteri; or this has been done in one case by the common operation of paracen- tesis, the woman surviving, and labour taking place on the twenty-first day.* This practice is, however, generally im- proper, and is seldom requisite, pains usually coming on whenever the symptoms become severe. When the os uteri is considerably dilated by the pains, it may be proper to rup- ture the membranes, as has been advised by Puzos. § 24. WATERY DISCHARGE. Discharges of watery fluid from the vagina are not unfre- quent during pregnancy, and generally depend upon secre- tion from the glands about the cervix uteri. It has been supposed, that in every case they proceeded from this cause, or from the rupture of a lymphatic, or the evacuation of a fluid collected between the chorion and amnion, or the water of a blighted ovum, in a case of twins; for in every instance, where the liquor amnii has been artificially evacuated, labour has taken place. But we can suppose, that the action of ges- tation may, in some women, be so strong, as not to be inter- rupted by a partial evacuation of the liquor amnii. Even granting the water to be collected exterior to the chorion, there must be a strong tendency to excite labour, if the quan- tity discharged be great ;f and if the uterus can resist this, it may also be unaffected by the evacuation of liquor amnii. I have known instances, where after a fright or exertion, a * Vide case by Noel Desmarais, in Recueil Period. Tom. VI. p. 349. M Baudelocque gives a memoir on this subject in the same volume. •j- Vide Dr. Alexander's case, in Med. Comment. Vol. III. p. 187. VOL. I. D D 202 considerable quantity of water has been suddenly discharged, with subsidence of the abdominal tumour, or feeling of slack- ness ; and even irregular pains have taken place, and yet the woman has gone to the full time.* These prove, as far as the nature of the case will admit of proof, that the water has been evacuated. Sometimes, only one discharge has taken place, but oftener the first has been followed by others; and these are often tinged with blood. The aperture seems to heal, if gestation go on ; for during labour, a discharge of water takes place. Much more frequently labour does take place. Even when the discharge proceeds only from the vessel 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 copions dis- charge. The practice in these cases, is to confine the patient for some time to bed. An anodyne ought also to be given, and may be repeated occasionally, if she be affected either with irregular pain, or nervous irritation; previous venesection often renders this more useful. The bowels are to he kept open. If we suppose the discharge to be from the glands or vessels about the os uteri, we may, with advantage, inject some astringent fluid, such as a solution of sulphate of alu- mine. It sometimes happens, that a large hydatid is lodged be- tween the ovum and the os uteri, and it may be expelled se- veral weeks before parturition. If care be not taken, this may be followed by hemorrhage. * Dr. Pentland relates a very distinct case, where the liquor was, in the third or fourth month, discharged in a fit of coughing. The belly fill, but she still went on to the full time, and had a good labour Dubhn 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 demonstration that the membranes had been previously open, and that the discharge of liquor did not speedily excite labour. 203 § 25. VARICOSE VEINS. Varicose tumours sometimes appear on the legs. They are not dangerous, but are often painful. By pressure, they can be removed; but I am not sure that it is altogether safe to apply a bandage round the legs, so tight as to prevent their return. It is better, in ordinary cases, to do nothing at all; but where there is much pain, a recumbent posture, and mo- derate pressure, give relief. § 26. MUSCULAR PAIN. From the distension of the abdominal muscles, pain may be produced, either about the extremities of the recti muscles, or the origins of the oblique or transverse muscles. These pains are not dangerous, but give unnecessary alarm if the cause be not known. It is impossible to remove them, hut they may be mitigated by anodyne embrocations. If the pain be severe along the edge of the ribs, relief may be obtained by applying round the upper part of the abdomen a narrow band of leather, spread with adhesive plaster. There is another cause of pain, which sometimes affects these muscles, but oftener those about the pelvis and hips. This seems to consist in a diminished power of the muscles, in consequence of the uterine action, and thus the fibres are not capable of the same exertion as formerly. A long walk, or some little fatigue, may produce such an effect, as to render them painful for a long time: or even without any unusual degree of motion, they may ache, and produce the sensation of weariness. These pains have been supposed to be most frequent when the woman has twins, but this is far from being a general rule. They may occasion an apprehension that she is going to miscarry. Rest is the principal remedy; but if they be severe, relief may often he obtained by vene- section. Pain in the side, particularly the right side, is sometimes at an advanced period of gestation, both muscular, and also connected with the state of the bowels, especially of the colon. 504 It is frequently most severe, and may be rendered still more distressing by being combined with violent heartburn, or water brash. It comes on chiefly at night, and instead of being relieved by lying down, is often increased on going to bed. It is usually accompanied with much motion of the child. Venesection sometimes gives relief, but generally more advantage is derived from rubbing with anodyne balsam, attending to the state of the bowels, and regulating the diet. Although the pain be very severe, it seldom brings on labour. § 27. SPASM OF THE URETER. Spasm of the ureter, or some violent nephritic affection, may occur during gestation. The pain is severe, the pulse slow and soft, and the stomach often filled with wind. The symptoms are attended with distressing strangury, .vnd, if not soon removed, may cause premature labour. Decided relief is obtained by giving a saline clyster, and, after its operation, injecting eighty drops of laudanum, mixed with a little starch. A sinapism is to be applied to the loins, and if these means fail, blood must be taken away. § 28. CRAMP. Spasms in the inferior extremities are often very distress- ing. These may come on suddenly, but occasionally, they are preceded by a sense of coldness, and accompanied with a feeling of heat. They are removed by change of posture, and gentle friction. They have, by some, been thought to indicate a wrong presentation of the child, but this opinion is not supported by experience. They proceed from the pres- sure of the uterus on the nerves in the pelvis. § 29. DISTENSION OF THE ABDOMEN. In a first pregnancy, the abdominal muscles generally preserve a greater degree of tension than they do afterwards; and therefore the belly is not so prominent as in succeeding 205 pregnancies. Sometimes the muscles and integuments yield so readily to the uterus, that it falls very much forward, producing a great prominence in the shape, inconvenience from the pressure on the bladder, and pain in the sides, from the increasing weight of the projecting uterus. In such cases, benefit may be derived from supporting the abdomen with a bandage connected with the shoulders. In other in- stances, the muscles and integuments do not yield freely, but the belly is hard and tense; the woman feels shooting pains about the abdomen, and sometimes miscarries. This state is relieved by blood-letting and tepid fomentations. When the skin does not distend freely, and becomes tender and fretted, or when these effects are produced by very great distension, benefit is derived from fomenting with decoction of poppies, and afterwards applying a piece of soft linen, spread very thinly with some emollient ointment. There is sometimes a disposition to distend unequally, so that one side yields more than the other, or even part of one side, or one muscle more than the rest, producing a peculiar shape. This is attended with no inconvenience. § 30. HERNIA. It is very usual for the navel of pregnant women to become prominent, even at an early stage. In some instances, such a change is produced, as to allow the intestine or omentum to protrude, forming an umbilical hernia; or if the woman have been formerly subject to that disease, pregnancy tends to increase it, whilst, on the other hand, the intestines being soon raised up by the ascending uterus, inguinal and femoral hernise are not apt to occur, or are even removed if they for- merly existed. Umbilical hernia ought to be either kept re- duced by a proper bandage, or at least prevented, by due support, from increasing; and during delivery, we must be careful that the intestine he not forcibly protruded, as it might be difficult to replace it. After delivery, a truss must be applied, with spring wings which come round by the side of the belly. 206 In some cases, during gestation, the fibres of the abdomi- nal muscles separate, so that a ventral hernia is formed. The same circumstance may take place during parturition ; and the laceration is sometimes so large, that afterwards, when- ever the muscles contract, as, for instance, in the act of rising, a quantity of intestine is forced out, forming a hard tumour like a child's head. It is necessary in this, and in all other cases of large hernia, to be careful that compression be applied immediately after delivery, and also during the expulsion of the child. By neglecting this, syncope and uterine hemorrhage have been occasioned. 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 uneasiness of the body; the mind is to be cheered and supported by those who have most influence with the patient. § 32. RETROVERSION OF UTERUS. Retroversion of the uterus was described by Gregoire and Levret, but was in this country first accurately explained by Dr. Hunter, in 1754. It is an accident, which is always at- tended with painful, and sometimes fatal consequences, chiefly owing to the effect produced on the bladder. If the pelvis be of the usual size, it may take place at any time during the 207 third and fourth months of pregnancy;(«) or if the pelvis be large, or the ovum not much distended with water, it may occur in the fifth month. It may also be produced, when the womb is enlarged to a certain degree by disease.1 We recog- nise retroversion of the uterus chiefly by its effects on the blad- der, and also by difficulty in voiding the faeces; for although the patient may be distressed sometimes with tenesmus, she usually passes little at a time. When the retroversion is com- pleted, bearing-down pains may be excited, as if an attempt were made to expel or force down the uterus itself. These are much connected also with the state of the bladder, being most severe when it is distended, and abating when the urine is evacuated. The acute symptoms produced by the distension of the bladder, or the inability to pass the urine freely, first of all call the attention of the woman to the disease; and when we come to examine her, we find a tumour betwixt the rectum and vagina.2 This is formed by the fundus uteri, which is thrown backwards and downwards, whilst the os uteri is directed forward, and sometimes so much upwards, as not to be felt by the finger. This is a disease which we would (a) A suppression of urine from retroversion of the uterus, may arise at other periods, as well as during a state of pregnancy, and generally from the same cause, viz. over-distension of the bladder. Thus, after delivery, the uterus sometimes becomes retroverted, occasioning an entire suppres- sion of urine, and excessive pain; and the same thing, not uncommonly, takes place when the uterus is in a state of disease ; and sometimes at the period of life when the Catamenia usually cease. At this period the uterus is apt to enlarge and grow heavy, without manifesting any other indications of disease ; and in this state more than one instance have occurred of its be- coming retroverted. Dr. Merriman says, that the cases of retroversion of the uterus after deli- very, which have fallen under his observation, have principally occurred on the second day after the birth of the child; probably because the degree of contraction, which the womb has by that time undergone, has reduced it to a size the most fit to suffer such a displacement. It lias happened after easy labours, and notwithstanding the patients had passed their urine once or twice. The second day after delivery has not, however, been invariably the period of this occurrence ; for a case occurred to Dr. Merriman, where the patient was attacked with a suppression of urine from this cause on the ninth diy after delivery. " Vide Merriman's Dessertation on Retroversion of the womb," p. p. 19,20. 208 think cannot be mistaken, and yet it is sometimes dillieult to distinguish it; for in extra-uterine pregnancy, it has hap- pened, that the symptoms have been nearly the same with those of retroversion ;* and tumour of the ovarium has some- times produced similar effects. Perhaps the diagnosis can- not, in every case, be accurately made, but this is of less im- mediate importance, as the indication in such instances must be the same, namely, to draw off the urine, and procure stools. Retroversion may take place slowly, and it has been said that its progress could be ascertained from day to day ;3 but in most instances, and in every case that I have seen, it has taken place pretty quickly ; and occasionally the woman has been sensible at the time, of a tumbling or motion within the pelvis. Sometimes the urine dribbles away involuntarily, or can be passed in small quantity, especially during the com- mencement of the disease; but often, within a few hours, it becomes almost completely obstructed, with pains about the loins, tenderness in the lower belly when it is touched, and a severe bearing-down sensation. The great danger proceeds from the distension4 of the bladder, which either bursts5 or inflames,6 and an opening takes place, in consequence of gan- grene; or the bladder adheres to the abdominal parietes, its coats becoming thickened and diseased.7 If the urine cannot be drawn off, of which I have never yet met with an instance, death is preceded by abdominal pain, vomiting, hiccup, and sometimes convulsions. These effects are chiefly produced by mistaking the nature of the complaint. Their duration is 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 prevent a speedy termination, it occasionally happens, that hectic fever is produced. The pulse becomes frequent, the body • * Vide Mr. Giffard's case, in Phil. Trans. Vol. XXXVI. p. 435, and Mr White's very instructive case, in Med. Comment. Vol. XX. p. 254. t Dr. Perfect's patient died thus on the sixth dav. Cases in Midwiferv Vol 1. p.594. 209 wastes, and purulent urine is voided ;8 or the person may become cedematous, and the disease pass for dropsy ;9 occa- sionally 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 catheter,10 which maybe slightly curved, the concavity being directed to the sacrum; or we may employ an elastic catheter; but in general, the common instrument succeeds. If it do not pass easily, we may derive advantage from introducing the finger into the vagina, and endeavouring to depress the os uteri, or press back the vaginal tumour.11 If the catheter cannot be introduced, we have been advised to tap the blad- der;12 but this, fortunately, is never requisite. We must not be deceived with regard to the state of the bladder, by observing that the woman is able to pass a small quantity of water, for it may, nevertheless, be much distended. We must examine the belly, and attend to the sensation pro- duced by pressure on the hypogastric region. Even although the catheter have been employed, only part of the urine may have been drawn off, particularly if the complete evacuation has not been assisted by moderate pressure over the bladder. It has happened, that only so much has been taken away as to give a little relief, and alter the position of the uterus so much as to lessen the pressure on the orifice of the bladder. In this case, on getting up, a great quantity of urine has flowed spontaneously, and the womb immediately returned to its proper state. The urine being evacuated, and the most immediate source of alarm being thus removed, we must, in the next place, pro- cure a stool, by means of a clyster; detract blood, if there be fever or restlessness; and give an anodyne injection, if there be strong bearing-down efforts. This is, in general, all that is requisite; and I wish particularly to inculcate the necessity of directing the chief attention to the bladder, which ought to be emptied at least morning and evening. By this plan, we generally find, that the uterus resumes its proper situation in the course of a short time, perhaps in forty-eight VOL. T. I E 310 hours ;" and the retroversion is seldom continued for more than a week, unless the displacement has been very complete. The precise time, however, required for the ascent of the womb will be determined cseteris paribus, by the degree to whicli it has been retroverted, and the attention which is paid to the bladder. If the fundus be very low, the ascent may be tedious; but I consider myself as warranted from experience to say, that in every moderate degree of retrover- sion, in every recent case, it is sufficient to empty the blad- der regularly without making any attempt to push up the womb. But if the uterine tumour be very low, and near the perineum, it may be necessary, and certainly it is allowable, to endeavour to replace the womb. This is also proper, if there be much irritation excited by the state of the womb, and which does not give way to the use of the catheter, and of anodyne clysters. I fear, however, that these efforts shall seldom succeed, and that more harm than good is generally done by them. It may be said, that although the immediate danger be done away by the regular use of the catheter, yet the womb may remain forever in its malposition, and give rise to great difficulty in labour, or to the same event as in extra-uterine pregnancy. I can only reply, that in almost every instance where the bladder has been regularly emptied, the case has done well; and I do believe, that in those where the uterus did not rise spontaneously, very little good could have been done by mechanical efforts. The attempt to replace the uterus is to be made by intro- ducing two fingers of one hand into the rectum, and a suffi- cient number of those of the other hand, or the whole hand itself, into the vagina. The uterine tumour is then to be pressed up slowly, firmly, and steadily ; and this may some- times be assisted by elevating the breech of the woman. Forcible and violent attempts are, however, to be strongly reprobated; they give great pain, and may even excite abor- tion, inflammation, or convulsions. They can only be justifi- ed on the principle of preventing a great danger. Now we know that the chief risk proceeds from the distension of the bladder; if, therefore, it can be emptied, the danger is usually 211 at an end. When the retroversion ceases, the uterus usually resumes completely its proper situation; but it sometimes happens, especially if the vagina have been much relaxed, that when the retroversion is removed, the uterus is found very low, forming a prolapsus, which continues for some time. It requires, chiefly, attention to the urine and stools; for it may occupy the pelvis fully, and pretty firmly ; and almost the whole 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 patient; or when inflammation had taken place, as in the cases related by Drs. Bell and Ross. When this happens, the uterus rises indeed, but the patient is cut off by peritoneal inflammation,1* followed by vomiting of dark coloured stuff. Abortion will generally take place, if the liquor amnii have been discharged. That the uterus does generally rise spontaneously, if the urine be regularly evacuated, is a fact of which I am fully convinced from my own experience, as well as from the ob- servations of others. But it is nevertheless possible for it to continue in a certain degree of malposition even to the end of gestation.1' In this case, the uterus cannot, indeed, at last be said exactly to be retroverted; for it has enlarged so much, that it occupies nearly as much of the abdomen as usual; but it has enlarged in a peculiar way, the os uteri being still directed to the symphysis pubis, or even perhaps raised above it. In such a case, which is exceedingly rare, the labour will be very tedious and severe. The os uteri will be very long of being felt, and will be first perceived at the pubis.(fi) We * M. Roger's case, in Act. Havn. Tom. BE. art. 17. (6) The first case of this kind that has been accurately stated as such, is to be met with in a small, but judicious work, by Dr. H. S. Jackson, entitled, "Cautions to Women respecting the State of Pregnancy. London, 1798," and was attended by several of the most respectable practitioners of Lon- don ; the next case which has been made public, was that which fell under the immediate notice of Dr. Merriman, and by him minutely detailed in the London Medical and Physical Journal, for 1806; and afterwards pubUshed in a distinct and separate work, entitled, " A dissertation on Retroversion of 212 are indebted to Dr. Merriman for an explanation of this fact, and likewise for the observation that it is possible for the termination to be similar to that of extra-uterine pregnancy, the Womb, including some Observations on'Extra-uterine Gestation. Lon- don, 1810." It will be found by consulting Dr. 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 Devcnter 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 ot tlie 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. 1. p. 310.] There is also another class of cases, of which many are recorded by writers on Midwifery, which may probably owe their orign and cause to a retroverted state of the uterus. We here allude to those cases of extra-ute- rine foetuses discharged per anum, or through an ulcerated opening in the vagina, after having remained for many years in the abdomen of the modier. [Vide Mainwaring, in 2d vol. of Transactions of the Society for the Im- provement of Med. and Chirurg. Knowledge, and Coleman in 2d vol. of Med. and Phys. Journal, and GiflFard, in Eclectic Repertory, vol. 1. p. 346, & seq.] When foetuses have been found in the cavity of the abdomen entirely dis- engaged from the uterus, it is probable that a rupture of this viscus, or an ulcerated opening through its parietes, in consequence of its deranged situa- tion, had permitted the escape of the foetus after it had ceased to five, and not that the conception had advanced to maturity, in a part apparently so illy adapted to such a purpose. By this explanation, we may solve what has hitherto been to many a diffi- culty in the history of these cases. It has, for instance, been observed in every case of foetus carried, as it was supposed, in the abdomen beyond the period of nine months, that near the usual time of parturition, the pains of labour have regularly come on, and strong efforts appear to have been made by the uterus, as if for the expulsion of the child. Now, as it has been well observed, it is difficult to assign any reasons for these contractions of the uterus, if the foetus has no connection with that organ; but if the foetus is contained in the partially retroverted uterus, or in any of the appendages of the uterus, die occurrence of these contractions might naturally be expected. Vide Dr. Merriman's paper and work above referred to. 213 namely, by suppuration. A case of this kind, well marked in all respects, except suppression of urine, is related by Dr. Barnum* as an instance of extra-uterine gestation. In the fifth month, after some imprudence, the patient had pain ac- companied with a discharge of water and some blood, a mark that the ovum was in the uterus. She got relief at this time; but next month, (Nov.) she had a return of pain, and the os uteri was felt directed to the pubis, and the fundus to the sacrum. All attempts to reduce it failed, as they generally do, suppuration took place, and foetal bones were discharged by the anus. She died in March. In order to prevent retroversion, we must understand its cause, which most frequently, if not always consists in dis- tension of the bladder. The os uteri is thus elevated, and the fundus falls in the same proportion backward. Now in the unimpregnated state, the uterus is not sufficiently large to remain retroverted ; and after the fourth month of preg- nancy, the uterus is too heavy to be much raised by the blad- der, and too large to fall into the pelvis. If, however, the pelvis be very wide, and the uterus have consequently been longer, than usual of rising, it may be retroverted at a later period. It would appear, that agitation, or violent exer- tion,16 may cause this state to take place more readily than would otherwise happen; but whether concussions, or other circumstances, can produce retroversion, without some pre- vious distension of the bladder, is not positively proved, though some facts favour the supposition. The same woman has been known to have the uterus retro- verted in two successive pregnancies.f § 33. ANTIVERSION. The uterus is also said to be sometimes antiverted, that is, the fundus is thrown forward, so as to compress the neck of * Vide New York Med. Rep. V. 40. | Vide case by Dr. Senter, in Trans, of Phya, at Philadelpiiia, p. 130. Both times it was reduced by the hand. 21* tlie bladder, and its mouth is turned to the sacrum.17 Of this accident I have never seen an instance, and, from the nature of the case, it must he very rare. The urine should be evacuated, and the fundus raised up. § 34. RUPTURE OF UTERUS. Rupture of the gravid uterus may take place at any period of gestation. The moment of the accident is generally mark- ed by severe pain, occasionally by vomiting, and frequently by a tendency to syncope, which, in some instances, con- tinues for a length of time to be the most prominent symp- tom.* The pain sometimes resembles labour, but more fre- quently colic, and its duration is variable. In some cases, hemorrhage takes place from the vagina, but the greatest quantity of the blood18 flows into the abdomen. At the time of the accident, and for a little thereafter, the child is felt to struggle violently. Then the motion ceases, the woman feels a weight in the belly, and, if the pregnancy be far ad- vanced, the members of the child can be traced through the abdominal parietes.19 The tumour of the belly generally20 lessens, and milk is secreted, indicating the death of the ehild. If hemorrhage, or peritoneal inflammation, do not quickly carry off the patient, we find, that at the end of some time, occasionally of the ninth month of gestation, pains like those of labour come on, which either gradually go off, and the child is retained for many years,f being inclosed in a kind of cyst; or inflammation and abscess take place, and the child is discharged piece-meal.21 In some instances, it would appear, that the ovum may be expelled entire into the abdomen ; and in that case, it is pos- sible for the child to live for some time, and even to grow, although out of the uterus. When this happens, its motions * Vide Dr. Underwood's case, in Lond. Med. Journ. Vol. VII. p. 321. f In Dr. Percival's case, the foetus was retained for 22 years, and then dis- charged by the rectum. 215 are felt more freely and acutely than formerly. As the os uteri opens a little after the expulsion, and a sanguineous dis- charge takes place, the woman has sometimes been supposed to miscarry. If she survives, the womb slowly decreases in size, and returns to the unimpregnated state,22 which will as- sist materially in the diagnosis, between this and extra-ute- rine pregnancy existing from the first. The menses return, and though the belly does not subside completely, yet the person continues tolerably well, unless inflammation come on. She may even hear children before the extra-uterine foetus be got rid of.* If the case is to prove fatal, the pulse be- comes quick and small, the belly painful, the strength sinks, and sometimes continued vomiting ushers in dissolution.23 Rupture of the uterus may be the consequence of mental agitation,! but in most cases it js owing to external vio- lence.24:}: Three modes of treatment present themselves. To leave the case to nature; to deliver per vias naturales; and to per- form the csesarean operation. To dilate the os uteri forcibly, and thus extract the child, is a proposal so rash and hazard- ous, that I know none in the present day who would adopt it. I question if the woman would live till the delivery were accomplished. The csesarean operation is safer, and in every * Vide Journ. de Med. Tom. V. p. 422. f Dr. PercivaPs patient attributed her accident to a fright; Dr. Underwood's referred tier's to mental agitation. > i 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 convidsions. 4. By the inordinate action of the uterus, constituting what is termed spon- taneous rupture. This last is, by much, the most common cause. But when rupture is thus produced, we may suspect that an improper treatment has been pursued. We can, undoubtedly, by copious bleeding, and the subse- quent, administration of opium, so far overcome the resistance, and mitigate the violence of the pains, as to prevent its occurrence. The same remedies will, moreover, obviate, in most instances, rupture from convulsions; and should never be neglected as precautionary means, where there are any ap- prehensions of the accident from turning the child. C. 316 respect preferable; but we cannot yet, from experience, de- termine its advantages, and certainly it ought not to be per- formed, unless we can thereby save the child. The third proposal, therefore, to leave the case to nature, like an extra- uterine pregnancy, is most likely to be successful, more espe- cially when the rupture happens in the early months of ges- tation. We find, from the result of cases, that the woman has the best chance of recovery, if we are satisfied with ob- viating symptoms, and removing inflammation in the first instance; and supporting the strength of the patient through the progress of the disease, should it not prove rapidly fatal; enjoining rest, giving mild''diet, and favouring the expulsion of the bones, by poultices and fomentations, and, if necessary, by enlarging the abscess if it point externally.* • This negative sort of practice has, undoubtedly, met with many very re- spectable advocates. There are, at the present day, several eminent prac- titioners, besides Mr. Burns, who strenuously recommend it. Notwith- standing, however, the weight of authority in its favour, I cannot believe it to be right. The powers of nature seem to me to be totally incompetent in such cases. By prompt delivery only we can hope to do good. This, then, we should always attempt. In some cases the forceps may be used, but they are few, as the rupture commonly takes place before labour is suffi- ciently advanced to admit of their application. We, therefore, turn the cliild, and bring it away by tlie feet. Delivery in this manner has been more than once effected, and the woman preserved, even where the child had escaped through the rupture of the uterus into the abdominal cavity. I al- lude now, more particularly, to the case recorded by Dr. Douglass, and to one which occurred to Dr. J. Hamilton. To these, I may also add, as show- ing, at least, the practicability of delivery under such circumstances, a case, related by my friend Dr. James, in the Medical Repository of New York. Were the rupture to happen in the earliest stage of labour, I should nevertheless not be deterred from adopting this practice. I would forcibly, but not violently, dilate the uterus. It does not strike me that the attempt would be " rash and hazardous " We often in other emergencies do it with advantage, as in labour attended with hemorrhage or convulsions. Why may it not also be done in lacerated uterus ? But if, by deformity of the pelvis, or contraction of tlie uterus, (the child being in the cavity of tlie abdomen) or indeed from any other circumstances, there exists insuperable impediments to delivery per vias naturales, Hvould, without hesitation, resort to the cesarean section. In deliberating on the ex- pediency of adopting this dreadful alternative, we should constantly bear in recollection that we are not without examples of the success of the ope- ration. 217 § 3S. ABORTION AND TREATMENT OP PREGNANT WOMEN. The usual period of utero-gestation is nine months, but the foetus may be expelled much earlier. If the expulsion take place within three months of the natural term, the woman is said to have a premature labour; if before that time, she is said to miscarry, or have an abortion. The process of abor- tion consists of two parts, detachment and expulsion; but these do not always bear a uniform relation to each other in their degree. The first is productive of hemorrhage, the second of pain; for the one is attended with rupture of ves- sels, the other with contraction of the muscular fibres. The first may exist without being followed by the second, but the second always increases, and ultimately completes the first. The symptoms then of abortion, must be those pro- duced by separation of the ovum, and contraction of the uterus. To these, which are essential, may be added others more accidental, induced by them, and varying according to the constitution and habits of the patient. The ovum may be thrown off at different stages of its growth ; and the symptoms, even at the same period, vary in duration and degree. The process of gestation may be checked, even before the 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 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 na- tural passages. On opening the abdomen, the child was found in the cavity, and the uterus considerably lacerated. But notwithstanding the extent and severity of the injury, the woman entirely recovered. Let it not, however, be understood that 1 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 ? To leave them to nature, " like an extra-uterine concep- tion," would be, either to consign the woman to immediate death, or what is still worse, to death from protracted and torturing illness. C. VOL. I. FF 218 a copious discharge of blood, which coagulates or forms clots. This is accompanied with marks of uterine irritation, such as pain in the back and loins, frequently spasmodic affections of the bowels, and occasionally a slight febrile state of the system. In plethoric habits, and when abortion proceeds from over-action, or hemorrhagic action of the uterine ves- sels, the fever is idiopathic, and precedes the discharge. In other circumstances it is either absent, or, when present; it is symptomatic and still more inconsiderable, arising merely from pain or irritation. As the primary vessels are very small, and are soon displaced, they cannot be detected in the discharge. Nothing but coagulum can be perceived; and this, as in other cases of uterine hemorrhage, is often so firm, and the globules and lymph so disposed, as to give it, more especially if it have been retained for some time about the uterus or vagina, a streaked or fibrous appearance, which sometimes gives rise to a supposition, that it is an organized substance. The discharge does not cease when the primary vessels are destroyed, but generally continues until the small vesicle passes out of the fallopian tube. Then it stops, and an oozing of serous fluid finishes the process. The only interruption to the discharge in this case of abor- tion, proceeds from the formation of clots, which, however?" are soon displaced. Women, if plethoric, sometimes suffer considerably from the profusion of the discharge; but, in ge- neral, they soon recover. If the vesicle have descended into the uterus, the symptoms are somewhat different. We have an attempt in the uterus to contract, which formerly was not necessary; we have pains more or less regular in the back and hypogastric region; we have more disturbance of the abdominal viscera, particularly the stomach. The discharge is copious, and small bits of fibrous substance can often be observed. Sometimes the vesi- cle may be detected in the first discharge of blood, and will be found to be streaked over with pale vessels, giving it an appearance as if it had been slightly macerated. When all the contents are expelled, a bloody discharge continues for a few hours, and is then succeeded by a serous fluid. At this 219 time, and in later abortion, if the symptoms take place gra- dually, we may sometimes observe a gelatinous matter to come away before the hemorrhage appears. If the uterus contain more vascular and organized matter, as in the beginning of the third month, the vesicle never escapes first; but we have for some time a discharge of blood, accompanied or succeeded by uterine pain. Then the inferior part or short stalk of the ovum may be expelled, gorged with blood, and afterwards the upper part equally injured. Some- times the whole comes away at once and entire; but this is rare. As considerable contraction is now required in the uterus, the pains are pretty severe. The derangement of the stomach is also greater than formerly, giving rise to sickness or faintness, which is a natural contrivance for abating the hemorrhage. When the membranes come to occupy more of the uterus, and a still greater difference exists betwixt the placenta and decidua, we have again a change of the process; we have more bearing-down pain, and greater regularity in its attack; we have a more rapid discharge, owing to the greater size of the vessels; but there is not always more blood lost now than at an earlier period, for coagula form readily from temporary fits of faintness, and other causes, and interrupt the flow until new and increased contraction displaces them. Often the membranes give way, and the foetus escapes with the liquor amnii, whilst the rest of the ovum is retained for some hours or even days,* when it is expelled with coagulated blood se- parating and confounding its different parts or layers. At other times the foetal and maternal portions separate, and the first is expelled before the second, forming a very beautiful preparation. In some rare instances we find the whole ovum expelled entire, and in high preservation. After the expul- sion, the hemorrhage goes off, and is succeeded by a dis- charge, somewhat resembling the lochia. In cases of twins, after one child is expelled, either alone or with its secundines, the discharge sometimes stops, and the * In all cases the placenta is retained much longer after the expulsion of the child in abortion, than in labour at the full time. 220 woman continues pretty well for some hours, or even lor a day or two, when a repetition of the process takes place, and if she has been using any exertion, there is generally a pretty rapid and profuse discharge. This is one reason, amongst many others, for confining women to bed for several days after abortion. There is frequently, for a longer or shorter time before the" commencement of abortion, pain and irregular action in the neighbouring parts, which give warning of its approach, before either discharge or contraction take place ;* unless when it proceeds from violence, in which case the discharge may instantly appear. This is the period at which we can most effectually interfere for the prevention of abortion. I need not be particular in adding, that we are not to confound these symptoms with the more chronic ailments which accom- pany pregnancy. A great diversity obtains in different instances with regard to the symptoms and duration of abortion. In some cases the pains are xevy severe and long continued ; in others, short and trifling; nor is the degree of pain always a correct index of the force of contraction. Sometimes the hemorrhage is profusef and alarming; at other times, although circum- stances may not be apparently very different, it is moderate or inconsiderable. Often the sympathetic effects on the stomach and bowels are scarcely productive of inconvenience, whilst in a greater number of instances they are very prominent symptoms. I may only add, that, cmteris paribus, we shall find, that the farther the pregnancy is advanced beyond the third month, and the nearer it approaches to the end of the sixth, the less chance is there of abortion being accompanied, but the great- er of its being succeeded, by nervous affection. As there is a diversity in the symptoms, so is there also * In some cases, shooting pains and tension are felt in the breasts before abortion, and the patient is feverish. ■j- Those who are plethoric generally lose much blood, unless the contrac- tion have been brisk. In some cases six or seven pounds of blood have been lost in a few hours. 221 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 before the expulsion takes place. In some cases the child appears to be dead for a consider- able time before the symptoms which accompany expulsion occur. But in a great majority of cases it is living, when the first signs of abortion are perceived, and in some in- stances is born alive. The signs by which we judge that the child in utero is dead, are the sudden cessation of the morn- ing sickness, or of any other sympathetic symptom which may have been present. The breasts become flaccid. If milk had been formerly secreted, it sometimes disappears, but in other instances the contrary happens, and no evident secretion takes place until the action of gestation, or at least the life of the child be lost. In almost every case, however, the breasts will he found to have lost their firmness. If the pregnancy had advanced beyond the period of quickening, the motion of the child will be lost, and a feeling of heaviness will be felt about the pelvis. When all these signs are ob- served, and when they are followed by discharge, and espe- cially when this is attended with pain, there can be no doubt that expulsion will take place, and it would be improper to* prevent it. We are not, however, to conclude that the child is dead, merely because it does not move; and when abortion is threatened before the term of quickening, this sign cannot enter into our consideration. When the ovum perishes at a very early period, and is not immediately discharged, we find that the sympathetic signs of pregnancy disappear, and not unfrequently a serous or milky fluid comes from the nipples. The woman feels lan- guid and hot at night, or has fits of sickness, or hysterical symptoms; a discharge of foetid dark coloured fluid takes place from the vagina, and is often mixed with particles like snuff. This continues till all the remains of the ovum have come away, and then the health and spirits are restored. If at a more advanced period, the ovum remains after the 222 ehild dies, it is converted either into a mole or hydatid ; and this may also happen even at a very early stage of pregnancy. These cases have already been considered. It is generally most prudent to obviate symptoms, and wait until the os uteri open and pains come on. Then we are to be directed by ex- isting circumstances. Whether the ovum become putrid, or undergo a change into hydatids, it is reasonable to expect that the vessels of the uterus being no longer employed in the growth of the foetus should diminish, and become in the first case merely sufficient to nourish the uterus ; and, in the se- cond, to supply the necessities of the substance attached to the inner surface of the womb; for there is a communication between them, and a discharge of blood attends the expulsion of either a mole or hydatid; whereas, on the other hand, if tlie ovum has perished completely and become putrid, the discharge is rather a foetid sanies than red blood. Abortion may very properly he divided into accidental and habitual. The exciting causes of the first class may, in ge- neral, be easily detected; those giving rise to the second are often more obscure; and, without great attention, the woman will go on to miscarry, until either sterility, or some fatal dis- ease, be induced. In many cases there can be no peculiar pre-disposing cause of abortion ; as, for instance, when it is produced by blows, rupture of the membranes, or accidental separation of the de- cidua: but when it occurs without any very perceptible excit- ing cause, it is allowable to infer, that some pre-disposing state exists; and this frequently consists in an imperfect mode of uterine action, induced by age, former miscarriages, and other causes. It is well known, that women can only bear children until a certain age; after which, the uterus is no longer capable of performing the action of gestation, or of performing it properly. Now, it is observable, that this in- capability or imperfection takes place sooner in those who are advanced in life before they marry, than in those who have married and begun to bear children earlier. Thus we find, that a woman who marries at forty, shall be very apt to miscarry; whereas, had she married at thirty, she might have 223 borne children when older than forty; from which it may b« inferred, that the organs of generation lose their power of act- ing properly sooner, if not employed, than in the connubial state. The same cause which tends to induce abortion at a certain age in those who have remained until that time sin- gle, will also, at a period somewhat later, induce it in those who have been younger married; for in them we find, that, after bearing several children, it is not uncommon to con- clude with an abortion; or, sometimes after this incomplete action, the uterus, in a considerable time, recruits, as it were, and the woman carries a child to the full time, after which she ceases to conceive. In the next place, 1 mention that one abortion paves the way for another; because, setting other circumstances aside, it give the uterus a tendency to stop its action of gestation at an early period after conception, and therefore it is difficult to make a woman go to the full time, after she has miscarried frequently. This fact has also been explained upon the prin- ciple of repeated abortion weakening the uterus*, and this certainly may have some influence. The renewed operation of those causes which formerly induced abortion, may like- wise account in many cases for its repetition. But I am also inclined to attribute the recurrence, sometimes, to habit alone, by which I understand that tendency which a part has to re- peat or continue those modes of acting which it has frequent- ly performed, as we see in many diseases of the stomach and windpipe; spasmodic affections of these and other organs, being apt to return at the same hour, for a long time. With regard to the uterus, one remarkable instance is related by Schulzius, of a woman, who, in spite of every remedy, mis- carried twenty-three times at the third month. In this, and similar cases, slighter causes applied at the period when abortion formerly happened, will be sufficient to induce it, than would be required at another time. We also find that an excessive or indiscriminate use of ve- • Perhanc vero consuetudinem nihil aliud intelligo, quam pravam vasorum uteri laxitatem et inde provenientem humorum stagnationem, ex abortiendi labore ssepius repetito inductam. Hoffman, Tom. iii. p. 180 224 nery, either destroys the power of the organs of generation altogether, making the woman barren, or it disposes to abor- tion, by enfeebling these organs. Some slight change of structure in part of the uterus, by influencing its actions, may, if it do not prevent conception, interfere with the process of gestation, and produce prema- ture expulsion. If, however, the part affected be very small, and near the os uteri, it is possible for pregnancy to go on to the full time. Indeed, it generally does go on, and the la- bour, as may be foreseen, will be very tedious; but the opera- tion of cutting the indurated os uteri, which has been pro- posed, is seldom necessary. I have known one instance, in which a very considerable part of the uterus, I may say al- most the whole of it, was found, after delivery, to be extreme- ly hard, and nearly ossified; but this state could not have existed before impregnation took place, for I cannot conceive that so great a proportion of the uterus should have been originally diseased, and yet that conception, and its conse- quent actions, should take place ; but there is less difficulty in supposing, that, during the enlarging of the uterus, the vessels deposited osseous or cartilaginous matter, instead of muscular fibres. A general weakness of the system, which must affect the actions of the uterus, in common with those of other organs, is likewise to be considered as giving rise to abortion, though not so frequently as was at one time supposed. A local weakness of the uterus sometimes exists when the general system is not very feeble; or when the constitution is delicate, the uterus may be weaker in proportion than other organs. In this case, it cannot perform its function with the necessary activity and perfection, but is very apt, after a time, to flag. We cannot operate with medicines di- rectly upon the womb, for the purpose of strengthening it, but must act on it by invigorating the general system, and at- tending to all the other functions. Sea-bathing is of great service; and after impregnation, every exciting cause of abortion must be guarded against. Women of this descrip- tion are generally pale, of a weakly, flabby habit, and sub- 225 ject to 'irregular, often to copious menstruation, or fluor al- bus. When they conceive, the cold bath, light digestible food, open bowels, and free air, should be enjoined; and if any uneasy sensation be felt about the uterus or back, or the pulse throb, a little blood should be slowly taken away, and the woman keep her room for some days. Bleeding prevents the womb from being oppressed, and it is as necessary to at- tend to this, as it is to prevent the stomach from being load- ed in a dyspeptic patient. But, on the other hand, were we to bleed copiously, we might injure the action of the uterus, and destroy the child. It has been supposed that abortion might arise from a rigi- dity of the uterus, which prevented its distension. But the uterus does not distend like a dead part, upon which pres- sure is applied, but it grows, and therefore I apprehend that an effect is here considered as a primary cause. The uterus is not only affected by the general conditions of the system, more especially with regard to sensibility, and the state of the blood vessels; but it likewise sympathizes with the principal organs, and may undergo changes in con- sequence of alterations in their state. Thus we often find that loss of tone, or diminished action of the stomach, produces amenorrhoea; and it may also on the same principle induce abortion ; on the other hand, the action of the uterus may influence that of other viscera, as we see in pulmonary consumption, which is sometimes suspend- ed in its progress during pregnancy; or, if there be any dis- position in an organ to disease, frequent abortion, partly by sympathy betwixt the uterus and that organ, and partly by the weakness which it induces, and the general injury which it does to the system at large, may excite the irregular or mor- bid action of the organ so disposed. As the action of the uterus is increased during pregnancy, it must require more nervous energy; but the size of the nerves of the uterus is not increased in proportion to the ac- tion ; we must therefore depend for the increased supply upon the trunks, or larger portion of the nervous substance, from which they arise, for we well know that the quantity of energy VOL. I. G G 326 expended in an organ, does not depend upon the size of the nerve in its substance, but on the trunk which furnishes it. Whenever action is increased in an organ, it must either perish, or the larger nerve must send the branches more energy; for the branches themselves cannot form it, their ex- tremities being only intended for expending it; from which it follows, that in pregnancy there must be more energy sent to the uterus, and less to some other part. This is the case with all organs whose action is increased, other parts being deprived in proportion as they are supplied, except when irritation raises general action above the natural degree; the consequence of which is, that the power is not sufficient for the action, which becomes irregular, and the system is exhausted, as we see in febrile conditions. There being increased action of the uterus in gestation, re- quiring an increased quantity of energy to support it, we find that the system is put pro tempore into an artificial state, and obliged either to form more energy, which cannot be so easily done, or to spend less in some other part. Thus the function of nutrition, or the action by which organic matter is deposit- ed, in room of that which is absorbed, often yields, or is les- sened, and the person becomes emaciated, or the stomach has its action diminished, or the bowels, producing costiveness and inflation. If no part give way, and no more energy than usual be formed, gestation cannot go on, or goes on imper- fectly. Hence some women have abortion induced by being too vigorous: that is to say, all the organs persist in keeping up their action in perfection and complete degree. A tendency to abortion also results from a contrary cause, from organs yielding too readily, allowing the uterus to act too easily. In this state it is as liable to go wrong, as the general system is when it is at the highest degree of action, compatible with health; the most trifling cause deranges it. Thus, sometimes, the intestines yield too readily, and become almost torpid, so that a stool can with difficulty be procured. Here costiveness is not a cause of abortion, though it may be blamed. In like manner, the muscular system may yield and become enfeebled; and in this instance debility is accused as 227 the cause of abortion although it be, indeed, only an effect of too much energy being destined for the uterus. In this case, the woman is always weaker during menstruation and gesta- tion than at other times. If the neighbouring parts do not accommodate themselves to the changes in the direction of energy, and act in concert with the uterus, their action becomes irregular, and conse- quently painful. In this case, the uterus may have its just degree of power and action; but other parts may not 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 symptoms are different. The pain is felt chiefly at night, a time at whhjlj weakened parts always suffer most; it returns pretty regular- ly for several week, but the uterus continues to enlarge, the breasts to distend, and all things are as they ought to be, if we except the presence of the pain. This may he alleviated by bleeding, and sometimes by anodynes; but can only be cured by time, and avoiding, by means of rest and care, any additional injury to parts already irregular and ticklish in the performance of their actions. If this be neglected, they will re-act on the uterus at last, and impede its function. It is therefore highly necessary, especially in those disposed to abortion, to pay attention to pains about the back, loins, or pubis; and to insist upon rest, open bowels, and detracting blood, if the state of the vascular system indicate evacuation. Even although the different organs, both near and remote, may have accommodated themselves to the changes in the uterine action, in the commencement of gestation, the proper balance may yet be lost at a subsequent period; and this is most apt to take place about the end of the third, or begin- ning of the fourth month, before the uterus rises out of the pelvis: and hence a greater number of abortions take place at that time than at any other stage of pregnancy. There is from that time, to the period of quickening, a greater sus- ceptibility in the uterus to have its action interrupted, than either before or afterwards; which points out the necessity of 228 redoubling our vigilance in watching against the operation of any of the causes giving rise to abortion from the tenth to the sixteenth week. If the action of gestation go on under restraint, as, for in- stance, by a change of position in the uterus, or by its pro- lapsing too low in the vagina, it is very apt to be accompanied by uneasy feelings, for, whenever any action is constrained, sensation is produced. The woman feels irregular, and pretty sharp pains in the region of the uterus, and from sympathetic irritation both the bladder and rectum may be affected, and occasionally a difficulty is felt in making water, by which a suspicion is raised that retroversion is taking place. Some- times the cervical vessels in these circumstances yield a little blood, as if abortion were going to happen; but by keeping the patient at rest, and attending to the state of the rectum and bladder, no harm is done; and when the uterus rises out of the pelvis, no farther uneasiness is felt. Occasionally a pretty considerable discharge may take place under these cir- cumstances, if the vascular system be full, or the vessels about the cervix large. But, by care, gestation will go on ; for dis- charge alone does not indicate that abortion must necessarily happen. It, indeed, often causes abortion, and is almost al- ways an attendant upon it; but we form our judgment, not from this symptom alone, but also from the state of the mus- cular fibres, and the vitality of the child. Retroversion of the uterus likewise constrains very much its action, and may give rise to abortion, though in a greater number of instances, by care, gestation will go on, and the uterus gradually ascend. The bowels are to be kept open, and the urine gradually evacuated. Sometimes in irritable or hysterical habits, the process of gestation produces a considerable degree of disturbance in the actions of the abdominal viscera, particularly the sto- mach ; exciting frequent and distressing retching or vomiting, which may continue for a week or two, and sometimes is so violent, as to invert the peristaltic motion of the intestines near the stomach, in which case feculent matter, and, in some instances, lumbrici are vomited.. 229 This affection is often accompanied by an unsettled state of mind, which adds greatly to the distress. We sometimes, in these circumstances, have painful attempts made by the mus- cles to force the uterus downward, and these are occasionally attended by a very slight discharge of blood. We have, however, no regular uterine pain; and, if we are careful of our patient, abortion is rarely produced. The best practice is to take away a little blood at first, to keep the bowels open, to lessen the tendency to vomit, by ap- plying leeches, or an opium plaster, or a small blister, to the region of the stomach, and to allay pain by doses of hyoscy- amus or opium, conjoined with carminatives. When the mind is much affected, or the head painful, it is proper to shave the head, and wash it frequently with cold vinegar, or apply leeches to the temples; at the same time we keep the patient very quiet, and have recourse to a soothing manage- ment. The uterus being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influenced by those regulating new-formed parts ; with this difference, how- ever, that new-formed parts or tumours are united firmly to the part from which they grow by all kind of vessels, and ge- nerally by fibrous or cellular substance, whilst the ovum is connected to the uterus only by very tender and fragile arte- ries and veins. If, therefore, more blood be sent to the ma- ternal part of the ovum, than it can easily receive and circu- late and act under, rupture of the vessels will take place, and an extravasation and consequent separation be produced; or, even when no rupture is occasioned, the action of the ovum may be so oppressed and disordered, as to unfit it for conti- nuing the process of gestation. There must, therefore, be a perfect correspondence betwixt the uterus and the ovum, not only in growth and vascularity, but in every other circum- stance connected with their functions. Even when they do correspond, if the uterus be plethoric, the ovum must also be full of blood, and rupture is very apt to take place. This is a frequent cause of abortion, more especially in those who menstruate copiously. On the other 230 band, when the uterus is deficient in vascularity, which often happens in those who menstruate sparingly or painfully, or who have the menses pretty abundant, but watery, the child generally dies before the seventh month, and is expelled. The process is prematurely and imperfectly finished. The existence of plethora is to be considered as a very fre- quent cause of abortion, and requires most particular atten- tion. It more especially obtains in the young and vigorous, or in those who live luxuriously, and sleep in soft warm beds. It renders the uterus too easily supplied with blood: the in- crease is not made in the regular degree, corresponding to the gradual increase of action, and augmentation of size; but it is, if I may use the expression, forced on the uterus, which is thus made for a time to act strongly and rapidly. This ac- tion is sometimes so great, that the person feels weight in the region of the uterus, and shooting pains about the pelvis; but, in other instances, the vessels suddenly give way, with- out previous warning, and the blood bursts forth at the os uteri. This cause is especially apt to operate in those who are newly married, and who are of a salacious disposition, as the action of the uterus is thus much increased, and the existence of plethora rendered doubly dangerous. In these cases, when- ever the menses have become obstructed, all causes tending to increase the circulation must be avoided, and often a tem- porary separation from the husband is indispensable. Often do we find that slight exertion, within a fortnight after the menses stop, will produce a speedy and violent eruption of blood, which continues until the vessels are fully unloaded, and until all that part of the process of forming an ovum which has been effected, be undone. Abortion necessarily implies separation of the ovum, which may be produced mechanically, or by spontaneous rupture of the vessels, or by an affection of the muscular fibres. It un- avoidably requires, for its accomplishment, contraction of those fibres which formerly were in a dormant state. A natural and necessary effect of this contraction is to develope the cervix uteri. This, when gestation goes on regularly, is accomplished gradually and slowly by the extension and 231 formation of fibres. In abortion, no fibres are formed ; but muscular action does all, except in those instances where the action of gestation goes on irregularly and too fast; in which case, the cervix distends, sometimes by the third month, by the same process which distends the fundus. But much more frequently the cervix only relaxes during abor- tion, as the os uteri does in natural labour, and yields to the muscular action of the fundus, or distended part. The existence and growth of the foetus depend on the foetal portion of the ovum. The means of nourishment, and the accommodation of the foetus in respect of lodgment, depend on the uterus; and these circumstances requiring both foetal and maternal action, are intimately connected. The condi- tion of the uterus qualifying it to enlarge, to continue the ex- istence and operation of the maternal portion of the placenta or ovum, and to transmit blood to the ovum, exactly in the degree correspondent to its want, constitutes the action of gestation. When the action of gestation ceases universally in the uterus, another action, namely, muscular contraction, begins, and then all hope of retaining the ovum any longer is at an end. I know that we have been told of instances where contraction, after beginning, stopped for several 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 the os uteri, which has less to do with the action of gestation than any other part of the uterus; and this action is often at- tended with considerable pain or uneasiness. Sometimes it is connected with convulsive agitation of several of the ex- ternal muscles of the body. Even in this case, expulsion does not always immediately take place; for by bleeding, and rest, and opiates, the motion may sometimes be checked; but regular and universal action of the muscular fibres never yet has been stopped. It may, like other muscular actions, be suspended by anodynes or artificial treatment; but it never has, and never can be stopped, otherwise than by the expulsion of the ovum, when a new train of actions com- 232 mence. Whenever, then, at any period of pregnancy, we have paroxysms of pain in the back,* and region of the uterus, more especially if these be attended with feeling of weight in that region, tenesmus, micturition, descent of the uterus in the pelvis, and opening of the os uteri, we may be sure that expulsion, though retarded, will soon take place. This fact is not always attended to in abortion, for many think that if by anodynes they can abate the pain, they shall make the woman go to the full time.—This is true, with re- gard to many painful sensations, which may attend a threatened abortion, or which may be present, although there be no appearance of abortion ; but it does not hold with regard to those regular pains proceeding from universal ac- tion of the uterine fibres ; and we may save both ourselves and our patients some trouble, by keeping this in remem- brance. Seeing, then, that contraction is brought on by stopping the action of gestation, and that when it is brought on it can- not be checked, nor the action of gestation restored, we must next inquire how this action may be stopped. I have already mentioned several circumstances affecting the uterus, and likely to injure its actions; and these I shall not repeat, but go on to notice some others, which are often more percepti- ble : and first I shall mention violence, such as falls, blows, and much fatigue, which may injure tlie child, and detach part of the ovum. If part of the ovum he detached, we have not only a discharge of blood, but also the uterus, at that * It may not be improper to mention, that in some febrile affections we have pain in the back and loins, occasionally remitting, or disappearing alto- gether for a short space, and then returning. Sometimes along with this we have, owing to the affection of the circulation, and in some instances to pre- vious exertion, a slight discharge from the vessels about the os uteri. This state is distinguished from uterine contraction, by our finding that the cervix is unaffected, that the pains are increased by motion or pressure, and are more 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- maining period of gestation, will renew the pain in the back. 233 part, suffers in its action, and may influence the whole organ, so as to stop the action universally. But the time required to do this is various, and opportunity is often given to prevent the mischief from spreading, and to stop any farther effu- sion—perhaps to accomplish a re-union. Violent exercise, as dancing, for instance, or much walk- ing, or the fatiguing dissipations of fashionable life, more es- pecially in the earlier months, by affecting the circulation, may vary the distribution of blood in the uterus, so much as to produce rupture of the vessels, or otherwise to destroy the ovum. There is also another way in which fatigue acts, namely, by subducting action and energy from the uterus : for the more energy that is expended on the muscles of the inferior extremities, the less can be afforded or directed to the uterus; and hence abortion may be induced at an early stage of gestation.* Even at a more advanced period, in- convenience will be produced upon the principle formerly mentioned ; for the nerves of the loins conveying less energy, in many instances, though not always, to the muscles, they are really weaker than formerly, and are sooner wearied, producing pain, and prolonged feeling of fatigue for many days, after an exertion which may be considered as mo- derate. This feeling must not be confounded with a ten- dency to abortion, though it may sometimes be combined with it, for generally by rest the sensation goes off. Neither must we suppose that the child is dead, from its being usually quiet during that period, for as soon as the uterus, which has been a little impaired in its action, recovers, it moves as strongly as ever. In the next place, I mention the death of the child, which may be produced by syphilis, or by diseases perhaps peculiar to itself, or by that state which produces too much liquor am- nii, or by injury of the functions of the placenta, which may arise from an improper structure of the gland itself, or aneu- * The same effect is observable in the stomach and other organs. If a de- licate person, after a hearty meal, use exercise to the extent of fatigue, he feels that the food is not digested, the stomach having been weakened or in- jured in its actions. VOL. I. HH 234 rism, or other diseases of the cord. But in whatever way it is produced, the effect is the same in checking the action of gestation, unless there be twins, in which case it has been known, that the uterus sometimes did not suffer universally, but the action went on, and the one child was born of the full size, the other small and injured.* The length of time required for producing abortion from this cause is various ; sometimes it is brought on in a few hours ; at other times not for a fortnight, or even longer.(c) In these and similar cases, when the muscular action is commencing, the discharge is trifling, like menstruation, until the contraction becomes greater, and more of the ovum be separated. When symp- toms of abortion proceed from this cause, it is not possible to prevent its completion; and it would be hurtful even if it were possible. When, therefore, after great fatigue, profuse evacuations in delicate habits, violent colic, or other causes, the motion of the child ceases, the breasts become flaccid, and the signs of gestation disappear, we need not attempt to retard expulsion, but should direct our principal attention to conduct the woman safely through the process. * It has even been known, that, in consequence of the death of one child, the uterus has suffered partially, and expulsion taken place ; but the other child continuing to 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 al- most every instance, the death of one child produces an affection of the ac- tion of gestation in the whole uterus, and the consequent expidsion of both children. (c) In one instance that fell under my notice, a lady who had suffered se- veral previous abortions, but who had also borne two healthy living children, was overturned in a carriage before the completion of the third month of ges- tation. She was extremely bruised, and was, in consequence, confined to her bed for several days; yet upon getting about again, she fancied, after the period of quickening, that she felt the motion of the child, with all the other symptoms of favourable and healthy pregnancy. She thus went on to the full period of utero-gestation; and on the very day she calculated, was deli- vered of a foetus that certainly had lost the principle of vitality for several months, not appearing larger than an embryo of five months. The placenta was also almost exangueous, and appeared as if it might have been detached from the uterine parietes for some time. Indeed, the whole appeared like a preparation that had been preserved in sp. vini, or sp. terebinth. The lady had a speedy recovery, and at no distant period bore a healthy living child. 235 Another cause is, any strong passion of the mind. The influence of fear, joy, and other emotions on the muscular system, is well known; and the uterus is not exempted from their power; any sudden shock, even of the body, has much effect on this organ. The pulling of a tooth, for instance, sometimes suddenly produces abortion. Emmenagogues, or acrid substances, such as savine and other irritating drugs, more especially those which tend to excite a considerable degree of vascular action, may produce abortion. Such medicines, likewise, as exert a violent action on the stomach or bowels, will, upon the principle formerly men- tioned, frequently excite abortion; and very often arc taken designedly for that purpose in such quantity as to produce fatal effects ;* hence emetics, strong purgatives, diuretics, or a full course of mercury, must be avoided during pregnancy. If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion be produced. Hence the acces- sion of morbid action or inflammation in any important or- gan, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why small-pox often excites * It is an old observation, that those purgatives, which produce much tenesmus, will excite abortion ; and this is certainly true, if their operation be carried to a considerable extent, and continue long violent. Hence dy- sentery is also apt to bring on a miscarriage. Those strong purges which are -sometimes taken to promote premature expulsion, not only act by exciting tenesmus, but likewise by inflaming the stomach and bowels, and thus affect the uterus in two ways It cannot be too 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 contraiy, the action of the uterus is then more independent of that of other organs, and therefore not easily injury bv changes in their condition. I have already shown, that abortion more frequently happens when the pregnancy is farther advanced, because then not only the uterus is more easily affected, but the foetus seems to suffer more readily. It is apt, either from diseases directly affecting itself, or from changes in the uterine action, to die about the middle of the tlurd month, in which case expulsion follows within a fortnight. 236 abortion, whilst the same degree of fever, unaccompanied with eruption, would not have had that effect. Hence also increased secretory action in the vagina, if to a great degree, though it may have even originally been excited in conse- quence of sympathy with the uterus, may come to incapa- citate the uterus for going on with its actions, and therefore it ought to be moderated by means of an astringent injec- tion. Mechanical irritation of the os uteri, or attempts to dilate it prematurely, will also be apt to bring on muscular contrac- tion. At the same time, it is worthy of remark, that the effect of such irritation is generally at first confined to the spot on which it acts, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for some time, produced; and therefore slight uneasiness at the lower part of the belly, with or without a tendency in the os uteri to move or dilate, whether brought on by irritation at the upper part of the vagina or os uteri, or by affection of the neck of the bladder, &c. may be often prevented from extend- ing farther, by rest, anodynes, and having immediate re- course to such means as the nature of the irritation may re- quire for its removal.* The irritation of a prolapsus ani, or of inflamed piles, with or without much sanguineous discharge, may excite the uterus to contract; and if the bleeding from the anus have been pro- fuse, a/id 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 w hich 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 * Chronic inflammation of the heart is generally attended with pain at the bottom of the abdomen, which is sometimes mistaken for symptoms of cal- culus. In one case abortion seemed to proceed from this disease of the heart. 237 strong as not, at least for a very considerable time, to stop in consequence of this violence, and, if it do not stop, con- traction will not take place. I do not, however, mean to say, that all discharges of watery fluid from the uterus, not fol- lowed by abortion, are discharges of the liquor amnii. On the contrary, I know, that most of these are the consequence of morbid action about the os uteri, the glands yielding a serous, instead of a gelatinous fluid, and this action may con- tinue for many months. In all these cases, the woman must be confined to bed, and have an anodyne every night at bed-time, for some time, pre- mising venesection if the pulse indicate it, and conjoining gentle laxatives. There is just so much probability of gesta- tion going on, as to encourage us to use endeavours to con- tinue it. In those instances where the discharge is small, and the oozing pretty constant, we conclude that it is yielded chiefly by the glands about the os uteri, and may derive ad- vantage from injecting three or four times a-day a strong in- fusion of galls, or solution of alum. The woman ought to use no exertion, as the membranes are apt to give way. It is sometimes necessary to lay down rules for the manage- ment of pregnant wTomen, even although they may not have been liable to abortion. These are to be drawn from the re- marks already delivered, and it is only requisite to add, that in all cases it is proper to attend to the effects of utero-gesta- tion, or the diseases of pregnancy, which are to be mitigated when severe by suitable remedies. The danger of abortion is to be estimated by considering the previous state of the health, by attending to the violence of the discharge, and the difficulty of checking it; to its dura- tion, and the disposition to expulsion which accompanies it; to the effects which it has produced in weakening the system, and to its combination with hysterical or spasmodic affections. In general, we say that abortion is not dangerous, yet in some cases it does prove fatal very speedily, either from loss of blood, or spasm of the stomach, or convulsions. It is satisfac- tory, however, to know, that this termination is rare, that these dangerous attendants are seldom present, and that a 238 great hemorrhage may be sustained, and yet the strength soon recover. But if there be any disposition in a particular organ to disease, abortion may make it active, and thus, at a remote period, carry off the patient. Miscarriages, if fre- quently repeated, are also very apt to injure the health, and break up the constitution. When abortion is threatened, the process is very apt to go on to completion; and it is only by interposing, before the ex- pulsive efforts are begun, that we can be successful in prevent- ing it; for whenever the muscular contraction is universally established, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the pro- cess. As this is often the case before we are called, or, as in many instances abortion depends on the action of gestation being stopped by causes, whose action could not be ascertain- ed until the effect be produced, we shall frequently fail in preventing expulsion. This is greatly owing to our not being called until abor- tion, that is to say, the expulsive process has begun; where- as, had we been applied to upon the first unusual feeling, it might have been prevented. What I wish then particularly to inculcate is, that no time be lost in giving notice of any ground of alarm, and that the most prompt measures be had recourse to in the very beginning; for, when universal uterine contraction has commenced, then all that we can do is to con- duct the patient safely through a confinement, which the power of medicine cannot prevent. The case of threatened abortion, in which we most fre- quently succeed, is that arising from slipping of the foot, or from causes exciting a temporary over-action of the vessels producing a slight separation; because here the hemorrhage immediately gives alarm, and we are called before the action of gestation be much affected. Could we impress upon out- 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 239 of contraction appear, the mischief has proceeded too far to be checked. Prompt and decided means used upon the first approach of symptoms indicating a hazardous state of the uterus, or on the earliest appearance of hemorrhage may, pro- vided the child be still alive, be attended with success. In considering the treatment, I shall first of all notice the most likely method of preventing abortion in those who are subject to it; next, the best means of checking it, when it is immediately threatened; and, lastly, the proper method of conducting the woman through it, when it cannot be av oided. The means to be followed in preventing what may be cal- led habitual miscarriage, must depend on the cause supposed to give rise to it. It will, therefore, be 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- stitution, as this may be productive of permanent mischief, and occasion the diseases which proceed from a broken habit. Whenever the strength is diminished, the appetite impaired, or any other bad effect is produced, we have gone too great length. There is, in plethoric habits, a weakness of many, if not all of the functions; but this is not to he cured by tonics, but by continued and very gradually increased exercise, laxatives, and light diet, consisting chiefly of vegetables. This plan, 240 however, must not be carried to an imprudent length, nor established too suddenly; but regard is to be had to the pre- vious habits. It is a general rule, that exercise should not be carried the length of fatigue, and that it should be taken, if possible, in the country; whilst late hours, and many of the modes of fashionable life, must be departed from. We may also derive such considerable advantage from conjoining with this plan, the shower bath or sea-bathing, that they ought not to be omitted. There is, I believe, no remedy more powerful in preventing abortion than the cold bath, and the best time for using it is in the morning. By means of this, conjoined with attention to the vascular system, and prudent conduct on the part of the patient, I suppose that nine-tenths of those who are subject to abortion, may go on to the full time. If the shower-bath be employed, we must begin with a small quantity of water; and, in some instances, may at first add so much warm water as shall make it just feel cold, but not to give too great a shock. If the cold bath cause head-ache, this may often be prevented by premising one or two doses of physic. After conception, the exercise must be taken with circum- spection : but the diet must still be sparing, and the use of the cold bath continued. If the pulse be at any time full, or inclined to throb, or if the patient be of a vigorous habit, a little Mood should be taken away at a very early period. In some cases where the action is great, we must bleed al- most immediately after the suppression of the menses. It is not necessary to bleed copiously; it is much better to take away only a few ounces, and repeat the evacuation when re- quired, and we should manage so as to avoid fainting. The cold bath should be conjoined, and we may derive advantage by using the digitalis,* so as slightly to affect the pulse, keeping it at or below its natural frequency, and to diminish * The acetite of lead has been recommended by the ingenious and justly celebrated Dr. Rush of Philadelphia, in doses of from one to three grains, given three times a-day. Of this practice I cannot speak from my own ex- perience : but Dr. Rush informs me, that in his hands it has been attended with great success. 241 its throbbing. But it is not requisite to be given to the de- gree employed in some other complaints; and, if it be pushed to an imprudent length, the child may suffer. Half a grain may be given, twice or thrice a-day. It may be continued for two days, and then omitted for a day; and in this way it may be continued till the danger is past. In those cases where the digitalis produces feebleness, it is evidently im- proper to continue it regularly. Indeed, when this effect takes place, its farther exhibition is unnecessary. It is also improper where it acts powerfully on the kidneys. By at- tending to these cautions, it may. in some cases requiring it, he 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 hardly add, that when con- sulted respecting habitual abortion, the strictest prudence is required on our part, and that the situation of the patient, and many of our advices, should be concealed from the most intimate friends of the patient. In other cases, we find that the cause of abortion is con- nected with sparing menstruation. This is often the case with women whose appearance indicates good health, and who have a robust look. This is not often to be rectified by medicine, but it may by regimen, &c. Here, as in the for- mer case, we find it useful to make the greatest part of the diet consist of vegetables ; but it is not necessary to restrict the quantity. When, on the other hand, the patient has a weakly deli- voi. i. l 1 242 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 irritation, or feeling of tension about the belly, or pain about the groins, or pubis, it may be employed, and is both safe and advantageous. But when the patient is of a phlegmatic habit, or subject to profuse fluor albus, it is not indicated, and sometimes is pernicious. The internal use of the bath waters previous to conception is often of service; or where the circumstances of the patient will not permit this, we may desire her to drink, morning and evening, a pint of tepid water, containing half a dram of sweet spirit of nitre. Throwing up into the vagina tepid salt-water twice or thrice a day, seems also to have a good effect. I have already mentioned, that abortion is sometimes the consequence of too firm action, the different organs refusing to yield to the uterus, which is thus prevented from enjoying the due quantity of energy and action. These women have none of the diseases of pregnancy, or they have them in a slight degree. They have good health at all times, but they either miscarry, or have labour in the seventh or eighth month, the child being dead ; or if they go to the full time, I have often observed the child to be sickly, and of a consti- tution unfitting it for living. Blood-letting is useful by making the organs more irritable. The tepid bath is in ge- neral of advantage, and may be employed every second even- ing for some time. There is another case in which all the functions are healthy and firm, except the circulation, which is accelerated by the uterine irritation. This is more or less the case in every pregnancy ; but here it is a prominent symptom. The wo- man is very restless, and even feverish, and apt to miscarry, 243 especially if she be of a full habit. Immediate relief is given by venesection ; and afterwards we may, for some time, give every night half a grain or a grain of digitalis, with two grains of the extract of hyoscyamus. When, on the contrary, abortion arises from too easy yielding of some organ, we must keep down uterine action, by avoiding venery, and injecting cold water often into the vagina, or pouring cold water every morning from a water- ing can, upon the loins and ilia; at the same time we must attend to the organ sympathizing with the uterus. Sometimes it is the stomach which is irritable, and the person is often very sick, takes little food, and digests ill. A small blister, or leeches applied to the pit of the stomach, often relieves this; a little of the compound tincture of bark", taken three or four times a-day, is serviceable; or a few drops of the tincture of muriated iron, in a tumbler glassful of aerated water. At other times, the bowels yjeld, and the patient is obstinately costive. This is cured by aloetic pills, or manna, with the tartarite of potash. When the muscular system yields, producing a feeling of languor and general weakness, the use of the cold bath, with a grain of opium at bed-time, will be of most service. It is evident, that it is only by attending minutely to the history of former miscarriages, that we can detect these causes ; and we shall generally find, that in each individual case, it is the same organ in every pregnancy which has yield- ed or suffered. Previous to future conception, we may with propriety, endeavour to render it less easily affected. General weakness is another condition giving rise to abor- tion ; and upon this I have already made some remarks. I have here only to add, that the use of the cold bath, the exhi- bition of the Peruvian bark, and wearing flannel next the skin, constitute the most successful practice. Syphilis is likewise a cause of abortion. When it occurs in the mother, it often unfits the uterus for going on with its actions. At other times, more especially when the father labours under venereal hectic, or has not been completely cured, the child is evidently affected, and often dies before 244 the process of gestation can be completed. In these cases, a course of mercury alone can effect a cure. But we are not to suppose that every child, born without the cuticle in an early stage of pregnancy, has suffered from this cause; on the contrary, as some of these instances depend on causes al- ready mentioned, and which cannot be cured by mercury. I wish to caution the student against too hastily concluding that one of the parents has been diseased, because the child is born dead or putrid at an early period. It is not always easy to form a correct judgment; but we may be assisted by finding that the other causes which I have mentioned are ab- sent ; that we have appearances of ulceration on the child, and that there are some suspicious circumstances in the for- mer history and present health of the parents. A child may be born dead, and even putrid, not only in consequence of syphilis, but also of some malformation of the foetus itself, or of its appendages; or of a general imperfection of the ovum, usually combined with an increased quantity of liquor amnii; or of original debility of constitution, unfitting the child for coming to maturity; or of fatal derangement of structure, or action taking place in utero, from causes not very obvious; or from weakness or imperfect action of the uterus itself, or such a condition of it as sometimes produces epilepsy; or it is in certain cases occasioned by a convulsion. Most of these causes are not under our control; and indeed, with the ex- ception of the case of syphilis, we can only propose to pre- vent the death of the child, by the use of such general means as invigorate the constitution of the parent, or as ob- viate palpable predisposing causes of injury to the uterine functions. Advancement in life, before marriage, is another cause of frequent abortion, the uterus being then somewhat imperfect in its action. In general, we cannot do much in this case, except avoiding carefully the exciting causes of abortion; and by attending minutely to the condition of other organs, dur- ing menstruation or pregnancy, we may, from the principles formerly laid down, do some good. It is satisfactory to know, that although we may fail once 245 or twice, yet, by great care, the uterus conies at last to act more perfectly, and the woman bears children at the full time. After these observations, it is only necessary to add, that in every instance of habitual abortion, whatever the condition may be which gives rise to it, we find it is essential that the greatest attention be paid to the avoiding of the more evident and immediate exciting causes of miscarriage, such as fatigue, dancing, &c. In some cases, it may even be necessary to confine the patient to her room, until the period at which she usually aborts is past. When abortion is threatened, we come to consider whe- ther, and by what means it can be stopped. I have already stated my opinion, that when the action of gestation ceaseof it cannot be renewed, and that general contraction of the ute- rine fibres is a criterion of this cessation. Still, as some of the means which may be supposed useful in preventing a threatened abortion, are also useful in mode- rating the symptoms attending its progress, we may very properly have recourse to them. Some causes giving rise to abortion, do not immediately produce it, but give warning of their operation, producing uneasiness in the vicinity of the uterus, before the action of that organ be materially affected. The detraction of a little blood at this time, if the pulse be in any measure full or frequent, or, if the patient be not of a habit forbidding evacuations, and the subsequent exhibition of an anodyne clyster, or a full dose of opium,* together with a state of absolute rest in a recumbent posture for some days, will often be sufficient to prevent farther mischief, and constitute the most efficacious practice. The patient should be strictly confined to bed, sleeping with few bed-clothes, and without a fire in her apartments. Indeed, the very first thing to be done on entering the room, is to order the patient to bed. The diet should, in general, be low, consisting of dry toast, biscuit and fruit; and much fluid, especially warm fluid, should be avoided. * Opiates are of signal benefit in this situation, and should seldom be omit- ted after venesection. 246 This is the time at which we can interfere with the most certain prospect of success; and the greatest attention should be paid to the state of the rest of the system; removing un- easiness, wherever it is present, and preventing any organ from continuing in a state of undue action. It is difficult to persuade the patient to comply with that strict attention which is necessary at this period : but being persuaded that if this period be allowed to pass over with neglect, and con- traction begins, nothing can afterwards prevent abortion, I wish particularly to impress the mind of the student with a due sense of its import^ce; and I must add, that as after every appearance of morbid uterine action is over, the slight- est cause will renew our alarm, it is necessary great atten- tion be paid for some time to the patient. Often, instead of an uneasy feeling about the loins, or lower belly, we have before the action of gestation stops, a discharge of blood, generally in a moderate, sometimes in a trifling degree. This is more especially the case when abor- tion is threatened, owing to an external cause; and, if im- mediately checked, we may prevent contraction from begin- ning. Even in those cases where we do not expect to ward off expulsion, it is useful to prevent, as far as we can, the loss of blood ; for as I cannot see that the hemorrhage is neces- sary for its accomplishment, although it always attends it, I conclude that our attempts to prevent bleeding can never do harm; if they succeed in checking abortion, we gain our object; if they fail, they do not increase, but diminish the danger. It should be carefully remembered, that the more we can save blood, the more do we serve our patient. As the means for checking the discharge will be immediately pointed out, it is unnecessary here to enter into any detail. Sometimes the vessels about the cervix and os uteri yield, post coitum, a little blood; and this may occur either in those who have the uterus in a high state of activity, or more frequently where it is feeble in its functions. The same dis- charge may sometimes appear in rather greater quantity af- 247 ter impregnation, passing perhaps for the menses, and mak- ing the woman uncertain as to her situation; but it is gene- rally, though not always, irregular in its appearance, and seldom returns above once or twice. In some instances, however, it becomes greater and more frequent in proportion as the vessels increase in size. It is now apt to pass for menorrhagia. If it be allowed to continue, it tends to injure the action of the uterus, and produces expulsion, which some- times is the first thing which shows the woman her situation. The discharge is best managed by rest, and the frequent in- jection of saturated solution of the sulphate of aliunine, or decoction of oak bark. When a slight discharge takes place, in consequence of a slip of the foot, or some other external cause, we may also derive advantage from the use of the injection; but if the dis- charge be considerable, it will often fail. It is better, in such a case, to trust to the formation of a coagulum. When in a plethoric habit abortion is threatened, from a flight, or mental agitation, we have often palpitation, rapi- dity of the pulse, head-ache, flushed face, and pain about the back or pubis; blood-letting relieves immediately the un- easiness in the head, and often the pain in the back; after- wards, the patient is to be kept cool and quiet, and an anodyne administered. In those cases, where regular uterine pain precedes or ac- companies the discharge, expulsion cannot be prevented; but when the discharge precedes the pain, it sometimes may ; nay, if the child be still alive, it frequently may. Rest is ab- solutely necessary, if we wish the person to go to the full time : and it is occasionally necessary to confine her to bed for several weeks, prescribe the prudent and occasional use of digitalis*, and give an anodyne at bed-time, taking care * I have in a preceding note, advised some caution in the use of digitalis in uterine floodings. I would here, also, recommend the same degree of circumspection. When given in sufficient quantity to make any very sen- sible impression on the system generally, it seems, in a very peculiar man- ner, to relax and debilitate the vessels of the uterus, disposing them, there- by, to passive hemorrhage. When, however, it is administered with proper restrictions, 1 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, f . 24S also to keep the bowels in a proper state by gentle medicine. Blood ought also, unless the pulse and habit of the patient forbid it, to be detracted. Styptic injections into the vagina, two or three times a-day are of great benefit. This is a very critical situation : much depends on the vi- gour and promptitude of our practice ; and much, very much, upon the prudence of the patient. It is teazing to find, that sometimes, after all our care and exertions, one rash act de- stroys in a single day the effect of the whole. When we cannot prevent abortion, the next thing is to conduct the patient safely through the process, by lessening the effects of separation or detachment of the ovum, and ac- celerating the contraction. The first point which naturally claims our attention is the hemorrhage. Many practitioners, upon a general principle, bleed, in order to check this, and prevent miscarriage; but miscarriage cannot be prevented, if the uterine contraction have universally commenced ; and the discharge cannot be prudently moderated by venesection, un- less there be undue or strong action in the vessels, or much blood in the system ; and if so, a vein may be opened with advantage. This is not always the case, and therefore, unless the vessels be at or above the natural force or strength of ac- tion, the lancet is not at this stage necessary. The fulness and strength of the pulse are lost much sooner in abortion than can be explained, by the mere loss of blood. This de- pends on an affection of the stomach, which has much influ- ence on the pulse; and the proper time for bleeding is before this has taken place. When abortion has made so much pro- gress before we are called, as to have rendered the pulse small and feeble; or when this is the case from the first, bleed- ing evidently can do no good. Instead of this, we may rather use the digitalis, but in ordinary cases, where the contrac- tion is brisk, and the process quick, it is not at this stage ab- solutely necessary; and I shall afterwards mention that, when the stomachic affection is urgent, and the pulse much affected by it, the use of this medicine is improper. When, however, the case is tedious, and the discharge long con- tinued, at the same time that the sickness is not considera- ble, the digitalis will be of essential service, and it may be 249 tery 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, whicli is a different operation from that which is expected from them. The application of cloths dipped in cold water to the back and external parts will have a much better effect than inter- nal astringents, and ought always to be had recourse to. If the digitalis have been exhibited, it assists that medicine in moderating the circulation. Even when trusted to alone, it lessens the action of the sanguiferous system, particularly of the uterine vessels. The introduction of a small piece of smooth ice into the vagina has been recommended, and has often a very speedy effect in retarding the hemorrhage, whilst it never, if properly managed, does any harm. A small snow- ball, wrapped in a bit of linen, will have the same effect; but neither of these must be continued so long as to produce pain, or much and prolonged shivering. The heat of the surface is also to be moderated, by having few bed-clothes, and a free circulation of cool air. But the most effectual local method of stopping the he- morrhage is by plugging the vagina. This is best done by taking a pretty large piece of soft cloth, and dipping it in oil, and then wringing it gently. It is to he introduced with the finger, portion after portion, until the lower part of the va- gina be well filled. The remainder is then to be pressed firmly on the orifice. This acts by giving the effused blood time to coagulate. It gives no pain; it produces no irrita- tion ; and those who condemn it, surely must either not have tried it, or have misapplied it. If we believe that abortion requires for its completion a continued flow of blood, we ought not, in those cases where the process must go on, to have re- course to cold, or other means of restraining hemorrhage. If we do not believe this, then surely the most effectual method of moderating it is the best. Plugging can never re- tard the process, nor prevent the expulsion of the ovum; for VOL. T. K K :>jO when the uterus contracts, it sends it down into the clotted blood in the upper part of the vagina, and the flooding ceases. Faintness operates also in many cases, by allowing co- agula to form, inconsequence of the blood flowing more slow- ly ; and when the faintness goes off, the coagula still restrain the hemorrhage in the same way as when the plug has been used. This naturally points out the advantage of using the plug, together with the digitalis, as we thus produce coagula- tion at the mouths of the vessels, and also diminish the vas- cular action. It will likewise show the impropriety of using injections at this time; for, by washing out the coagula, we do more harm than can be compensated by any astringent tffect produced on the vessels. The principal means, then, which we employ for restrain- ing the hemorrhage, are bleeding, if the pulse be full and sharp; if not, we trust to the digitalis, combined with sulphu- ric acid, except in those cases already specified, as forbid- ding its use : to stuffing the vagina: to the application of cold to the external parts, keeping the heat of the body in general at a low temperature; and enforcing a state of absolute rest, which must be continued during the whole process, however long it may, in some cases, be. The drink should be cold, and the food, if the patient desire any, light, and taken in small portions. Opiates have been advised, in order to abate the discharge, and are, by many, used in every case of abortion, and in every stage. But as we cannot finish the process without muscular contraction, and as they tend to suspend that, I do not see that their constant exhibition can be defended on ra- tional principles. If given in small quantity, they do no good in the present point of view; if in larger doses, they only postpone the evil, for they cannot check abortion after contraction has begun. But I will not argue against the use of opiates from their abuse. They are very useful in cases of threatened abortion, more especially in accidental separation of the membranes and consequent discharge. They do not directly preserve the action of gestation, but they prevent the 251 tendency to muscular contraction, and thus do good. In weakly or emaciated habits, opiates alone, if given upon the first appearance of mischief, are often sufficient to prevent abortion; and, in opposite conditions, when preceded by ve- nesection, they are of great service. Opiates are likewise useful for allaying those sympathetic pains about the bowels, and many of the nervous affections which precede or accom- pany abortion. They 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 merely to separate vessels, and excite hemorr- hagia. By suspending for a time its action, it returns after- w ards 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 opposed this practice, and it is now very properly given up as a general rule. I do not wish, however, to be understood as altogether forbidding manual assistance ; but I am much inclined to consider it a useful precept, not to be hasty in at- tempting to extract the ovum. If the discharge be protract- ed, and the membranes entire, we may, if the situation of the patient require it, sometimes accelerate expulsion, by evacuat- ing the liquor amnii. But if the pregnancy be not advanced beyond the fourth month, it will be better to trust to smart clysters, and restrain the hemorrhage by means of the plug. We thus have a greater likelihood of getting all the ovum off at once, and may excite the action by gently dilating the os uteri, and moving the finger round it. If the membranes have given way, and the foetus be still retained, we may, by insinuating a finger within the uterus cautiously, hook it out; or, in many cases, it will be found partly expelled through the os uteri, and may easily be helped away. But the most tedious and troublesome case generally is that in which the foetus has been expelled, but the sccundines are still retained. Now, we never can consider the patient as secure from he- 232 tnorrbage until these be thrown off, and therefore she must be carefully watched, especially when gestation is consider- bly advanced. In a great majority of instances, the uterus, within a few hours, contracts and expels them. But in some cases, the hemorrhage does become profuse, and there is little disposition to separate them. By stuffing the vagina, we shall often find that the discharge is safely stopped, and the womb excited to act in a short time. But if we be disap- pointed, or the symptoms urgent, the finger must be intro- troduced within the uterus,* and the remains of the ovum slowly detached by very gentle motion; and we must be very careful not to endeavour to pull away the secundines until they be fully loosened, for we thus leave part behind, which sometimes gives a great deal of trouble ; and farther, if we rashly endeavour to extract, we irritate the uterus, and are apt to excite inflammation, or a train of hysterical, and some- times fatal symptoms. It is these two circumstances which make me cautious in advising manual assistance; and, for- tunately, the proportion of cases requiring it is not great in abortion at an early period. When part of the ovum is left, or the whole of the secun- dines are retained, then we have another danger besides he- morrhage ; for, within a few days, putrefaction comes on, and much 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 during the whole time, the woman is languid, hysterical, and subject to irregularities of the menstrua, very often to obstruction. But more frequently the symptoms are very acute, we have loss of appetite, prostration of strength, tumid or tender belly, frequent, small, and sharp pulse, hot and parched state of the skin of the hands and feet, nocturnal sweats, and various hysterical symptoms. The discharge from the vagina is abominably foetid, and hemorrhage soinc- * In some instances, the half of the secundines will be found in the vagina, and the other half still in the uterus. In this case, all that is necessary is gently to bring them out. 253 times occurs to a violent degree. The treatment of this will hereafter he pointed out. From these observations we may see, upon the one hand, the impropriety of allowing the secundines to remain too long in the uterus; and, on the other, the danger of making rash or unnecessary attempts to extract, by which we irritate the uterus, and tear the placenta, which is almost always pro- ductive of troublesome consequences. I now return to the consideration of the usual progress of abortion. The stomach very soon suffers, and becomes debilitated, producing a gene- ral languor and feebleness, with a disposition to faint, which seems in abortion, to depend more upon this cause than directly upon loss of blood. Indeed, the hemorrhage pro- duces both slighter and less permanent effects in abortion than at the full time, although less blood may have been lost in the latter, than in the former case, for the vessels are smaller and the discharge is not so sudden. There is still another cause for this; namely, that the action of the uterus is less in the early than in the late months. Now, we know that the effect of hemorrhage from any organ is, cceteris paribus, in proportion to its degree of action. Hence the discharge is less dangerous than at the full time, and still less in menorr- hagia than in abortion. The effect of abortion on the stomach seems to be in pro- portion to the period at wiiich it takes place, being greater when it occurs before the fourth month than after it. The effect, though distressing, and often productive of alarm, is nevertheless beneficial, lessening the action of the vessels in the same way with digitalis, the use of which is improper when this condition is present. The strength of the pulse is much abated; sometimes it becomes slower; but in general it remains much as formerly in point of frequency; we are therefore not to be too anxious in removing this condition, which restrains hemorrhage ; yet as it may go beyond due bounds, and produce dangerous syncope, we must check it in time. We must likewise be very attentive to the state of the discharge when this affection is considerable, for if, notwith- standing this, the hemorrhage should continue, it will pro- 254 duce greater and more immediately hurtful effects than if this were absent. The best method of abating this sinking and feebleness, is to keep the body perfectly at rest, and the head low. If neces- sary, we give small quantities of stomachic cordials, such as a little tincture of cinnamon, or a few drops of ether in a glass of aerated water; or we may give a little peppermint water, with fifteen drops of tincture of opium. In urgent cases, Madeira wine or undiluted brandy may be given; but these are not to be frequently repeated, and are very rarely necessary. Large doses of opium are also useful. Sometimes, instead of a feeling of sinking and faintness, the fibres of the stomach are thrown into a spasmodic con- traction, producing sudden and violent pain. This is a most alarming symptom, and may kill the patient very unexpect- edly. It is to be instantly attacked by a mixture of sulphuric ether and tincture of opium, in a full dose, whilst a sinapism is applied to the epigastric region ; but if, when this pain oc- curs, therebe symptoms of approaching convulsions, then bleed- ing should precede the anodyne, and no ether should be given. Spasms about the intestines are more frequent, and much less dangerous. They are very readily relieved by thirty drops of tincture of opium, in a desert-spoonful of aromatic tincture, or forty drops of the tincture of hyoscyamus in two tea-spoonfuls of the compound tincture of lavender. These disagreeable symptoms wiiich I have described, for- tunately do not often attend abortion; but the process goes on safely, and without disturbance. In this case, after it is over, we only find it necessary to confine the person to bed for a few days, as getting up too soon is apt to produce debili- tating discharge. We must also, by proper treatment, re- move any morbid symptoms which maybe present, but which, depending on the peculiarities of individuals, or their pre- vious state of health, cannot here be specified. When the patient continues weakly, the use of the cold bath, and some- times of the bark, will be of much service in restoring the strength; and, in future pregnancies, great care must be ta- ken that abortion may not happen again at the same period. 255 § 36. UTERINE HEMORRHAGE. Of all the incidents to which a pregnant woman is ex- posed, none is more alarming or troublesome than uterine hemorrhage, when it occurs in the advanced stages of gesta- tion, or after the delivery of the child. This, from its ex- tent and impetuosity, has aptly been called a flooding; and from the frequency of its occurrence, it must be extremely in- teresting to every practitioner. The ovum is connected to the uterus by means of a vast multitude of delicate vessels, which pass almost at every point from the one to the other. These vessels are large where the placenta is attached ; smaller where they pass into the de- cidua. As the ovum corresponds exactly to the inner surface of the uterus, and is in close and intimate contact with it, we find, that as long as this union subsists, the vessels, notwith- standing their delicacy, are enabled to transmit blood with- out effusion. But whenever a separation of the one from the other takes place, then these vessels are either directly torn ; or, even supposing them to extend a little, they must be ruptured by their own action, or by the force of the blood which they receive and circulate. When this happens, an extravasation or discharge must be the consequence, which will be greater or smaller in proportion to the number and magnitude of the vessels which have given way, and the strength of the action, which exists in the sanguiferous system. The membranes are never so full of water as to be put upon the stretch, and therefore they cannot forcibly distend the womb, and make pressure on its inner surface. The womb again, during gestation, does not embrace the mem- branes tightly, so as to compress them. Hence it is evident, that when rupture first takes place, no resistance can, by the action of the one upon the other, be afforded to the flow of the blood. The consequence of uterine hemorrhage, when considerable, is, that the force of the circulation is diminished; faintness, or absolute syncope being induced. 256 The blood in this state flows more feebly; coagulation is allowed to take place, and the paroxysm is for the present ended. This coagulation, in slight cases, may take place even without the intervention of faintness. Re-union, how- ever, when the separation is extensive, and the coagulum considerable, cannot be expected to take place ; and there- fore, when the clot loosens, a return of the hemorrhage is in general to be looked for. One or more copious discharges of blood must injure the functions of the uterus, and ultimately destroy altogether the action of gestation. This tends to excite the muscular action of the uterine fibres; and by their contraction two effects will be produced. The uterine vessels will be diminished in their diameter or capacity, and the whole surface of the womb pressing more strongly upon the ovum, a greater re- sistance will be given to the flow of the blood. Thus it appears, that nature attempts to save the patient in two ways. First, by the induction of a state of faintness, or sometimes of complete syncope, which tends to check the present attack. Secondly, when the hemorrhage is so great or obstinate as to prevent any possibility of the woman going safely to the full time, such effects are produced as tend to establish muscular contraction, and accelerate expulsion. This double process ought, in all our reasonings, to be held in view. Uterine contraction is of two kinds, w hich may be called permanent and temporary. The permanent is that continued action of the individual fibres by which the uterus is rendered tense, so that it feels hard if the hand be introduced into its cavity. The temporary is that greater contraction which is excited at intervals for the expulsion of the foetus, prqducing what are called the pains of labour. In those cases where nature effects a cure by expulsion, or the production of labour* it is chiefly to the permanent or to- nic contraction that we are indebted for the stoppage of he- morrhage ; because this contraction lessens the size of the vessels, and keeps up a firm pressure of the uterine surface upon the ovum, until the pains have accomplished the expul- 257 sion or delivery of the child. The pains alone could not do this good; for coming only at intervals, their effect would be fugacious. On the other hand, the permanent contrac- tion would not be adequate to the purpose, without the pains, for these temporary paroxysms excite this action to a stronger degree, and, by ultimately forcing down the child, accomplish delivery before the powers of the uterus be worn out. Such are the steps by which the patient is naturally saved. But we arc not to expect that these, shall, in every instance, or in a majority of instances, take place at the proper time, or in the due degree. The debility and syncope may go too far; or the clots may not form in proper time, or may come away too soon, or too easily. The action of gestation may continue, notwithstanding the violence of the hemorrhage, thus preventing the accession of muscular contraction ; or be- fore this contraction be established and the child expelled, the discharge may have been so great and constant as to ren- der the efforts of the womb weak and inefficient, and by still continuing, may destroy them altogether. These circumstances being considered, it will be evident, that although when the injury is small, and the discharge trifling, nature may permanently check it; or, in more seri- ous cases, may preserve the woman by the expulsion of the child; yet we cannot, with prudence, place our whole reli- ance on her unassisted operations. There is also another circumstance relating to a particu- lar species of flooding, which renders the accomplishment of a natural cure or escape still more doubtful. This is, that the placenta is sometimes attached to the os uteri, which ne- cessarily must produce a hemorrhage whenever the cervix comes to be fully developed, and the mouth to open. The vessels going to the placenta are much larger than those which enter the decidua; and therefore, if part of the placenta be detached, the quantity and velocity of the dis- charge must be greater, and the effects more to be dreaded, than when a part of the decidua alone is separated. If the placenta be fixed near the cervix uteri, and a part of it be de- VOL. t. J< *' 258 tached, then the blood which is effused w ill separate the mem- branes down to the os uteri, and a profuse hemorrhage will appear. But sometimes, if it be fixed to the fundus uteri, the blood may be confined, especially if the separation have been trifling, and a coagulum will be formed exterior to the mem- branes, the lower part of which will still adhere to the ute- rus ; or if the central portion of the placenta have been de- tached, a collection of blood may be formed behind it, but may not extend beyond its circular margin. But if the pla- centa 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 ute- rine contraction does come on, it will be weak, and incapa- •pfe 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, i n very many, the patient, if we trust to this contraction alone, will perish. Contrac- tion can only be expected in this case to do good, when it is powerful, and the pains come on so briskly as speedily to empty the uterus, at the same time that coagula shut the mouths of the placental vessels at the unsupported part. It has been a common opinion, that flooding proceeded always from the detachment of a part of the placenta; but this point is not established.* In several cases of uterine he- morrhage, the placenta will be found attached to the fundus uteri; and we cannot suppose that in all of these, the whole extent of the membranes, from the placenta to the os uteri, lias been separated: yet this must happen before the dis- charge can in these circumstances appear. We can often ac- * Long ago, Andrea Pasta questioned the opinion, that flooding was always produced by separation of the placenta. Vide Discorso del flusso di sangue, &c. We are not, however, to suppose, that hemorrhage does not proceed from detachment of the placenta in any instance when it is placed high up, but only that it is a rare occurrence. When the stream is rapid and profuse, we have every reason to suppose that part of the placenta is se- parated; 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. 259 count for the hemorrhage, by supposing a portion of the de- cidua to be detached; and we know that the vessels about the cervix are sufficiently able to throw out a considerable quantity of blood, if their mouths be open. But in most cases of profuse hemorrhage, we shall find, that the placenta is at- tached near the os uteri, and more or less of it separated. It is possible for blood to be effused in consequence of de- tachment of part of the ovum, and yet it may not be discharged by the os uteri.* This detachment may be produced by fatigue, falls, blows, &c. and the effusion is accompanied with dull internal pain at the spot where it takes place. This pain is something like colic, or like pain attending the approach of the menses. The part of the womb where the extravasa- tion takes place, swells gradually, and the uterus in a short time feels larger. If the quantity be considerable, the size in- creases, the uterus is firmer and tenser, as well as larger, the strength diminishes, and even faintings may come on. In course of time, weak slow pains are felt, but if the injury be great, these decline as the weakness increases. They may or may not be attended with the discharge of coagula from the os uteri. In such a case, it is evident, that nothing but de- livery can save the mother. But if no bad effect is produced, and the separation is not extensive, the accident may not be discerned or suspected, at least till after the child is born, when often a great quantity of blood is evacuated without af- fecting the pulse or strength, which it would do, did it come recently from the vessels of the uterus. Let us next consider the causes giving rise to hemorrhage in various degrees; and the first I shall mention is external violence, producing a separation of part of the ovum. As the ovum and uterus correspond exactly to each other, and are, in the advanced stages of gestation, composed of pretty pliable materials, falls or blows do not produce laceration so frequently as might be supposed. In a majority of instances, the effect is produced chiefly by the operation on the vessels, their action being violently and suddenly excited, and rupture * Vide Albinus Acad. Annot. lib. I. p. 58. Recueil Periodique, torn. ii. p. 15, and torn. iii. p. I. 260 of their coats thus produced. When the ovum is mechanical- ly detached, the injury must have been considerable, and in general the foetus is destroyed. Fatigue, or much exertion may injure the action of the uterus, and give rise to premature expulsion, which in this case is generally attended with considerable discharge. Such exertions are likewise apt, by their effect on the circulation, to operate on the vessels passing to the ovum, and produce in them a greater degree of activity than they are capable of sustaining without rupture. It is, therefore, very properly laid down as a rule of practice, to forbid pregnant women to Undergo much fatigue, or exert any great muscular action : and wherever this rule has been departed from, especially by a patient of an irritable or of a plethoric habit, it behoves the practitioner to attend carefully to the first appearance of in- jury, or to the first symptoms of decay in the uterine action. Rest, and an opiate will upon general principles be indicated, and when the circulation is affected, or we apprehend in- creased action about the uterine vessels, venesection must be premised, and the patient kept cool and tranquil. Violent straining at stool, or strong exertions of the abdo- minal muscles, made in lifting heavy bodies, or in stretch- ing to a height, or frequent and continued stooping, may all, by compressing the womb, cause separation. For the greatest effect will be produced where the resistance is least, or the support smallest, which is at the under part of the uterus, and there rupture will be apt to take place. A preternatural degree of action in the vessels going to the placenta or decidua, must be dangerous, and likely to pro- duce rupture and extravasation. This may either be connect- ed with a general state of the vascular system, marked by plethora, or by arterial irritation; or it may be more imme- diately dependent on the state of the uterus itself. When the woman is plethoric, or when the action of the vascular system is increased, it is natural to suppose, that the effect will be greatest on those parts of the womb which are in the highest state of activity. These are chiefly two; the part to which the placenta is attached, for there the vessels 261 are large and numerous; and the cervix and os uteri, because there the greatest changes are going forward. At one or other of these two places, rupture is most likely to take place, and it will happen still more readily if the placenta be attach- ed at or near to the cervix. It may be excited either by too much blood circulating permanently in the system, or by a temporary increase of the strength and velocity of the circu- lation produced by passion, agitation, stimulants, &r. A ple- thoric state is a frequent cause of hemorrhage in the young, the vigorous, and the active ; the decidua is separated, and a considerable quantity of blood flows; perhaps the placenta is detached, and the hemorrhage is more alarming. In some cases the rupture is preceded by spitting of blood, or bleed- ing at the nose, and in these cases the lancet may be of much service. We sometimes find that extravasation is produced by an in- creased action of the uterine vessels themselves existing as a local disease. In this case, the patient fur some time before the attack, feels a weight and uneasy sensation about the hy- pogastric region, with slight darting pains about the belly or back. These precursors have generally been ascribed to a different cause; namely, rigidity of the ligaments of the womb or of the fibres of the uterus itself. Spasmodic action about the os uteri, must produce a sepa- ration of the connecting vessels. The causes giving rise to this in the advanced period of gestation, are not always ob- vious, neither can we readily determine the precise cases in which this action excites flooding. We should expect that the discharge ought always to be preceded by pain, but wc know that motion may take place in some instances about the os uteri without much sensation; and, on the other hand, many cases of flooding, not dependent on motion of the ute- rine fibres, are attended with uneasiness or irregular pain about the abdomen. This spasmodic action is not unfrequent- ly produced by hanging pregnant animals. Whatever stops prematurely the action of gestation, may give rise to a greater or less degree of hemorrhage. For in this case, the developement of the cervix takes place quickly, 262 and the ovum must be separated. The quantity of the dis- charge* will depend upon the state of the circulation—the magnitude of the vessels which are torn—the contraction of the uterus—and the care which is taken of the patient Hence it follows as a rule in every premature labour, more especially in its first stage, that we prevent all exertion, re- frain from the use of stimulants, and confine the patent to a recumbent posture. It sometimes happens, that effective contraction does not take place speedily after the action of gestation ceases, but a discharge appears. This may stop by the induction of syn- cope, or the formation of clots. The blood which is retained about the cervix and os uteri putrefying, produces a very of- fensive smell. Milk is secreted as if delivery had taken place, and sometimes fever is excited. In this state the patient may remain for some days, when the hemorrhage is renewed, and the patient may be lost if we do not interfere. Some undue state of action about the os uteri, removing, or ceasing to form that jelly which naturally ought to be se- creted there, is another cause. This is generally productive of a discharge of watery fluid, tinged with blood; and if the patient be not careful, pure blood may be thrown out in considerable quantity. It may even happen, that the hemorrhage, under certain circum- stances, may prove fatal; and yet, upon dissection, no separa- tion of the ovum be discovered, the discharge taking place from the vessels about the os uteri itself.f In some instances, where a portion of the placenta has been detached, I have observed, that near the separated part, the structure of the placenta was morbid, being hard and gristly. In these cases, I could not detect any other cause of separa- * In those cases where the contraction becomes universal and effective, we have Uttle discharge, and the patient is merely said to have a premature labour; but if the contraction be partial, and do not soon become effective, then we have considerable discharge, and the patient is said to have a flooding. f Vide a case in point, by M. Heinigke, in the first volume of Brewer's Biblioth. Germ. 263 tion, and suppose that by the accidental pressure of the child upon the indurated part, the uterus may have been irritated. The insertion of the placenta over the os uteri,* may give rise to flooding in different ways. The uterus and placenta may remain in contact until the term of natural labour, the one adapting itself to'the other; but whenever the os uteri begins to dilate, separation and con- sequent hemorrhage must take place. It is rare, however, for the accident to be postponed so long. In general, at an earlier period, in the eighth or by the middle of the ninth month, wre find that either the uterus and placenta no longer grow equally, in consequence of which, the fibres about the os uteri are irritated to act; or so much blood as must neces- sarily, in this situation, circulate about the cervix uteri, in* terferes with its regular actions, and induces premature con- traction of its fibres, with a consequent separation of the connecting vessels. In order to ascertain whether the hemorrhage proceed from this cause, we ought in every case to which we are called, carefully to examine our patient. The introduction of the finger is sometimes sufficient for this purpose, but frequently it may be necessary to carry the whole hand into the vagina. If the placenta present, we shall feel the lower part of the uterus thicker than usual, and the child cannot be so dis- tinctly perceived to rest upon it. This is ascertained by pressing with the finger on the fore part of the cervix, be- twixt the os uteri and bladder, and also a little to either side.f • So far as I have observed, uterine hemorrhage, when profuse, is pro- duced most frequently by this cause; at least two-thirds of those cases re- quiring delivery, proceed, I think, from the presentation of the placenta; and in the majority of the remaining tliird, it will be found attached near to the cervix. Most of those hemorrhages, which are cured without delivery, proceed from the detachment of the decidua alone, or of a very small portion of the placenta, which has been separated under circumstances favourable for firm coagulation. f When a large coagulum occupies the lower part of the uterus, we may be deceived if we trust to external feeling alone, without introducing the 264 If the os uteri be a little open, then by insinuating the fin- ger, and carrying it through the small clots, we may readily ascertain whether the placenta or membranes present, by at- tending to the difference which exists betwixt them. But in this examination, we must recollect, that only a small portion of the edge of the placenta may present and this may not readily be felt at first. To conclude this part of the subject, I remark in general, that hemorrhage from the uterus is not merely arterial, but also veinous, and the orifices of these latter vessels are ex- tremely large. Almost immediately after conception, the veins enlarge and dilate, contributing greatly to give to the uterus the doughy feel wiiich it possesses. In the end«of gesta- tion the sinuses are of immense size, and their extremities so large that in many places they will admit the point of the finger. Now, as all the veins communicate more freely than the arteries, and as they have in the uterus no valves, we can easily conceive the rapidity with which discharge will take place, and the necessity of encouraging coagulation, which checks veinous still more readily than arterial hemorr- hage. In whatever way flooding is produced, it has a tendency to injure or disturb gestation, and to excite expulsion ; but these effects may be very slowly accomplished, and in a great many instances may not take place in time to save the patient or her child. Having already noticed those changes produced on the womb itself by hemorrhage, and the danger of trusting to them for the recovery of the patient, I will not recapitu- late, but proceed very shortly to mention the effects produced on the system at large. During the contin ance of the hemorrhage, or by the re- petition of the paroxysms, if this be allowed to take place, certain alterations highly important are taking place. There is much less blood circulating than formerly; and this blood, when the hemorrhage has been frequently renewed, is lesj finger within the os uteri. If the uterus have its usual feel, and the child be felt distinctly throught it, then we are sure that, however near the pla- centa may be to the os uteri, it is not fixed exactly over it. 265 stimulating in its properties, and less capable of affording energy to the brain and nerves. The consequence of this is, that all the actions of the system must be performed more languidly, and with less strength. The body is much more irritable than formerly, and slight impressions produce greater effects. This gives rise to many hysterical, and sometimes even to convulsive affections. The stomach can- not so readily digest the food—the intestines become more sluggish—the heart beats more feebly—the arteries act with little force—the muscular fibres contract weakly—the whole system descends in the scale of action, and must, if the ex- pression be allowable, move in an inferior sphere. In this state, very slight additional injury will sink the system ir- reparably—very trifling causes will unhinge its actions, and render them irregular. If the debility be carried to a de- gree farther, no care can recruit the system—no means can renew the vigour of the uterus. We may stop the hemorr- hage, but recov ery will not take place. We may deliver the child, but the womb will not contract. If when the system is debilitated by hemorrhage, some irritation be conjoined, then the vascular action becomes more or less irregular, and an approximation is made to a state of fever. The pulse is feeble, but sharp ; the skin rather warm; and the tongue more or less parched. This state is dangerous, both as it exhausts still more a system already very feeble, and also as it tends to renew the hemorrhage. It will often be found to depend upon slight uterine irritation, upon accumulation in the bowels, upon pulmonic affections, upon muscular pain, or upon the injudicious application of stimuli. Such organs as have been previously disposed to disease, or have been directly or indirectly injured during the con- tinuance of protracted flooding, may come to excite irrita- tion, and give considerable trouble. An acute attack of hemorrhage generally leaves the pa- tient in a state of simple weakness; but if the discharge be allowed to be frequently conjoined, and the case thus pro- tracted, some irritation often comes to be produced, which VOI/. i. mm 266 adds to the danger, and excites, if the patient be not delivered, more speedy returns. A woman seldom suffers much in a first attack of hemorr- hage. If she be stout and plethoric, she may lose a great quantity of blood and yet to appearance not be greatly in- jured. The hemorrhage may come on in every different situation; in bed she may awake suddenly from a dream, and feel herself swimming in blood; or it may attack her when walking; or may be preceded by a desire to make water, and she is surprised to find the chamber-pot half filled with blood. She recovers from her consternation ; perhaps in spite of every injunction, she walks about as usual, and , finds no bad effect from motion; the feeling of heaviness w%ich may have preceded the accident is gone, she is lighter and better than she was before it, and hopes all is well; but in a few days the hemorrhage is repeated, and again stops; at last, after one or two attacks, for the time is uncertain, the os uteri becomes soft, and opens a little, perhaps without pain, or she feels dull slight pains, which, however, give her very little uneasiness. This state may take place early, and without dangerous debility ; it may take place in the second or thii'd attack; or possibly the hemorrhage may never have entirely ceased, continuing for a day or two like a flow of the menses, and then being suddenly increased, or flowing in a torrent. But although this state may take place with- out alarming debility, it may also, and that very suddenly, be attended with the utmost danger, or may be accompanied with so much hemorrhage as to prove absolutely fatal. The patient is found without a drop of blood in her face, the ex- tremities cold, the pulse almost gone, the stomach unable to retain drink. She is in the last stage of weakness, but it is not the weakness produced by fever or disease, for we find her voice good and generally the intellect clear. The he- morrhage has stopped, and a young man would suppose it still possible for her to recover. But although not a drop of blood is afterwards lost, the debility increases, the pulse is quite gone, she breathes with difficulty, and gives long sighs, wavers in her speech, and in a short time expires. 267 We may lay it down as a general observation, that few cases of profuse hemorrhage, occurring in an advanced stage of gestation, can be cured without delivery or the expulsion of the child. For when the discharge is copious or obstinate, the placenta is generally separated, sometimes to a very con- siderable extent, and a re-union, without wiiich the woman can never be secure against another attack, can rarely be ex- pected. If the placenta present, the hemorrhage, although suspended, will yet to a certainty return, and few shall sur- vive if the child be not delivered. But in those cases where only a portion of the decidua, or a little bit of the margin of the placenta* has been detached, and the communicating vessels opened, cither by a state of over-action in the vascular system, or by too much blood in the vessels, or by some mechanical exertion, if proper care be taken, the hemorrhage may he completely and permanently checked; or if it should return, it may be kept so much un- der, or may consist so much of the watery discharge from the glands about the os uteri, as neither to interfere with gesta- tion, nor injure the constitution ; yet it is to be recollected, that even these cases of flooding may sometimes proceed to a dangerous degree, requiring very active and decided means to be used ; and in no case can the patient be considered as safe, unless the utmost care and attention be paid to her con- duct. It would thus appear, that some hemorrhagies almost in- evitably end either in the delivery of the child, or the death of the parent; whilst others may be checked or moderated without an operation. A precise diagnostic line, liable to no exceptions, cannot be drawn betwixt these cases ; and there- fore, whilst we believe that rapid and profuse hemorrhagies, which indicate the rupture of large vessels, can seldom be permanently checked, we still, provided the placenta do not present, are not altogether without hopes of that termination, * In this case, after labour is over, we may discover the separated por- tion by the difference of colour; it is generally browner and softer tlianthe rest. "% 268 which is more desirable for the mother, and safer for the child, than premature delivery. In slighter cases, our hope is joined with some degree of confidence. A second attack, especially if it follow soon after the first, and from a slight cause, or without any apparent cause, greatly diminishes the chance of carrying the woman to a happy conclusion without manual interference. In forming our opinion respecting the immediate danger of the patient, we must consider her habit of body, and the previous state of her constitution. We must attend to the state of the pulse, connecting that in our mind with the quan- tity and rapidity of the discharge. A feeble pulse, with a hemorrhage, moderate in regard to quantity and velocity, will, if the patient have been previously in good health, gene- rally be found to depend on some cause, the continuance of which is only temporary. But when the weakness of the pulse proceeds from profuse or repeated hemorrhage, then although it may sometimes be rendered still more feeble by oppression, or feeling of sinking at the stomach; yet, when this is relieved, it does not become firm. It is easily com- pressed, and easily affected by motion; or, sometimes, even by raising the head. If the paroxysm is to prove fatal, the debility increases— the pulse flutters—the whole body becomes cold and clam- my—the breathing is performed with a sigh—and syncope closes the scene. If irritation be conjoined with hemorrhage, then the pulse is sharper, and, although death he near, it is felt more dis- tinctly than when irritation is absent. The termination in this case is often more sudden than a person, unacquainted with the effect of pain and irritation on the pulse, would suppose. For when the pulsation is dis- tinct, and even apparently somewhat firm, a slight increase of the discharge, or sometimes an exertion without discharge, speedily stops it, the heat departs, and the patient never gets the better of the attack. We must likewise remember, that a discharge, which takes place gradually, can be better sustained than a smaller quan- 269 tity, which flows more rapidly. For the vessels in the former case come to be accustomed to the change, and are able more easily to accommodate themselves to the decreased quantity. But when blood is lost rapidly, then very speedy and univer- sal contraction is required in the vascular system, in order that it may adjust itself to its contents, and this is always a debilitating process. The difference too betwixt the former and the present condition of the body, is rapidly produced, and has the same bad effect as if we 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 number of fainting fits may be great, but unless the patient be much exhausted, we generally find that the pulse returns, and the strength recruits. The prognosis here must depend greatly on the quantity and velocity of the discharge ; for it may happen, that the first attack of hemorrhage may-produce a syncope, from which the patient is never to recover. When we are called to a patient recently attacked with flooding, our most obvious duty is immediately to restrain the violence of the discharge; after which we can take such mea- sures as the nature of the case may demand, either for pre- serving gestation, or for hastening the expulsion of the child. A state of absolute rest, in a horizontal posture, is to be en- forced with great perseverance, as the first rule of practice. By rest alone, without any other assistance, some hemorr- hages may be cured; but, without it, no woman can be safe. Even after the immediate alarm of the attack is over, the woman must still recollect her danger. She should be con- fined to bed, upon a firm mattress for several days, and ought not to leave her apartment for a much longer period. In general, the patient has gone to bed before we are call- ed ; and, perhaps, by the time that we arrive, the bleeding has in a great measure ceased. The partial unloading of the "vessels, produced by the rupture, the induction of a state 270 approaching to syncope in consequence of the discharge, the fear of the patient, and a horizontal posture, may all have conspired to stop the hemorrhage. The immediate alarm from the flooding having subsided, the patient often expresses herself as more apprehensive of a premature labour, than of the hemorrhage, which she con- siders as over. If the attack have been accompanied with slight abdominal pain, her fears are confirmed. But we are not to enter into these views of the case; we are to consider the discharge as the prominent symptom, as the chief source of danger. We are to look upon the present abatement as an uncertain calm; and whatever advice we may give, whatever remedies we may employ, we are not to leave our patient un- til we have strongly enforced on her attendants the danger of negligence, and the necessity of giving early intimation should the hemorrhage be renewed. There is no disease to which the practitioner can be called, in which he has greater responsibility than in uterine hemorrhage. The most prompt and decided means must be used ; the most patient attention must be bestowed ; and, whenever he undertakes the man- agement of a case of this kind, whatever be the situation of the patient, he must watch her with constancy, and forget all consideration of gain and of trouble. His own reputa- tion, his peace of mind, the life of his patient, and that of her child, are all at stake. I am doing the student the most essential service, when I earnestly press upon his attention these considerations. And when I intreat, implore him to weigh well the proper practice to be pursued, the necessary care to be bestowed, I am pleading for the existence of his patient, and for his own honour and happiness. Procrasti- nation, irresolution, or timidity, have hurried innumerable victims to the grave; whilst the rash precipitation of unfeel- ing men has only been less fatal, because negligence is more common than activity. I shall endeavour to point out the proper treatment in the commencement of uterine hemorrhage, and the best method of terminating the case when the patient cannot be conduct- ed ^ith safety to the full time. After the patient is laid in 271 bed, it is next to be considered how the hemorrhage is to be directly restrained, and whether we may be able to prevent a return. It is at all times proper to ascertain exactly the situation of the patient by examination, as we thus learn the state of the cervix and os uteri, and whether there be any tendency to labour; whether the discharge be stopped by a coagulum in the mouths of the vessels,* or by a large clot in the upper part of the vagina; whether the placenta be attached to the os uteri, or whether the membranes pre- sent. We likewise endeavour to ascertain the quantity of blood which has been lost—the rapidity with which it flowed—. the effect which it has produced upon the mother or child— and the cause which appeared to excite the hemorrhage. The first remedy which, upon a general principle, offers itself to our attention, is blood-letting. In those cases, where the attack has been produced by over-action of the vessels, or a plethoric condition; or where it seems to be kept up by these causes, this remedy employed early, and followed by other means, may be effectual not only in checking the pre- sent paroxysm, but also in preventing a return. By the time- ly and decided use of the lancet much distress may be avoid- ed, and both the mother and the child may be saved from danger. But we are not to apply the remedy for one state to every condition; we must have regard to the cause, and con- sider how far the hemorrhage is kept up by plenitude or mor- bid activity of the vessels. In those cases where the attack is not excited by, or connected with plethora, or undue action in the vascular system, venesection is not indicated. We have in these cases, which are, I believe, by far the most numerous, other means of safely, and powerfully moderating vascular action, without the detraction of blood, which in this disease it ought to be a leading principle to save as much as possible. Whatever lessens materially or suddenly the quan- * We may conjecture that this is the case, if we find no clot in the vagina, plugging the os uteri. We are not warranted to thrust the finger forcibly within the os uteri, in this examination; or to rub away the small coagula which may be formed within it, and which may be restraining the hemorr- hage- 272 tity of blood, must directly enfeeble, and call for a new sup- ply, otherwise the system suffers for a long time. We shall find, that except under those particular circum- stances which I have specified, and where we have ground to believe, that the rupture of vessels has been dependent on their plenitude or over-action, the circulation may be speedily moderated by other means, and especially by the application of cold. This is to be made not only by applying cloths dipped in cold water to the back and vulva, but also by spong- ing over the legs, arms, and even the trunk, with any cold fluid; covering the patient only very lightly with clothes, and promoting a free circulation of cold air, until the effect upon the vessels be produced. After this we shall find no advantage, but rather harm from the further application of cold. All that is now necessary, is strictly and constantly to watch against the application of heat, that is, raising the temperature above the natural standard. The extent to which this cooling pain is to be carried, must 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 paroxysm, has gone so far as to reduce the heat much below the natural standard, the vigorous application of cold might sink the sys- tem too much. In some urgent cases it may even be neces- sary to depart from our general rule, and apply warm cloths to the hands, feet, and stomach. This is the case where the discharge has been excessive, and been suffered to continue profuse or for a long time, and where we are afraid that the system is sinking fast, and the powers of life giving way. There are cases in which some nicety is required in deter- mining this point, and in these circumstances we must never leave our patient, but must watch the effects of our practice. This is a general rule in all hemorrhagies, whatever their case may have been, or from whatever vessels the blood may come. A cold skin and a feeble pulse never can require the positive and vigorous application of cold; but, on the other hand, they do not indicate the application of heat, unless they be increasing, and the strength declining. Then we cau- 273 tiously use heat to preserve what remains, not rashly and speedily to increase action beyond the present state of power. 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 water, or vinegar and water; but these are not always effec- tual, and sometimes, from the state of the patient, are uot 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 be resorted to. The advantage is so great and speedy, that I am surprised that it ever should be neglected. I grant that some women may, from delicacy or other motives, be averse from it; but every consideration must yield to that of safe- ty : and it should be impressed deeply on the mind of the pa- tient, as well as of the practitioner, that blood is most pre- cious, and not a drop should be spilled which can be preserved. Unless the flooding shall in the first attack be permanently checked, which, when the separated vessels arc large or nu- merous, is rarely accomplished, we may expect one or more returns before expulsion can be accomplished. The more blood, then, that we allow to be lost at first, the less able shall the patient be to support the course of the disease, and the • The insertion of a small piece of ice in the first fold of the napkin, is at- tended with great advantage, and has often a. very powerful effect. Dr. Hoffman employed the introduction of lint, dipped in solution of vitriol, but this was rather as an astringent than a plug, and he does not propose it as a general practice. He considers, that he was obliged to have recourse ad anceps et extremum auxilium.—Vide Opera Omnia, T. iv. Leroux em- ployed the plug more freely.—Vide Observations sur les Pertes, 1776. VOL. I. N N 271 more unfavourable shall delivery, when it comes to be per formed, prove to her and to the child. It is of consequence to shorten the paroxysm as much as possible ; and, therefore, when circumstances will permit, we should make it a rule to have from the first a careful nurse, who may be instructed in our absence to use the napkin without delay, should the he- morrhage return. But whilst I so highly commend, and so strongly urge the use of the plug, I do not wish to recommend it to the neglect of other means, or in every situation. In the early attacks of hemorrhage, when the os uteri is firm, and manual inter- ference is improper, I know of no method more safe or more effectual for restraining the hemorrhage and preserving the patient. But when the hemorrhage has been profuse, or fre- quently repeated, and the circumstances of the patient de- mand more active practice, and point out the necessity of de- livery, then the use of the plug cannot be proper. If trusted to, it may be attended with fatal and deceitful effects. We can indeed restrain the hemorrhage from appearing outward- ly ; but there have been instances, and these instances ought to be constantly remembered, where the blood has collected within the uterus, which, having lost all power, has become relaxed, and been slowly enlarged with coagula; the strength has decreased—the bowels become inflated—the belly swelled beyond its size in the ninth month, although the patient may not have been near that period; and in these circumstances, whilst an inattentive practitioner has perhaps concluded that all was well with regard to the hemorrhage, the patient has expired, or only lived long enough to permit the child to be extracted. All practical writers warn us against internal flooding; nay, so far do some carry their apprehension, that they advise us to raise the head of the child, and observe whether blood or liquor amnii be discharged*; an advice, however, to which 1 cannot subscribe, because in those cases where the membranes have given way, or been opened, the head cannot be thus moveable, nor these trials made, unless » Vide Dr. Johnson's System of Midwifery, p. 157, and Dr. Leake's.Diseases of Women, vol. ii. p. 280. 27^ we have waited until a dangerous relaxation has taken place in the uterine fibres ; and if, on the other hand, we have de- livery in contemplation, it is our object to confine the liquor amnii as much as possible, until we turn the child. Besides using these means, it will also, especially in a first attack, and where we have it not in contemplation to deliver the woman, be proper to exhibit an opiate,((f) in order to allay irritation; and this is often attended with a very hap- py effect. Such are the most effectual methods of speedily or imme- diately stopping the violence of the hemorrhage. The next points for consideration are, whether we can expect to carry the patient safely to the full time, and by what means we are to prevent a renewal of the discharge. It may, I believe, be laid down as a general rule, that when a considerable portion of the decidua has in the seventh month, or later, been separated, the hemorrhage, although it may be checked, is apt to return. When a part of the pla- centa has been detached, and more especially if that organ be fixed over the os uteri, gestation cannot continue long; for either such injury is done to the uterus as produces ex- pulsion and a natural cure, or the woman bleeds to death, or we must deliver, in order to prevent that dreadful termi- nation. If the discharge be in small quantity, and have not flowed with much rapidity—if it stop soon or easily—if no large clots are formed in the vagina—if the under part of the uterus has its usual feel, showing that the placenta is not attached there, and that no large coagula are retained within the os uteri— if the child be still alive—if there be no indication of the ac- cession of labour—and if the slight discharge which is still coming away be chiefly watery, we may in these circum- stances conclude that the vessels which have given way are (, Uneasiness about the bladder or rectum, or even in more distant parts, should be immediately checked ; for, in many cases, hemorrhage is renewed by these irritations. In those cases, or where the patient is troubled with cough or affected with palpitation, or an hysterical state, much advantage may be derived from the exhibition of opiates. In many instances where an attack of flooding is brought on by some irritation affecting the lower part of the uterus in particular, or the sys- tem in general, or where the bowels arc pained, and the pulse ing to the urgency of tlie symptoms. It shoidd be combined with a portion of opium. Professor Barton, who has called the attention of American practitioners to this powerful article of the materia medica, in restraining internal hemorr- hage, recommends the combining with it a portion of ipecacuanha. For his opinion on this subject, we must refer the student to the Professor's edition of Cullen's Materia Medica, vol. ii. p. 20, 21, and 334. Other practitioners, among whom is Dr. Chapman, in these cases place considerable confidence in a combination of opium and ipecacuanha, in the proportion of two grains of the former to half a grain of tlie latter, to be repeated every two hours. From my own experience, I should be induced to decide in favour of tlie acetate of lead, when combined as above directed. Dr. Kuhn informs me that the late Dr. Glentworth of this city, placed the greatest reliance on yarrow-tea, or a strong decoction of yarrow (Achillea Millefolium L.) in uterine hemorrhage, and said that he never was disap- pointed in his expectations of a cure after the proper use of this article of the materia medica. Instances of its good effects in hemorrhages arc mentioned by several of the German physicians, particularly by Stahl and Hoffman. 281 not full nor Strong, rest, cool air, and an adequate dose of tincture of opium will terminate the paroxysm, and perhaps prevent a return. This is especially the case, if only a part of the decidua have been separated, and the discharge have not been profuse. When the vascular system is full, vene- section is necessary before the anodyne be administered, and the digitalis may either succeed the opiate, or be omitted, ac- cording to the state of the pulse and of the stomach. But although anodynes be in many instances, and especial- ly in first attacks, of great benefit, yet they are not to be in- discriminately employed nor exhibited when the circum- stances of the patient require delivery, unless the strength be much impaired; and then, a full dose is to be given as a cor- dial, previous to delivery. It may happen that we have not been called early in a first attack, and that some urgent symptom has appeared. The most frequent of these, is a feeling of faintness or com- plete syncope. This feeling often arises rather from an af- fection of the stomach than from absolute loss of blood; and in this case it is less alarming than when it follows copious hemorrhage. In either case, however, we must not be too hasty in exhibiting cordials. When the faintishness depends chiefly upon sickness at the stomach, or feeling of failure, circumstances which may accompany even a small discharge, it will he sufficient to give a few drops of hartshorn in cold water and sprinkle the face with cold water. When it is more dependent on absolute loss of blood, we may find it ne- cessary to give small quantities of wine warmed with aro- matics; but our cordials even in this case must not be given with a liberal hand, nor too frequently repeated.* It is .scarcely necessary for me to add, that we are also to take * As syncope and loss of blood have both the effect of relaxing the muscular fibre, as is well known to surgeons, it may be supposed that they should in- crease the flooding by diminishing tlie contraction of the uterus, if that have already taken place. But the contrary is the case, for by allowing coagula to form, syncope restrains hemorrhage, and therefore ought not to be too rapidly removed. vol. i. » o 283 immediate steps by the use of the plug, &c. for restraining the discharge. This 1 may observe once for all.(/) Complete syncope is extremely alarming to the byc-stand- ers; and, if there have been a great loss of blood, it is indeed a most dangerous symptom. It must at all times be relieved, for although faintness be a natural mean of checking hemorr- hage, yet absolute and prolonged syncope is hazardous. But we are not to exhibit large doses of cordials for its re- moval. We must keep the patient at perfect rest, in a hori- zontal posture, with the head low, open the windows, sprinkle the face smartly with cold vinegar, apply volatile salts to the nostrils, and give some hartshorn, or a spoonful of warm wine internally. Universal coldness is also a symptom which must not be allowed to go beyond a certain degree, and this degree must be greatly determined by the strength of the patient, and the quantity and rapidity of the discharge. When the strength is not previously much reduced, a moderate degree of cold- ness, is, if the hemorrhage threaten to continue, of service; but when there has been a great loss of blood, then universal cold- ness, with pale lips, sunk eyes, and approaching deliquium, may too often be considered as a forerunner of death. When we judge it necessary to interfere, we should apply warm cloths to the hands and feet, a bladder half filled with tepid water to the stomach, and give some hot wine and water in- wardly. Vomiting is another symptom whicli sometimes appears. It proceeds very generally from the attendants having given more nourishment or fluid than the stomach can bear, or from a gush of blood taking place soon after the patient has (/) In restraining uterine hemorrhage, we should not forget that injec- tions thrown up the vagina, and if possible into the uterus, may have a con- siderable effect in repressing the discharge. In this way I have known solu- tions of the acetate of lead, of the sulphate of alumine, and a strong decoction or infusion of galls, produce salutary eflects. 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. 283 had a drink. It in this case is commonly preceded by sick- ness and oppression, which are most distressing, and threaten syncope, until relief is obtained by vomiting. Sometimes it is rather connected with an hysterical state, or with uterine irritation. If frequently repeated, it is a debilitating opera- tion, and by displacing clots may renew hemorrhage; but sometimes it seems fortunately to excite the contraction of the uterus, and gives it a disposition to empty itself. For abating vomiting, we may apply a cloth dipped in laudanum, and camphorated spirits of wine, to the whole epigastric re- gion ; or give two grains of solid opium, or even more, if the weakness be great. Sometimes a little infusion of capsicum is of service. It should just be gently pungent. In flooding it is of importance to pay much attention to the state of the stomach, and prevent it from being loaded; on the other hand, we must not let it remain too empty, nor allow its action to sink. Small quantities of pleasant nourishment should be given frequently. We thus prevent it from los- ing its tone, without oppressing it, or filling the system too fast. Hysterical affections often accompany protracted floodings, such as globus, pain in the head, feeling of suffocation, pal- pitation,* retching, in which nothing but wind is got up, &c. These are best relieved by some foetid or carminative sub- stance conjoined with opium. The retching sometimes re- quires an anodyne clyster, or the application of a camphorat- ed piaster,! 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 * The quantity of blood lost is sometimes so great as to do irreparable in- jury to the heart, and ever after to impede its action. One well marked in- stance of this is related by Van Swieten, in his commentary on Aph. 1304, where, for twelve years the woman after a severe flooding, could not sit up in bed without violent palpitation -and anxiety. ■f This may be made by melting a little adhesive plaster, and then adding to it a large proportion of camphor, previously made into a thick hniment by rubbing it with olive oil. 284 speak of the method of delivering the patient when that is necessary. I have separated the detail of the medical treat- ment of a paroxysm from the consideration of the manual assistance, which may be required; because, however inti- mately connected the different parts of our plan may be in actual practice, it is useful in a work of this kind, in order to avoid confusion, that I lay them down apart. As some peculiarities of practice arise from the implanta- tion of the placenta, over the os uteri, I shall confine may present remarks to those cases in which the membranes arc found at the mouth of the womb, desiring it to be remem- bered, however, that this circumstance does not necessarily indicate that the hemorrhage does not proceed from separa- tion of the placenta, which may be fixed very near the cervix, although it cannot be felt. The operation of delivering the child is not difficult to de- scribe or to perform. The hand, previously lubricated, is to be slow ly and gently introduced completely into the vagina. The finger is to be introduced into the os uteri, and cautious- ly moved so as to dilate it; or if it has already dilated a little more, two fingers may be inserted, and very slow and gentle attempts made at short intervals to distend it; and the prac- titioner will do well to remember, that he will succeed best when he rather acts so as to stimulate the uterus, and make it dilate its mouth, than directly to distend it. On the part of the operator, is demanded much tenderness, caution, firmness, and composure; on the part of the patient is to be desired patience and resolution. The operator is to keep in mind, that painful dilation is dangerous, it irritates and in- flames the parts, and that the woman should complain rather of the uterine pains which are excited, than of the fingers of the practitioner. More or less time will be required fully to dilate the os uteri, according to the state in which the uterus was when the operation was begun. If the os uteri is soft and pliable, and has already by slight pains been in part dis- tended, a quarter of an hour, or perhaps only a few minutes will often be sufficient for this purpose; but if it has scarce- ly been affected before by pains, and is pretty firm, though 285 not unyielding, then half an hour may 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 womb is contracting. The delivery must be hut slow until the breech is passing, then we must be careful that the cord be not too long compressed before the rest of the child be born. The child being re- moved, and the belly properly supported, and gently pressed on by an assistant, the hand should again be cautiously in- troduced into the womb, and the two knuckles placed on the surface of the placenta, so as to press it a little, and excite the uterus to separate it. The hand may also be gently moved in a little time, and the motion repeated at intervals, so as to excite the uterus to expel its contents; but upon no account are we to separate the placenta and extract it. This must be done by the uterus; for we have no other sign that the contraction will be sufficient to save the woman from fu- ture hemorrhage. The whole process, from first to last, must be slow and deliberate, and we are never to lose sight of our object, wiiich is to excite the expulsive power of the uterus. It is not merely to empty the uterus—it is not mere- ly to deliver the child, that we introduce our hand : all this we may do, and leave the woman worse than if we had done nothing: the fibres must contract and press upon the vessels ; and as nothing else can save the patient, it is essential that the practitioner have clear ideas of his object, and be con- vinced on what the security of the patient depends. But to teach the method of delivery, and say nothing of 38b" the circumstances under which it is to be performed, would be a most dangerous error. I have in the beginning of this section, pointed out the effect of hemorrhage, both on the constitution and on the uterus; and I have stated, that the action of gestation is always impaired by a certain loss of blood, and a tendency to expulsion brought on. But before the uterine contraction can be fully excited, or become effec- tive, the woman may perish, or the uterus be so enfeebled as to render expulsion impossible. Whilst then we look upon the one hand to the induction of contraction, we must not on the other delay too long. We must not witness many and repeated attacks of hemorrhage; sinking the strength; bleach- ing the lips and tongue, producing repeated fainting fits, and bringing life itself into immediate danger. Such delay is most inexcusable and dangerous; it may end in the sudden loss of mother and child ; it may enfeeble the uterus, and render it unable afterwards to contract; or it may so ruin the constitu- tion, as to bring the patient, after a long train of sufferings, to the grave. Are we then uniformly to deliver upon the first attack of flooding, and forcibly open the os uteri ? By no means; safety is not to be found either in rashness or procrastina- tion. The treatment wiiich I have pointed out, will always secure the patient until the delivery can be safely accomplished. As long as the os uteri is firm and unyielding—as long as there is no tendency to open, no attempt to establish contraction, it is perfectly safe to trust to the plug, rest, and cold. But I must particularly state to the reader, that the os uteri may dilate without regular pains ; and in almost every instance it does, whether there be or be not pains, become dilatable. Did I not know the danger of establishing positive rules, I would say, that as long as the os uteri is firm, and has no disposi- tion to open, the patient can be in little risk if we understand the use of the plug; we may even plug the os uteri itself, which will excite contraction. But if the patient be neglected, then I grant that long before a tendency to labour or contraction be introduced, she may perish. I am not, however, consider- 28? ing what may happen in the hands of a negligent practi- tioner; for, of this, there would be no end, but what ought to be the result of diligence and care. It is evident, that when the uterus has a disposition to con- tract, and the os uteri to open, delivery must be much safer and easier than when it is still inert, and the os uteri hard. We may with confidence trust to the plug, until these de- sirable effects be produced; and, in some instances, we shall find, that by the plug alone we may secure the patient: the contraction may become brisk, if we have prevented much loss of blood, and expulsion may naturally take place. Who Would in those circumstances, propose to turn the child, and deliver it ? Who would not prefer the operation of nature to that of the accoucheur ? To determine in any individual case whether this shall take place, or whether delivery must be re- sorted to, will require deliberation on the part of the prac- titioner. If he have used the plug early and effectually, and the pains have become brisk, he has good reason to expect natural expulsion; and the labour must be conducted on the general principles of midwifery. But if the uterus have been enfeebled by loss of blood—if the pains are indefinite—if they have done little more than just open the os uteri, and have no disposition to increase, then he is not justified in expecting that expulsion shall be naturally and safely accomplished, and he ought to deliver. When he dilates the os uteri, he excites the uterine action, and feels the membranes become tense. But he must not trust to this, he ir t finish what he has begun. Thus it appears, that by the early and effective use of the plug, by filling the vagina with a soft napkin, or with tow, we may safely and readily restrain the hemorrhage, until such changes have taken place on the os uteri as to render delivery easy; and then we either interfere or trust to na- tural expulsion, according to the briskness and force of the contraction, and state of the patient. By this treatment, we obtain all the advantage that can be derived from the operations of nature, and, where these fail, 288 are enabled to look with confidence to the aid of artificial de- livery. But it may happen that wc have not had an opportunity of restraining the hemorrhage early; we may not have seen the patient until she has suffered much from bleeding.* In this case, we shall generally be obliged to deliver, and must upon no account delay too long; yet, if the os uteri be very firm, and without disposition to open, we shall generally find that the sinking is temporary : we may still trust for some time to the plug. Hemorrhage is naturally restrained by faintness. A repe- tition is checked in the same way; and faintness takes place sooner than formerly. In one or two attacks, the uterus suf- TOS, and the os uteri becomes dilatable. Slight pains come on, or are readily excited by attempts to distend the os uteri. Syncope then will, in general, even when the plug has not been used, and the patient has been neglected, restrain he- morrhage, and prevent it from proving fatal until the os uteri has relaxed; but a little delay beyond that period will destroy the patient; and it is possible, by giving wine, and otherwise treating her injudiciously, to make hemorrhage prove fatal, even before this takes place. But although I have considered it as a general rule, that where the os uteri is firm and un- yielding, we may, notwithstanding present alarm, trust some time to the plug, yet I beg it to be remembered, that there may be exceptions to this rule ; for the constitution may be so delicate, and the hemorrhage so sudden, or so much in- creased by stimulants, as to induce a permanent effect, and make it highly desirable that delivery should be accom- plished : but such instances are rare; and although I have spoken of the effects, of syncope in restraining hemorrhage, I hope it will not be imagined by the student that I wish to make him familar with this symptom. It is very seldom safe, when we have our choice, to wait till syncope be in- * We are not to confine our attention to the quantity which has been lost, but to the effect it has produced; and this will cxteris paribus be great in proportion as tlie hemorrhage has been sudden. 289 duced; and if it have occurred, it is not usually prudent to run the risk of a second attack. The old practitioners, not aware of the value of the plug, nor acquainted with the sound principles of physiology, had no fixed rule relating to delivery, but endeavoured to empty the uterus early; but it was uniformly a remark, that those women died who had the os uteri firm and hard.* What is this hut to declare, that the rash and premature operation is fatal ? It is an axiom which should be deeply engraved on the memory of the accoucheur, and which should constantly influence his conduct. Pain and suffering are the immediate consequence of the practice ; whilst a repetition of the flood- ing after delivery, or the accession of inflammation, are tb.e messengers of death. It was the fatal consequence of this blind practice that sug- gested to M. Puzos the propriety of puncturing the mem- branes, and thus endeavouring to excite labour. His reason- ing was ingenious; his proposal was a material improvement on the practice which then prevailed. The ease of the ope- ration, and its occasional success, recommend it to our no- tice ; but experience has now determined that it cannot be relied on, and that it may be dispensed with. If we use it early, and on the first attack, we do not know when the con- traction may be established; for, even in a healthy uterus, when we use it on account of a deformed pelvis, it is some- times several days before labour be produced. We cannot say what may take place in the interval. The uterus being slacker, the hemorrhage is more apt to return, and we may be obliged after all to have recourse to other means, particu- larly to the plug. Now we know that the plug will, with- out any other operation, safely restrain hemorrhage, until the os uteri be in a proper state for delivery.! The propo- * Vide the works of Mauriceau, Peu, &c. f The ingenious M. Alphonse Le Roy seems much inclined to trust al- most entirely to the plug, and supposes that the blood will act as a foreign body, and excite contraction; but this, as a general doctrine, must be-greatly qualified. Respecting the proposal of M. Puzos, he observes, "Puzos, en conseUlant assea hardiment de perccr les eax, n'avoit d'autres YUes que la 290 sal of M. Puzos then is. I apprehend, inadmissible before this time. If after this, there be occasion to interfere, it is evident that we must desire some interference which can be depended on, both with respect to time and degree. This method can be relied on in neither; for we know not how long it may be of exciting contraction, nor whether it may be able to excite effective contraction after any lapse of lime. If it fail, we render delivery more painful, and consequently more dangerous to the mother, and bring the child into hazard. It has been observed, in objection to this, by Dr. Denman,* that if turning be difficult, the flooding will be stopped by the contraction of the womb. But we know that .tjic uterus, emptied of its water, may embrace the child so clbsely as to render turning, if not difficult, at least painful, and yet not be acting so briskly as to restrain flooding: nothing but brisk contraction can save a patient in flooding, if the vessels be large or numerous. The only case then which remains to be considered, is that in which pains come on, and expulsion is going forward. Now, in this case, the flooding is stopped either by the con- traction or by the plug, and the membranes burst in the natural course of labour; after which it is speedily con- cluded. Here, then, interference is not required; hut 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 ac- tion : and in determining this, the practitioner must be in- fluenced by the previous discharge; for if the uterus have been much reduced by it in its vigour, it will be less under the influence of a stimulus; and if, upon the present diminu- tion of the pains, the flooding is disposed to return, I should contraction de la matrice, qui est la suite de cette operation et la cessation de la perte, et il la conseilla meme dans les cas des pertes qui arrivent avant terme. Mais un grand nombre de femmes sont peries par reflect de cette meme pratique." Lecons sur les pertes de sang, p. 45. » Introduction to the Practice of Midwifery, vol. ii. p. 310. 291 think that we surely ought to trust rather to the hand, which can stimulate in the necessary degree, and finish the process with safety, than to a method which is much more uncertain and less under our command.* The proposal of M. Puzos then will, if this reasoning is just, be very limited in its utility. Its simplicity gave me at first a strong partiality in its favour; and if 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 allow- ed to lose a great deal of blood frequently and suddenly, when the strength is gone, the pulse scarcely to be felt, the extremities cold, the lips and tongue without blood, and the eye ghastly, shall we venture to deliver the woman ? Shall we by plugging, endeavour to prevent farther loss, and by nourishment and care recruit the strength; or empty the uterus, and then endeavour to restore the loss ? We have only a choice of two dangers. The situation of the patient is most perilous, and I have in practice weighed the argu- ment with that attention which the awful circumstances of the case required. I think myself justified in saying, that we give both mother and child the best chance of surviving by a cautious delivery. For in these cases the uterus is al- most torpid, it possesses no tonic contraction ;f the very con- tinuance of the ovum within it is more than it can bear, and on the most favourable supposition, it would require many days before it could be brought into a state capable of con- tracting. The general system is completely exhausted, and * In those cases where the placenta presents, few practitioners would think of trusting to the evacuation of the liquor amnii; they would deliver. If then dehvery be considered as safe and proper in one species of flooding, it cannot be dangerous in the other; and whenever interference in the way of operation is necessary, the security afforded by the introduction of the hand will much more than compensate for any additional pain. But even in this respect, the two operations are little different, if properly performed. \ The use of the plug cannot here certainly prevent the farther loss of blood, for the uterus affords no resistance, the hemorrhage continues, and after death large coagula will be found within the womb. cannot support its condition long. I have never known a woman live twenty-four hours in these circumstances. On the other hand, I grant, that it is possible the woman may die in the act of delivery, or very soon after it; but if she can be supported for two days, we may have hopes of recovery. By a very slow and cautious delivery, and by endeavouring to excite the action of the uterus, so as to pre- vent discharge afterwards, we not only remove the irritation of the distended womb, but we likewise take away a recepta- cle of blood. During the contraction of the uterus, the blood in its sinuses will be thrown into the system, and tend to support it. Part, no doubt, will escape; but by keeping the hand in the uterus, by supporting the abdomen with a com- press, and exciting the uterine action by cold applications to the belly, we may prevent a great loss. When to these considerations we add the additional chance which the child has for life, our practice, I apprehend, will, in this very haz- ardous case, be decided. When the pulse becomes firmer and fuller upon the contraction of the uterus, the risk from debility is diminished. A full dose of laudanum ought to be given previous to delivery. The remarks upon the subsequent management of the pa- tient, I shall reserve until I consider the treatment of flood- ing, after delivery. At one time it was supposed, that the placenta was, in every instance, attached originally to the fundus uteri, and that it could only be found presenting in consequence of having been loosened and falling down. This accident was supposed to retard the birth of the child, by stopping up the passage, and also was considered as dangerous on account of the flood- ing which attended it. On this account Deventer endeavour- ed to accelerate the delivery by tearing the placenta, or rup- turing the membranes when they could be found. This was a dangerous practice, an ing, « 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 carried the plug before it: or when he was called to his patient, he may have found her already in labour, and the process going on so well and so safely, that all interference would have been injudicious. But these instances are not to hdkeonverted into .general rules, nor allowed to furnish any pretext for procrastination. They happen very seldom, and never ought to be related to a young man without an express intimation that he is not to neglect delivery, when it is re- quired, upon any pretence whatsoever. % 37. FALSE PAINS. Many women are subject, in the end of gestation, to pains about the back or bowels, somewhat resembling those of la- bour, but which, in reality, are not connected with it. These, therefore, are called false pains. They sometimes only pre- cede labour a few hours; but in many cases, they come on several days, or even some weeks, before tlie end of pregnan- cy, and may be very frequently repeated, especially during the night, depriving the woman of sleep. They are often con- fined altogether to the belly, shifting their place, and being very irregular both in their attacks and continuance. In some cases they affect the side, particularly the right side, in the region of the liver, and are exceedingly severe, especially in the evening; they are accompanied with acidity or water- brash, or retching, and generally the child is at that time very restless. These pains may doubtless occur in any habit, but they chiefly harass-those who are addicted to the use of cordials. On other occasions, the false pains occupy chiefly 299 the back or hips or upper part of the thighs. They even somfr- times resemble still more nearly parturient pains, in being at- tended with an involuntary effort on the part of the abdominal muscles, to press down, so as to make the woman suppose that she is about to be delivered; and this is occasionally accom- panied with tenesmus, or with protrusion of the bladder from the vagina, very like the membranes of the ovum. In other cases, they are attended with a discharge of watery fluid from the vagina. False pains may be occasioned by many causes: the most frequent arc flatulence ; a spasmodic state of the bowels, resembling slight colic; or irritation, connected with cos- tiveness or diarrhoea; or nephritic affections, often accom- panied with strangury. A sudden motion of the back, or un- usual degree of fatigue, may cause a remitting pain in the back and loins: or getting suddenly out of bed when warm, and placing the feet on the cold floor, may have the same effect. A slight degree of lumbago may also resemble the parturient pains. Agitation of mind, or a febrile state of the body, or some irritation in the neighbourhood of the ute- rus, or some unusual motion of the child, may produce an uneasy sensation in the uterus; and sometimes this is ac- companied by a discharge of watery fluid from the vagina. False pains may often be distinguished by their situation; as for instance, when they affect the bowels or kidneys ; by their shifting their situation; by their duration; by their ir- regularities ; and by the symptoms with which they are at- tended. But the best criterion is, that they seldom affect the os uteri, that part not being dilated during their con- tinuance. It is necessary however to observe, that a dilated state of the os uteri does not always prove that the pains are those of labour; for it may be found prematurely dilated, to a slight degree, before the proper term of labour, without any pain. In this case, if the pains proceed from affections of the bowels, no effect is produced during the pain, in ren- dering the os uteri tense, or making it larger. On the other hand, it sometimes happens, that the fibres about the os uteri are prematurely irritated; and this state may be accompanied with pain, and with a perceptible change in the os uteri 300 during a pain. This is a very ambiguous case; but we may be assisted in our judgment, by discovering, that the term of utero-gestation is not completed, that the os uteri is hard or thick, and the pains irregular. In all such cases, it is best to proceed on the supposition, that the woman is not ac- tually in labour; for by letting her alone, she most likely will have a continuance of pain, terminating, it is true, in labour, but the process will be tedious and fatiguing; whereas, by suspending the action by an opiate, and if necessary by vene- section, the woman may go on for some time longer, and shall at all events lrave an easier delivery. When the false pains are accompanied with a febrile state, or are very distressing during the night, it will be proper to detract blood, and afterwards give an anodyne. In all other cases, it is generally sufficient to keep the woman in a state of rest, open the bowels by means of a clyster, if there be no diarrhoea, and afterwards give an opiate to be succeeded by a laxative. Rubbing with anodyne balsam is also useful. Shivering and tremor occur in some cases, in the end of pregnancy; and as they also occasionally precede labour, they often give rise to an unfounded expectation, that delivery is approaching. They appear to be connected sometimes with the state of the stomach, or alimentary canal; in other instances with some change in the os uteri itself, w hich, even without pain, may be so far opened or relaxed as to allow the finger very easily to touch the child's head through the membranes. It is usually in the evening, or through the night, that the shivering is felt; and it is occasionally pretty severe, and may be several times repeated. Nothing, how- ever, is required, except a little warm gruel, or a moderate dose of laudanum, which is always effectual. NOTES. BOOK I. CHAP. II. NOTE 1, Page 12.—Dr. Deiiman 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 bv the third dehvery. Introd. Vol. I. p. 16. NOTE 2, p. 13.—In one case, where the symphysis was divided, tlie pa- tient was able to walk on'the 15th day.—In Dr. Smollet's case, although in the 8th month of gestation, the bones were found to rise above each other, yet the woman recovered in two months after dehvery. Smellie, Vol. II. coll. 1, n. i. c. 2. NOTE 3, p. 13.—As an illustration of this disease, I shall relate tlie out- fines of a case mentioned by Louis, in the Memoirs of tlie 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 contained of strangury. She was bled, and purged, and kept at rest, by which means, especially by the last, she grew better. But in the two latter months of pregnancy, the symptoms were renewed, so that presently she could neither walk, nor even turn in bed, without great pain; but her greatest suffering was caused by raising the legs to pull on her stockings, as then the bones were more powerfully acted on. A slight degree of hectic fever now appeared. Her dehvery was accomplished easily; but on the evening of the 3rd day, when straining at stool, after having received a clyster, the pain, which had troubled her little since her labour, returned with as much severity as ever. On the 5th day the pulse was very weak and frequent, she sweated profusely, and had a wildness in her Countenance, with symptoms of approaching delirium. In the afternoon the pulse became full and tense, with vertigo and throbbing of the arteries of the head. The pain at the symphysis was excruciating, and although she was fomented and bled seven times, she obtained no reUef. 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 80S worth our consideration. I am disposed to answer it in tlie affirmative, from observing, that wherever tlie patient has recovered in such circumstances, it has uniformly happened, that a discharge of matter has taken place. NOTE 4, p. 14.—Dr. Laurence shewed Dr. Smellie a pelvis, where all the bones were separated to the extent of an inch. NOTE 5, p. 14.—In a case related by De la Malle, the pain did not ap- pear till the 14th day after dehvery, and was felt first in the groin. The pa- tient was unable to move the leg, and had acute fever, which proved fatal. The sacrum was found separated, three lines from the ilium. In the operation of dividing die pubis in a parturient woman, it was found that one side yielded more than tlie other, and consequently that side would suffer most at the sacrum. Baudelocque L'Art, &c. section 2063. NOTE 6, p 14.—Dr. Smellie relates an instance, where, during labour, the woman felt violent pain at the right sacro-iliac symphysis. On the 5th day this pain was extremely severe, and attended with acute fever; but the symptoms were abated by blood-letting, and a clyster, and fomentations, wfach produced a copious perspiration. She was not able to walk for five or six months without crutches, but was restored to the use of the limb, by means of the cold bath. Coll. 1. n. i. c. 1. CHAP. VI NOTE 1, p. 30.—It is not necessary to give examples of every degree of deformity; but it will be useful to select some specimens of the different kinds. The slighter degrees do not require to be particularized. I shall first of all give the dimensions of a dried pelvis, so contracted, as to prevent a child at the full time from passing without assistance. From the pubis to the sacrum, it measures three inches; from the acetabulum to the sacrum, on the right side, two and a half inches; on the left, two inches and seven- eighths ; from the brim above the foramen thyroideum, to the opposite sa- cro-iliac junction, five inches; from the same part of the brim on one side, to the same on the opposite, three inches and a half; transverse diameter, four inches and seven-eighths; from the arch of the pubis to the hollow of the sacrum, five inches ; from one tuberosity of the ischium to the other, four inches and a half; from one spine to another, four inches and a half; the arch of the pubis is natural. The distance from the face of the third lumbar vertebrae, to the spine of the ilium on both sides, is six inches. These di- mensions maybe compared with those of the well-formed pelvis. The sym- physis pubis has the cartilage in the inside, projecting like a spine, which, added to the smallness of the pelvis when recent The linea ilio-pectinea also, on the left side, is for the length of two inches as sharp as a knife; and from these two causes, the cervix uteri and bladder were torn in labour. NOTE 2, p. 30.—In a pelvis of this kind, which I shall describe, the ver- tebrae and sacrum lean much to the left sid.^. The line from the promontory of tlie sacrum to the part of the pubis opposite it, is barely an inch and a half; but an oblique line drawn to the symphysis, which is to the right of the pro- montory, is near two inches. From the promontory to the side of the brim 303 at the 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 tlie 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 a half, and whose short diameter is barely two inches. In a pelvis with a semicircular brim, whose short diameter, at the middle and each side, is one inch and a half, an oval could pass when the soft 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. 31.—In a well-formed pelvis, a line drawn transversely along the brim, and in contact with the sacrum, either touches at its two extremi- ties, the sacro-iliac junctions or tlie 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 op- poside side, is about an inch, or an inch and a half distant from the sacAun. But in a deformed pelvis, this line would either pass through the sacrum, or altogether behind it. NOTE 4, p. 31.—The following are the dimensions of a pelvis of this kind, which I select as a specimen. From the spinous process of the ilium on one side to the other, is eight inches and three-fourths. From the lumbar ver- tebrae 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 ridgc, two inches and a half. From the symphysis pubis to the sacrum, one inch and three-fourths. From the right acetabulum to the sacrum, six-tenths of an inch; from the left, seven-eighths of an inch. From the brim above the foramen thyroideum to tlie same point on the opposite side, seven-eighths of an inch. From the same part of the brim to the oppo- site sacro-iliac junction, three inches and a half on both sides. From the tu- berosity of one ischium to that of the other, two inches and a half. From the tuberosity to the coccyx, three inches. From the spine of one ischium to that of the other, three inches and a half. From the lower part of the sym- physis pubis to the hollow of the sacrum, four inches; distance of the rami of the pubis, five-eighths of an inch. This pelvis has a triangular brim; for it will be observed, that the brim above the foramen thyroideum measures nearly an inch across, and there- fore there is a considerable space betwixt the two ossa pubis, gradually, how- ever, becoming narrower toward the junction of the bones; but little advan- tage in delivery can be gained from this. When we examine it with a view to determine what bulk may be brought through the brim, we find that it is by its shape virtually divided into two cavities, one on the right, and the other on the left side, and the short diameter of the one is six-tenths of an inch, and that of the other seven-eighths of an inch; therefore no art can bring a child at the full time through it. In this pelvis, the sacrum has fallen so forward at the top, that in a stand- 304 ing posture the face of that bone is almost horizontal, and its under part with the coccyx is bent forward like a hook. The vertebrae are much distorted. NOTE 5, p. 31.—This is the case in a pelvis where the distance from the part of the brim above the foramen thyroideum on one side, across to tlie same part on the opposite side, is only five-eighths of an inch. From the right acetabulum to tlie 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 die bones, virtually semicircular, the space betwixt the two ossa pubis being so trifling as not to merit consideration; and the diameter of the brim here is one inch, exclusive of the small slit betwixt the bones. The sacrum in this pelvis is very much curved, and the outlet is small. NOTE 6, p. 33.—Dr. Denman mentions a fatal case of this kind, to which Dr. Hunter was called. The child was delivered by the crotchet, but the patient died on the fourth day. A firm fatty excrescence, springing from one side of the sacrum, was found to have occasioned the difficulty. Vide Introd. Jfol. n. p. 72.—Baudelocque, in the 5th vol. of Recueil Periodique, relates a case, where, in consequence of a scirrhous tumour adhering to the pelvis, the crotchet was necessary. In a subsequent labour, the czsarean operation was performed, and proved fatal to the mother.—Dr. Drew records an instance where tlie tumour adhered to the sacro-sciatic ligament, and was successfully extirpated during labour. It was 14 inches in circumference. Vide Edin. Journal, Vol. I. p. 23. NOTE 7, p. 33.—A fatal case of this kind occurred to Dr. Ford, and is noticed by Dr. Denman. Vol. II. p. 75.—Another fatal instance is recorded by M. Baudelocque, L'Art. section 1964. See also a case by Dr. Merriman, Med. and Chir. Trans. III. 47. This ovarium contained a fluid, and probably might have been opened during labour with advantage. NOTE 8, p. 33.—Several cases of this kind have been met with, and in one related by M. Brand, and noticed by Dr. Sandifort in his Obs. Anat. Path. the woman died undelivered. NOTE 9, p. 33. M. Pelletin details several cases of tumours within the pelvis, some of them fatty or fibrous, and easily turned out, merely by mak- ing an incision over them, through the vagina; one encysted containing puri- form matter; and one about an inch long, of a cartilaginous nature, adher- ing to the descending branch of the pubis, the vagina being divided, it was cut off with scissars. Clinique Chirurgicale, Tom. I. 203, 206, 224, 228, 250. Mr. Park likewise relates several cases, chiefly of tumours containing liquid, or soft contents, and which were pierced from the vagina during labour. U.:d. Chir. Trans. II. 293. chap. vn. NOTE 1, p. 36.—The following are the dimensions of a very large pelvis which I possess. The conjugate diameter is four inches and three fourth ; the lateral, five inches and five-eighths; the diagonal, five inches and a half. 305 From the symphysis pubis to the sacro-iliac junction, five inches. From the top of the arch of the pubis to the sacrum, is five inches and three-eighths. From one tuberosity of the ischium to the other, is five inches and a half-, and the arch is very wide. Depth of the pelvis at the sacrum without the coccyx, five inches. Breadth of the sacrum at the top, four inches and seven- eighths. Depth of the pelvis at the sides, four inches. CHAP. IX. NOTE 1, p. 46.—In birds, we find that the ovaria contain a great number of yolks of different sizes. Those which are nearest the wide canal called the oviduct wliich 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 witii the albumen and the neces- sary membranes and shell. In viviparous fishes, as the skate, ray, &c. tlie same structure obtains. These animals have two ovaria, containing eggs of different sizes; the smaller are white, the larger yellowish, and they pass down to an oviduct, which contains a glandular body that furnishes the cover- ing of the egg. Each ovary has a separate oviduct, wliich forms a vast sac, that terminates in the sides of the cloaca, by orifices that have a duplicature like a valve. The cloaca itself forms an ample reservoir, diat seems more like a continuation of the oviduct than the termination of the rectum. In oviparous fishes, the ovaria are known under the name of roes, and all the visible eggs are of the same size, and so numerous, that some contain above 200,000. They are enveloped in a fine transparent membrane ; and septa from this envelope, divide the internal parts, and furnish points of attach- ment to the ova, which are expelled previous to fecundation. These are called oviparous fishes, and have, properly speaking, no oviduct. The ovaria of frogs resemble those of fishes, and the ova are, previous to expulsion, enveloped in a glary fluid. In the slug we find both testicles and ovaria. The ovarium is a grape-like tissue, containing numerous small grains, or ova, attached by pedicles, which are canals that lead into the oviduct. This is a serpentine canal, that after having adhered to the testicle, opens in the common cavity of generation, in which also the penis or duct from the tes- ticle opens, and during copulation, the two individuals mutually impregnate each other. The ovaria of the adder are like strings of beads. In many quadrupeds, the ovaria contain ova almost as distinct as some of those animals I have just noticed. The hedgehog has an ovarium like a bunch of grapes; and the ovarium of the civet has a knotted surface, and resembles a packet of little spheres : tlie ovarium of the didelphis is also vesicular. The common sow has also an ovarium somewhat resembling, ex- ternally, that of oviparous animals. Most other quadrupeds have an ovarium more smooth and somewhat oblong in shape, and in general the tube and ovarium are unconnected, as in the human female; but in the otter, my brother observed, that both were contained in a kind of capsule formed by VOX. I. SR 306 the peritoneum, so that ventral extra-uterine pregnancy cannot take place in this animal. CHAP. X. NOTE 1. p. 54.—The females amongst the Bosjesmans have the nymphae sometimes five inches long. Their colour is a livid blue, like the excrescence of a turkey. Vide Barrow's Travels in Africa, Vol. I. p. 279. NOTE 2, p. 54.—On the shores of the Persian gulph, among the Christians in Abyssinia, and in Egypt among the Arabs and Copts, girls are circumcised. Niebuhr says, that at Kahira, the women who perform this operation are as well known as midwives. Travels, Vol. II. p. 250.—Dr. Winterbothom, in his account of Sierra Leone, Vol. II. p. 239, says it is practised among the Mandingo, Foola, and Soosoo women. NOTE 3, p. 54.—M Causaubon has inserted a memoir on this subject, in the 1st Vol. of Recueil Periodique, which contains several useful cases. In dn« of these, the tumour was produced in the scventii month by a kick, and terminated fatally by hemorrhage.—In another given by Sedillot, the labia became prodigiously distended during labour, and the head of the child could not be touched. The labia were torn by the attendant. Afterward the child was delivered with the lever.—In cases related by Baudelocque, Brasdor, &c. the tumours were opened, and the vagina plugged whilst the wound was stuffed with lint dipped in solution of alum, to prevent hemorrhage NOTE 4, p 54.—In a case related by Mr. Reeve, the tumour which I sus- pect proceeded from the rupture of the nympha, was perceived first in perineo, but soon occupied all the left labium, wliich was enormously distend- ed. The pain at first was so great as to cause syncope. The parts sloughed, and discharged pus and clotted blood. Bark was given, and she got well. Lond Med. Journ. Vol. IX. p. 119. NOTE 5, p. 54.—Vide case by Dr. Maitland, in Med. Comment. Vol. VI. p. 95.—Dr. Perfect relates a case, where it burst itself before the child was born, and discharged much blood, Vol. H. p. 63.—In another, which ended fatally, the tumour burst after dehvery, and discharged five pounds of blood. Vide Plenk Elementa, p. 111.—Case by M. Sedillot, in Recueil Period. Tom. I. p. 260. NOTE 6, p. 54.—Vide cases by Dr. Macbride in Med. Obs* and Inq. Vol. V. p. 89. NOTE 7, p. 55.—In Mr. Blagden's case, related by Dr. Baillie, the woman soon after dehvery had violent bearing-down pains, as if another child were to be born. A monstrous swelling appeared in the right labium, extending to the perinaeum. A large incision was made, which did not heal till the 21st day. Med. and Physical Journal, Vol. II. p. 42. NOTE 8, p. 55.—Vide Fichet de Flechy, Observ. p. 375. The patient was cured by introducing a compress into the vagina, and dressing the sore with digestive ointment. 807 NOTE 9, p. 55.—Le Dran relates a case, where above 20 ounces of blood were evacuated by incision. Consultations, p. 413. NOTE 10, p. 55.—Mr. Simmons cut off a chtoris, which formed a tumour nine inches in length, and fourteen in circumference at the largest end. The circumference of the stem was five inches. Med. and Pkys. Journal, Vol. V. p. 1. NOTE 11, p. 55.—Schmucker's Miscel. Surg. Essays, art XXIII. NOTE 12, p. 56.—Upon this subject, see Arnaud on Hermaphrodites. In a child aged tiiree years, I found the mons veneris prominent, and, as veil as the labia, covered with a considerable quantity of red hair. The labia were large and Uiick, like those of a grown woman, but shorter. Their in- ner surface was white and rugous, until near the orifice of the vagina, where the skin was red. At the top the labia divaricated, and showed a large chtoris, which hung down hke the penis; it was upwards of an inch long, and about half an inch in diameter, and furnished with a thick wrinkled prepuce. It had a distinct glans, at the end of which was observed something like a per- foration ; but on raising it up, this was seen to be only the extremity of ji deep sulcus, which extended all the way to the urethra, or orifice of the vagina. It resembled the male urethra slit up. The sides of this were formed by tlie nymphae. A little before the orifice of the urethra, there was a longitudinal eminence, like the veru montanum. The vagina was shut up by the hymen. The uterus was large, hke that of a girl of fourteen years of age, and was shaped Uke hers. The ovaria were of corresponding size; one of them lay on the psoas muscle, the other was loose in the pelvis. . The tubes were fimbriated at their extremity, but in their course were knotted and serpentine, hke the commencement of the vas deferens. The uterus was very vascular, and had an inflamed appear- ance. Its mouth was apparently impervious. In a male cliild that I lately saw, the external parts resemble those of the female. The scrotum is cleft hke the vulva, the penis consists only of cor- pora cavernosa, and the urethra opens between the labia formed by the scrotum. NOTE 13, p. 56.—The same effect may be produced, by a continuation of the skin being extended over the parts. It must be cut up. See a case by M. Larrey, in Rapport General de la Society Philomatique, Tom. H. p. 86. NOTE 14, p. 56.—Vide case of a patient of Dr. Chamberlain's, in Cow- per's Anatomy.—Case by Mr. Fryer, in Med. Facts and Obs. Vol. VIII, p. 132. NOTE 15, p. 56.—Case by Mr. Sherwin, in Med. Records, &€. p. 279. NOTE 16, p. 56.—Case by Mr. Kaeymer, in Med, Annals, VoL VI. p. 347. By Mr. Eason, in Med. Comment. Vol. II. p. 187, and a variety of other cases. This, in every instance I have known, has been the greatest complaint NOTE 17, p. 56.—Dr. Smellie candidly acknowledges, that in one instance he took the protrusion of the hymen, for the membranes of the ovum, forced 308 down by labour pains. These pains were accompanied with suppression of urine. He let out about two quarts of blood. Col. I. n. i. c. 6. NOTE 18, p. 56.—In a case related by Benevoli, the belly was very much swelled, and the urine suppressed. He attempted to pass the catheter, but without success. Next day he repeated his endeavour, and pushing with more force than prudence, considering his object, he ruptured the hymen, and immediately a great quantity of dark matter was evacuated, even to the extent of 33 pints.—See also Mr. Fryer's case.—Mr. Warner relates the case of a little girl, where the hymen was continued half way over the orifice of the urethra. The effects were at first attributed to stone in the bladder; but the nature of the case being made out, she was cured by dividing the hymen. Cases, p. 75. NOTE 19, p. 56.—In a case by Mr. Bardy, the patient, who was 15 years of age, had every month, for some days, pain in the uterine region. The external parts were greatly protruded and stretched a9 in labour, and the nymphae formed merely two lines. The anus was thrust backward and dis- tended, and she passed the urine and faeces with great pain ; the hymen from irritation was covered with scab, the health had suffered. Six poimds of thick gelatinous matter were evacuated by incision. Med. and Chir. Re- view for September, 1807. NOTE 20, p. 56.—In Mr. Fynney's case, the part to be divided was very thick; and in Dr M'Cormick's case, the vagina seemed to be in part imper- vious. Med. Comment. Vol n. p. 188.—In general the membrane is thin. NOTE 21, p. 56.—Vide Mr. Niven's case, in Med. Comment. Vol. IX. p. 330. The symptoms gradually abated. NOTE 22, p. 56.—M. Baudelocque mentions an instance where the hymen resisted, for half an hour, the strong action of the uterus. Note to Section 341. NOTE 23, p. 59.—Upon this subject, vide La Motte's Traite; and cases and observations by Noel, Saucerote, Trainel, and Sedillot, in the fourth and seventh Vol. of the Recueil Periodique. Dr. Denman mentions an instance where tlie perinaeum was not torn up, but perforated by the head. NOTE 24, p. 59.—In a case where the vagina would not admit the point of the little finger, the child was delivered after eighteen hours labour. Plenk Elementa, p. 113. See also Van Swieten. NOTE 25, p. 59.—This may produce bad effects, from retention of the menses. M. Magnan relates the case of a girl, aged 22 years, who had been subject to monthly colics and suppression of urine. An incision was made through the membrane, and two pounds of blood let out. Hist, de la Societe de Med. pour. 1776, art. II. NOTE 26, p. 59.—In this case the faeces do not always pass continually. The patient has been known not to have a stool once in a fortnight; which probably depended on the faeces being indurated, and the communication small. "NOTE 27, p. 59.—In the 33d Vol. of the PhiL Trans, p. 142, there is a 309 case related, where there was a land of double vagina, separated by a trans- verse septum or membrane. The orifices were very small. During labour, the pain was so great as to produce convulsions. She was delivered, by laying the two passages into one. Chapman relates a case of malformation, where the woman was impregnated, and in labour all the forcing was felt at the anus. From this an opening was made through into the vagina, and the child was born per anum. Portal mentions a girl, who had only a very small aperture at the vulva, for the evacuation of the urine ; the menses came from the rectum ; nevertheless, she became pregnant. Before dehvery, the orifice of the vagina appeared, and she bore the child the usual way. Precis de Chirurgie, Tom. II. p. 745. NOTE 28, p. 59.—Richter in Comment. Gotting. Tom. in. art. 2. relates a case of a girl aged 20 years, who for three years had been subjects to vio- lent pains about the sacrum, with tremors and syncope every month. The vagina was found to be closed at the upper part, in consequence, it was im- agined, of a variolous ulcer in infancy. Fluctuation was felt in the vagina, when pressure was made with the other hand on the abdomen. The c^ff* traction was opened, and a quantity of blood let out. NOTE 29, p. 60.—In some parts of Africa, the vagina is made imperviousj in order to prevent coition. This operation is generally performed betwixt the age of eleven and twelve years. Brown's Travels, p, 349. NOTE 30, p. 61.—Burton relates a case, where the prolapsed vagina was mistaken for part of tlie placenta, and rudely pulled away, by which the vagina and bladder were torn. System, p. 170. Stollers relates a case, where this was complicated with calculi. These being removed, the parts were reduced, and a cure obtained. Cases, Obs. 2. NOTE 31, p. 61.—Mr. Henry Watson, in the Med. Communications, Vol. I. p. 162, called the attention of practitioners to this disease. In a case he relates, he drew off in the month of June, four gallons of fluid, by tapping the vagina; and immediately after this she passed the urine freely, which she could not do before. She required again to be tapped in two months and died in November The left ovarium was found to be converted into a cyst, about the size of a sow's bladder, but it had not been touched by the trocar. In one case, he punctured with a lancet instead of a trocar, but this was succeeded by troublesome hemorrhage. The good effects of tapping are also seen in a case related by Mr. Coley, in Med. and Phys. Journal, Vol. VII. p. 412. In this two gallons of water were drawn off, and she continued well for five months, after which, dropsical symptoms returned, and although diuretics gave her some relief, yet she was at last cut off. In the case of Mrs. Jarritt, related by Sir W. Bishop, in Med. Commun. VoL II. p. 360, pain was felt in the right side of the belly, after parturition, accompanied with tumefaction. In two years the vagina became prolapsed, the tumour being four inches in diameter. The tumour was punctured twice; the first time 46 pints, the second 51, were drawn off. Diuretics had no effect. In a case related by Dr. Denman, the woman was pregnant, and no operation was per- 310 formed. On the fourth day after her dehvery, after a few loose stools, she expired, Introd. Vol. 1. p. 150. NOTE 33, p. 71.—In a case of this kind, described by Mr. Patton as a spasmodic affection of the neck of the bladder, calomel appeared to cure the complaint. London Med. Journal, Vol. X.p.360. The use of the bougie may be proper. NOTE 34, p. 71.—Morgagni relates an important case, where there was a hard painful tumour in the hypogastric region, accompanied with fluor albus, uterine hemorrhage, and stillicidium of urine. After death, the bladder was found veiy large and scirrhous, with two large bodies in the cervix, prevent- ing the urine from being retained. The uterus was diseased only in con- sequence of its vicinity to the bladder. Epist. XXXIX. art. 31. NOTE 35, p. 72.—Of this disease I have never seen an instance; but Dr. Baillie mentions a case, in which the greater part of tlie bladder was filled with a polypus. Morbid Anat. p. 298. NOTE 36, p. 72.—The patient to whom I allude, had, I understood, four years before her death, been dehvered with the forceps, and soon afterwards had incontinence of urine. I found a large perforation in the bladder, exact- ly resembhng the fauces without an uvula. The uterus was a httle enlarged and indurated; and its mouth, which was ulcerated and fungous, lay in this opening, projecting into the bladder, and closing up the communication be- twixt the bladder and vagina. NOTE 37, p. 73.—In a case related by Sandifort, the suppression of urine was always attended with convulsive cough. Lib. I. cap. 5. And in a case related by Dr. J. Hamilton, where prolapsus took place before parturition, the muscles of the body were spasmodically agitated. Cases, &c. case 9. NOTE 38, p. 74.—Mr. Sharp mentions a case, where they grew in small quantity upon the orifice, producing excruciating torment till they were ex- tirpated. Critical Inq. p. 168. NOTE 39, p. 75.—In the instance related by Mr. Warner, the urine was voided in drops with great pain, especially about the menstrual period, and she sometimes even had convulsions. He dilated the urethra, by inclining t he catheter to one side and thus saw two excrescences near the upper end. He divided or laid open the urethra, and cut off the excrescences successfully with scissors. Cases, p. 309. NOTE 40, p. 75.—In the patient of Mr. Hughes, the disease was taken at first for prolapsus uteri, for there was a substance filling the os externum, and appearing without the vulva. It was a spongy excrescence from the whole circumference of the meatus. It was drawn out with a thread passed through it, and then cut off. Strangury, with pain above the pubis, and fever, took place, on which account the catheter was introduced. Suppres- sion of urine repeatedly occurred; and as it was often difficult to introduce the catheter, the semicupium was employed, and always with advantage j but once after it, she became faint, and the limbs were convulsed. A stricture being suspected at the upper part of the urethra, a bougie was introduced, 311 and kept in the canal, which removed the symptoms. Med. Fact, and Obs, Vol. ni. p. 26. NOTE 41, p. 75.—In Mr. Jenner's case, the irritation of the bladder was great, and the menses were irregular. A fungus was found filling the orifice of the urethra; this was cut off, and the bougie used for an hour every day for a fortnight; a little before the extirpation, a hemorrhage took place from the excrescences. Vide Lond. Med. Journal, Vol. VII. p. 160. NOTE 42, p. 75.—M. Sernin relates a case of a girl eleven years of age, who from her fifth year had been subject to frequent attacks of difficuly in voiding the urine. He had an opportunity of examining her after a violent attack, and found a cylindrical body, 4 inches long, projecting from the vul- va ; and whenever she attempted to make water, this projection swelled up. It was amputated with success. Recueil Period, torn. XVH. p. 304. NOTE 43, p. 75.—In Dr. Chamberlain's patient, who had the hymen im- perforated, the urethra was so dilated as to admit the finger; and Portal found it, in an analogous case, dilated so as to form a cul-de-sac, admitting the point of the thumb. Cours d'Anat. Medicale,' Tom. ni. p. 476. t» NOTE 44, p. 76.—Morgagni mentions a porter's wife, in whom the uterus was found not above an inch long, and without any ovaria. The pudendum was extremely small, and there was scarcely any appearanc of a clitoris. In the Phil. Trans, for 1805, there is a case where the uterus of a woman, 29 years of age, was not larger than in the foetal state, and scarcely any appearance of ovaria. She ceased to grow at ten years of age, had no hair on the pubis, never menstruated, and had an aversion to men. I have seen the uterus of the adult not larger than that of a child; the woman never menstruated, and had very flat breasts. NOTE 45, p. 76—Columbus dissected a woman who always complained of great pain in coitu. The vagina was very short, and had no uterus at its ter- mination. Fromondus relates an instance, where the place of the os externum was occupied with a cartilaginous substance. Morgagni was consulted by a barren woman, whose vagina was only a third part of the usual length, and its termination felt firm and fleshy. He advised dissolution of the marriage. M. Meyer in Schmucker's Essays, mentions a case where the vagina and uterus were wanting, but the ovaria existed. The labia and clitoris were; small, and there were no nymphae. Mr. Ford dissected a cliild who had no vagina, uterus, or ovaria. The urethra and rectum terminated close to each other. Med. Facts, Vol. V. p. 92. NOTE 46, p. 76.—Vide Hist, de I'Acad. de Sciences, 1705, p. 47.—Haller Opusc. path. 60. Acrell's cases.—Purcel in Phil. Trans. LXIV. p. 474.— Canestrini in Med. Facts, Vol. HI. p. 171.—Valisneri met with a double uterus and double vulva. Opera, Tom. m. p. 338.—Dr. Pole describes a double uterus in the 4th Vol. of Mem. of Medical Society, p. 92. NOTE 47, p. 76.—Littre found it almost cloBed, by a continuation of the 312 inner surface of the vagina. Mem. de I'Acad. de Sciences, 1704, p. 27 ; and in the seventh month of pregnancy, closed by a glandular substance, 1705, p. 2.—Morgagni found it shut with a membrane. Epist. XLV1. art. 17.— Boehmer quite shut up. Obs. Anat. fasc. 2, p. 62.—Iluysch saw it so small as scarcely to admit a pin; and Sandifort so well closed, that nothing but air could be forced through it Obs. Anat. Path, lib II. c. ii. p. 67. NOTE to Section 26, p. 80.—A peculiar growth is described by Dr. Clark under the name of cauliflower excrescence, which is probably of the nature of that I speak of, but I never have seen it after death, and therefore cannot be certain. It springs from the os uteri, the base is broad, the surface granulated, the substance brittle, and the fragments broken off white ; pres- sure does not cause much pain, but the patient has more or less pain at times, but not of the lancinating kind. The discharge is at first hke fluor albus, but frequently becomes watery and transparent, but stiffens the linen. When the excrescence is large, the discharge is so great as to wet 10 or 12 napkins daily, and occasion fatal debility. The progress is variable, some- times it is so rapid that in 9 months tlie cavity of the pelvis is filled by it. The only treatment that bids fair to give relief, is the application of a liga- ture, but the peculiarity is, that when the vessels are constricted by this during life, or collapse after death, the solidity of tlie tumour is lost, and it resembles merely a glary substance. Trans, of a Society, &c. Vol. in. p. 321. NOTE 48, p. 81.—Vide Stalpart Vander Wiel, obs. 87.—Segerus in Mis. Cur. 1671, obs. 121. Notwithstanding these cancerous excrescences about the os uteri, a woman may conceive. Dr. Denman relates a case where there was a large excrescence in the gravid state, with profuse bleeding. The head of the cliild was lessened, but the woman died undelivered. Vol. II. p. 65. When the os uteri has been affected with scirrhus, and the woman has conceived, the uterus has sometimes been ruptured, or the woman died un- delivered. Hildanus, cent. I. obs. 67. Horstius Opera, Tom. 11. lib. 2. obs. 5. Blancard Anat. p. 233. Hist, de I'Acad. de Sciences, 1705, p. 52. NOTE 49, p. 82.—Le Dran attended a patient who had all the symptoms of scirrhous uterus, and, by examination, fungous excrescences were found shooting down into the vagina. The pain was continual, and could only be mitigated by the constant use of opium. Urine was discharged by the va- gina, and after death the bladder was found to be perforated. The fundus and body of the uterus were not much diseased. NOTE 50, p. 83.—Absolute abstinence has been recommended by Pou- teau, OZuvres Post. Tom. p. 105. He relates a case, which was cured by confining the patient to eau de glace.—Mr. Pearson, p. 113, gives two suc- cessful cases. In the first, the uterus was enlarged and retroverted, but by very spare diet, was restored to its natural state. NOTE 51, p. 85.—Vide Mem. de I'Acad. de Chirurg. Lieutaud relates a case of a woman who had a tumid belly, and complained of great pain. The womb was not much larger than usual, but it was almost bony. Hist. Anat Med. p. 320.—Grandchamp found an osseous tumour, as large as the fist, 313 inclosed in a sac, betwixt the uterus and bladder. It produced constant ischuria, relieved only by lying on tlie back. Med. and Phys. Journal, Vol. HI. p 587. NOTE 52, p. 90.—Gaubius relates a case, where it was complicated with prolapsus uteri. After a length of time, severe pains came on, and in an hour a large stone was expelled; next day a larger stone presented, but could not be brought away until the os uteri was dilated. From time to time after this, small stones were expelled; but at last she got completely well. NOTE 53, p. 91.—In a case which occurred to the late Mr Hamilton of this place, the polypus was expelled by labour pains, but tlie woman died exhausted.—In a case related by Vater, it was expelled when the woman was at stool. Haller, Disp. Chir. Tom. III. p. 621. See also a case in the same work, p. 611, by Schunkius.—In the patient of Vacoussain, the polypus was expelled after severe pain; its pedicle was felt to pulsate very strongly, but a ligature being applied, the tumour was cut off. Instantly the ligature dis- appeared, being drawn up within the pelvis, but on the third day it dropped off. Mem. de I'Acad. de Chir. Tom. III. p. 533. NOTE 54, p. 91.—Vide case by Vater, in Haller, Disput. Chir. Tom. III. p. 621.—In tiie case furnished by M. Espagnet, an attempt was made to intro- duce the catheter; but a straight one being employed instead of a curved one, or an elastic catheter, it was found necessary previously to make an in- cision in the fore part of the polypus, which had protruded. Mem. de I'Acad. de Chir. Tom. III. p. 531. NOTE 55, p. 94—Dr. Denman, Vol. I. p. 94, mentions a young lady v ho had suffered long from uterine hemorrhage. A polypus was found just to have cleared the os uteri; a ligature was applied, but as she felt severe pain, and vomited, it was slackened. Every attempt to renew the ligature had the same effect. In six weeks she died, and it was found that the uterus was inverted. NOTE 56, p. 94.—M. Herbiniaux, Tom. II. obs. 17, relates a case. The ligature seemed to act on an inverted portion of the womb, producing pain, fever, and convulsions; it was slackened, but afterwards, notwithstanding a renewal of dreadful suffering, it was, with a perseverance hardly to be com- mended, employed so as at least to remove the polypus.—Desault found, after having applied a ligature round a polypus, and cut the tumour off next day, that part of the fundus uteri was attached to the amputated substance; the patient did well. Baudelocque supposes that some cases, related as ex- amples of amputation of inverted uteri, were merely polypi, accompanied with inversion. Recueil Period. Tom. IV. p. 115. NOTE 57, p. 95.—Dr. Denman, Vol. I. p. 95, relates a case of polypus with broad stem, which was supposed to be a cancer of the uterus. The ligature was applied, and iii eight or nine days it came away; but when the polypus was removed, another substance, nearly of the same size, was found to have grown into the vagina. The woman died in a month. I have seen the com- mon polypus combined with an indurated thickening of the uterus, and fun- VOL. I. S S 314 gous or flocculent state of the cavity. In one case of this kind, the uterus and rectum freely communicated by ulceration. See also some cases in Trans, of a Society, &c. Vol. III. NOTE 58, p. 96.—Sometimes the mass appears to be putrid, and is ex- pelled with great hemorrhage. Vide case by Dr. Blackbourn, Lond. Med. Journal, Vol. n. p. 122.—Sometimes it has a kind of osseous covering, as in the case by Hankoph, in Haller, Disp. Mud. IV. p. 715. NOTE 59, p. 97.—In the Hist, of Acad, of Sciences for 1714, is the case of a woman who received a fall in the third month of pregnancy. The belly, however, increased in size till the fifth, when it began to lessen. In the sixth she was dehvered of a bag, as large as the fist, with the placenta and i'cctus of the size of a kidney bean. In this case, hydatids were not formed; but in the History for 1715, is a case, where the woman, falling in the second month, had the ovum converted into hydatids, which were expelled in the tenth month. As hydatids often succeed to genuine pregnancy, the symp- toms may at first be exactly the same with those of pregnancy, nay, even motion may be felt, but afterwards the child may die, and hydatids form.— Mr. Watson, in the Phil Trans. Vol. XLI. p. 711, gives a case, where there was, for a long time before the expulsion of hydatids, a quantity of blood discharged every night; pains at last came on, and expelled many hydatids. In this case, tlie symptoms of pregnancy were evident from Nov. to Feb. When tlie ovum is blighted, the belly ceases to enlarge in the due propor- tion, and the breasts become flaccid. Dr. Denman gives an engraving of a diseased ovum: and Mr. Home relates a case, where the patient, after being attacked with flooding, vomiting, and spasm in the abdomen, died. On opening her, the womb was found filled with hydatids, and its mouth a little dilated. Trans, of a Society, &c. Vol. II. p. 300.—Such cases as I have seen have been attended with a consider- able discharge ; but as a great part of it was watery, it made a greater ap- pearance than the real quantity of blood would have caused. In a case related by Valleriola, p. 91, the woman had at first her usual symp- toms of pregnancy, but in the eighth month expelled hydatids.—Pichart in Zod. Med. Gall. an. 3, p. 73, relates a similar case, but the hydatids were ex- pelled in the fourth month without hemorrhage. Other cases of hydatids arc to be found in Tidpius, lib. HI. c. 32. Shenkius, p. 685. Mercatus de Mulier. affect, lib. III. c. 8. Christ, a Veiga Art. Med. lib. HI. § 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. 16, men- tions a widow who for several years had a tumid belly: after death, hydatids were found in utero. See also Mauriceau's Observations, obs. 367. Ruysch, Obs. Anat. Chir. p. 25. Albinus Anat. Acad. lib. I. p. 69. and tab. HI. fig. 1, describes in an abortion, the commencement of this change. The vesicles are not larger than the heads of pins. Wrisberg describes a more advanced stage in Nov. comment. Gotting. Tom. IV. p. 73; and Sandifort, in lus Obs. 815 Anat. Path. lib. II. c. 3. tab. VI. fig. 5, has a case extremely distinct. See also Haller, Opusc. Path. ob. 48. Vigarous, Malad. &c. Tom. I. p. 385, proposes mercury to kill the hydatids. He knew an instance where the woman discharged hydatids always when she went a la garde-robe. Mr. Mills relates a case, where the woman betwixt the second and tliird month, had symptoms of abortion, and afterwards, in tlie fifth or sixth, expelled above three pints of hydatids. Vide Med. and Phys. Journal, Vol. II. p. 447. When tlie mass is expelled, it is found either to consist entirely of small vesicles, or partly of vesicles, and partly of more solid remains of the ovum, or coagulum of blood NOTE 60, p. 99.—Hildanus relates a case of this kind in his own wife, dul- cissima et chanssima conjux mea. Hydatids may also be combined with preg- nancy. The same author tells us of a woman who, in tlie fifth month, was dehvered of a mola aquosa, or vesicles containing ten pounds of water; she did not miscarry, but went to the full time. NOTE 61, p. 100.—Kirkringius, p. 28, considers dropsy of the uterus as impossible, and says, that every case of collection of water depends out; a large hydatid. Dr. Denman seems to be much of the same opinion. But we find instances where water is accumulated and repeatedly discharged, ap- parentiy from the removal of a temporary obstruction. Fernelius relates a case, where the woman always before menstruation discharged much water, Path. lib. VI. c. 15. And M. Geoffroy describes a case of repeated discharge. Vide Fourcroy la Med. Eclare, Tom. II. p. 287. A case is related by Turner, where the external membrane of the uterus was said to be distended with water. The menses were suppressed, and a secretion of whitish fluid took place from the breasts. Phil. Trans. No. 207. NOTE 62, p. 102.—Sometimes the situation of the abdominal viscera is very much altered. In Mr. White's case, the liver was found to descend to the lower part of the belly, and the diaphragm was lengthened so as to allow the stomach to reach the umbilical region. Vide Med. Obs. and Inq. Vol. in. p. 1. In a complicated case, related by Schhncker, the pylorus hung down to the pubis. Haller, Disp. Med. IV. 419. NOTE 63, p. 102.—This point is very well considered by Verdier, in his paper on Hernia of the Urinary Bladder, in the first Vol. of Mem. de I'Acad. de Chir. See also a paper by M. Tenon, in Mem. de l'Institute, Tom. VI. p. 614.—Mr. Paget relates a very interesting case of prolapsus uteri, in which the bladder became retroverted, lying above the uterus. It could not de- scend before it, or along with it, being filled with a calculus, weighing 27 ounces, and others of a small size. Some parts of the bladder were an inch thick; a catheter could not be introduced. Med. and Phys. Journal, Vol. VI. p. 391. NOTE 64, p. 103.—Ruysch, feeling some hard bodies in the tumour formed by the protruded parts, cut out 42 calculi from the bladder. M. Tolet ex- tracted fifty, and afterwards cured the woman with a pessary. Duverney met with large calculus in the bladder, with procidentia uteri; and Mr. Whyte 310 relates a similar fact. Med. Obs. and Inq. Vol. III. p. 1. See also Drschampi Traite de la Tallie, Tom. IV. p. 158. NOTE 65, p. 103.—Kirkringius says, nemo vidit, nemo sennit, decepti otr.nei imagine falsa, alios decipiunt; laxitas quxdam colli qutt extra pudendum pro- minet hxc nobis fecit ludibrio. Opera, p. 48. Vide' also Job a Mcckren, Observ. Chir. c. 51. Barbette Chirurg. c. 8. Roonhuysen, Obs. Chir. part. I. ob. 2. NOTE 66, p. 103.—Dr. Monro mentions a procidentia uteri, in a very young girl. It was preceded by bloody discharge. Works, p. 535. Another case is related by Saviard, Obs. 15, in which the prolapsed uterus was mis- taken for the male penis; and as Goldsmith's soldier believed they would allow him to be born in no parish, so this girl was in danger of being deter- mined to have no sex. NOTE 67, p. 104.—Morand relates the case of a woman who had firtid discharge from the vagina, accompanied with pain. On examination, fungous excrescences were discovered in the vagina, and amongst these a hard sub- stance, which being extracted, was found to be part of a silver pessary The vagina contracted at this spot, and thus, though in a disagreeable way, pre- vented a return of the prolapsus. Pessaries have also ulcerated through to the rectum; and Mr. Blair mentions a woman in the Lock Hospital, who had introduced a quadrangular piece' of wood into the vagina as a pessary, and which ulcerated thus into the rectum, producing great irritation. Med. and Phys. Journal, Vol. X. p. 491. It is likewise necessary, if the pessary have an opening, in it, to observe that the cervix uteri do not get into the open- ing, and become strangulated. NOTE 68, p. 106.—See Rossuct, Plater, and Platner, Inst. Chir. section 1447. Wedelius de Procid. Uteri, c. 4. Volkamer, in Miscel. Cur. an. 2. ob. 226. Another case may be seen in Journal de Med. Tom LXVIIT. p. 195. Par£ OEuvres, p. 970.—Carpus extirpated it with success. Aide Longii Epist. Med. lib. n. epist. 39.—Slevogtius relates a distinct case, where the womb was found in the vagina, as if in a purse. Dissert. 12.—Benevenius says, he saw a woman whose uterus sloughed off. De Mirand. Morb. Causis, cap. 12.—Dr. Elmer supposes he has met with a similar case. Med. Phys. Journal, Vol. XVIH 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. Eelare", par Fourcroy, Tom. IV. p. 33. M. Baudelocque, however, says, that the uterus was enly partially ex- tirpated. Vide Recueil Period. Tom. V. p. 332. NOTE 69. p. 106.—Ilarvcy 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, spithama longitudine. Opera, p. 558. See alse a case by Mr. Antrobus, in Med. Museum, Vol. I. p. 227. 317 NOTE 70, p. 107.—Dr. Burton had a patient, who in the fourth month of pregnancy fell, and was thereafter seized with suppression 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. 107.—Mr. Dray mentions a case where, in the fourth month of pregnancy, the woman was seized with pains, like those indicating abor- tion, accompanied with suppression of urine. The os uteri was very near the orifice of the vagina. This disease proving fatal, the bladder was found to be thickened, enlarged, and in part mortified. Vide Med. and Phys. Jour- nal, Vol. HI. p. 456. NOTE 72, p. 107.—Reink mentions a woman who was pregnant of twins. In the fourth month the womb prolapsed, and caused a fatal suppression of urine. The vagina, at the upper part, was corrugated and inverted. Haller, Disp. Chir. Tom. HI. p. 585. NOTE 73, p. 109.—Sampson, in the Phil. Trans. No. 140, describes an ovarium filled with hydatids, containing 112 pounds of fluid.—Willi mentions a tailor's wife, whose ovarium weighed above 100 pounds, and contained partly hydatids, partly gelatinous fluid. Haller, Disp. Med. Tom. IV. p. 447.* NOTE 74, p. 109.—In a case detailed by Vater, tlie patient had symptoms of pregnancy, secreted milk, and even thought she felt motion. The belly continued swelled, and she had bad health for three years and a half, when she died. The abdomen contained much water, and the right ovarium was found to be as large as a man's head, containing capsules, filled with purulent looking matter. The uterus was healthy, but prolapsed, and the ureter was distended from pressure. Haller, Disp. Med. Tom. IV. p. 401. This was not a case of extra-uterine gestation, for the ovarium was divided into cells, and had no appearance of foetus. NOTE 75, p. 109.—In some cases it does not ascend out of the pelvis, or if it do, the inferior part of the tumour sinks again into it. Morgagni relates an instance where the ovarium weighed 24 pounds; and the lower part of it filled the pelvis so well, that when it was drawn out, it made a noise hke a cupping glass when pulled away from the skin. Epist. 39, art. 39. NOTE 76, p. 109.—It may be combined with effusion of water in the ab- dominal cavity. Dr. Bosch's patient had 16 pints of water in the abdomen, and both ovaria were enlarged so as to weigh 102 pounds. This patient com- plained of great pain and weight in the lower belly, and over the right hip. She was much emaciated, but the menses were regular. When she was tap- ped, not above two tea-cupfuls of fluid were discharged. Med. and Phys. Journal. Vol VHI. p. 444.—Mr. French met with a case of ascites and drop- sy of the ovarium. The ovarium extended from the pubis to the diaphragm. This patient had voracious appetite. Mem. of Medical Society, Vol. I. p. 234. NOTE 77, p. 110.—If only one of the ovaria be enlarged, or if both be af- fected, but only one much increased, the uterus is often not raised, because the ovarium tur:n on its axis, and the litems lies below it. In a case witit 318 which I was favoured by Dr. Cleghoni, both ovaria were greatly tumefied, and rould 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 dissection, a firm thick substance was found, extending from the pubis to the navel, be- twixt the ovaria. This was the uterus and vagina. The uterus itself was lengthened, the cervix was three inches long, and all appearance of os tincx was destroyed. Her complaints began after being suddenly terrified; first she felt severe pain in the right groin, with weakness of the thigh, and soon afterwards perceived a tumour in the belly, and presently another appeared in the left side. She was tapped 16 times. NOTE 78, p. 111.—In a case noticed by Dr. Denman, the labour was ob- structed until the ovarium was emptied, by piercing it from the vagina. The woman died six months afterwards. Introd. Vol. II. p'. 74. In Dr. Ford's case, related by Dr. Denman, the crotchet was employed. See also a case by M. Baudelocque, l'Artdes Accouch 1964. NOTE 79, p 112.—Dr. Denman justly observes, that diuretics have no ef- fect, Vol. I. p. 122. And Dr. Hunter remarks, that "the dropsy of the ovarium "is an incurable disease, and that the patient will have the best chance for *' living longest under it, who does the least to get rid of it. The trocar is " almost the only palliative." Med. Obs. and Inqu. Vol. II. p. 41. Willi, however, relates a case of 14 years standing, which was cured by diuretics; and it was calculated that the tumour contained 100 pounds of fluid Haller, Disp. Med. Tom IV. p. 451. NOTE 80, p. 112.—Dr. Denman advises the operation to be deferred as long as possible, and I believe he is right; for every operation is followed by re- accumulation, wliich is a debilitating process; yet it is astonishing how much may in the course of time be secreted, without destroying tlie patient Mr. Ford tapped his patient 49 times, and drew off 2786 pints. The secretion was at last so rapid, that three pints and three ounces were accumulated daily. Med Cpmmun. Vol. 11. p. 123. Mr. Martineau tapped his patient 80 times, and drew off 6831 pints, or 13 hogsheads; at one time he drew off no less than 108 pints. Phil. Trans. Vol. LXXIV. p. 471. [In the London Mcdico-chirurgical Transactions, Vol. ni. p. 40. ct seq. may be found the history of a remai'kable case of ovarian dropsy, by Thomas Chevalier, Esq. F. L. S. &c. The abdomen in this case measured 63^ inches in circumference, and 38 inches from the point of the ensiform cartilage to the top of the pubis. The navel when she sat was on aline with the knee. The quantity of fluid drawn off amounted to 17 gallons. The patient died.] NOTE 81, p. 113.—Le Dran relates two cases in the Mem. de I'Acad. do Chir. Tom. HI. In the first, th e cyst was opened, and the woman cured of the dropsy, but a fistulous opening remained, p. 431. In the second, he made a pretty large incision, and introduced a canula into the sac. The operation was followed by fever, delirium, and vomiting; the woman retained nothing but a httle Spanish wine for three weeks. She discharged daily 8 or 10 ounces of red fluid. At length, all of a sudden, 15 ounces of white pus wcl-< 319 evacuated, and then the. symptoms abated; but a fistula remained for twu years; then it healed, p. 442. [Dr. M'Dowell of Danville, Kentucky, relates three cases of extirpation of diseased ovaria, in Eclectic Repertory, for April, 1817. Vol. VII. p. 242. The patients recovered.] Dr. Houston relates the case of a woman in this neighbourhood, in whom he made an incision 2 inches long into tlie ovarium, and then with a fir splint turned out a great quantity of gelatinous matter and hydatids. He kept the wound open with a terit, 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.XVH. p. 381. And Portal gives an instance, where, by keeping the canula in the wound for a short time, a radi- cal cure was obtained, and the person afterwards had children. Cours d'Anat Tom. V. p. 554. NOTE 82, p. 113.—De La Porte tapped a woman who had a large tumour in the belly, but nothing came through the canula. He made an incision of considerable length, and, in the course of two hours and an half, extracted 351b. of jelly. The lips of the wounds were then brought together. Next day 15 lb. of jelly were evacuated, but presently vomiting and fever took place; and she died on the thirtieth day, having discharged altogether 67 lb. of fluid. , This disease was of sixteen months standing, and was attributed to hemorrhage. Mem. de I'Acad. de Chir. Tom. UL p. 452. Dr. Denman notices the case of a patient, who died the sixth day after in- jecting the ovarium. Vol. I. p. 122. NOTE 83, p. 113.—Dr. Monro, in Med. Essays, Vol. V.p. 773, details the history of a patient who had a diseased ovarium, and in whom the tumour pointed about four inches below the navel. It was opened, but nothing but air came out, followed next day by faeces; on the fifth day some pus was dis- charged. She gradually improved in health, and the tumour of the belly subsided; but in two years afterwards the suppuration was renewed, and she died. In this case, the colon had probably adhered to the ovarium. NOTE 84, p. 113.—Dr. Denman relates the case of a patient, who, having for some time suffered from pain and tenderness about the sacrum and ute- rus, and uterine hemorrhage, was suddenly seized with vomiting, syncope, pains in the belly, and costiveness; presently a tumour was felt in the right side, and this soon occupied the whole abdomen. This patient was cured, after purging a gelatinous fluid. Med. and Phys. Jour. Vol. II. p. 20. NOTE 85, p. 114.—Dr. Monro relates a case of supposed 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 paii < were excited, and the woman died exhausted. The left ovarium was found jrreatly enlarged with vesicles. Med. Essays, Vol. V. p. 770. NOTE 86, p. 114.—See Dr. Baillie's Morbid Anatomy, chap. 20. Dr. J. Cleghorn mentions a woman who died ten days after being tapped. The 320 right ovarium was found greatly enlarged, and had many cells, some con- taining hair, cretaceous matter, fragments of bone and teeth, other gelati- nous fluid. Trans, of Royal Irish Acad. Vol. I. p. 80. In Essays Phys. and Literary, Vol. II. p. 300, a case is mentioned, in which the one ovarium con- tained many vesicles; the other contained a mass, like brain, with bones and teeth. In the Museum attached to the hospital at Vienna, there is a large ovarium, the inner surface of which is covered with hair. Horstius met with an ovarium, containing hair, purulent-looking and oily matter. Opera, p 249. Schenkius met with fat and hair, p. 556, and Schacher relates a simi- lar case in Haller's Disp. Med. Tom. IX. p. 477. Ruysch, in his Adversaria, says, he met with bones and hair, and Le Rich, in the Hist, de I'Acad. de Sciences, 1743, met with hair and oil, in cells, together with bones and teeth. See also Recueil Period. Tome XVII. p. 462. NOTE 87, p. 114.—Duverney saw a tumour extirpated from the scrotum, containing fleshy matter and bones. OEuvres, Tom. II p. 562. And.M. Dupuy- tren presented a report to the Medical School at Paris, relating the history of a tumour found in the abdomen of a boy, containing a mass of hair, and a foetus nearly ossified. It was supposed, that at conception, one germ had got with- in another. See Edin. Med. Jour. Vol. I. p. 376. From the respectable evidence of Baudelocque, Le Roy, &c. this cannot be placed on a footing with Halley's case of a greyhound dog, who voided by the anus a living whelp ! Phil. Trans. Vol. XIX. p. 316. I beheve that bones, hair, &c have been found in a gelding. NOTE 88, p. 114.—Schlencker mentions a woman, who, soon "after deli- very, felt obtuse pains in the left side, and presently a swelling appeared in the belly. She had bad appetite, swelled feet, prolapsed uterus, and sup- pression of urine and faeces. The left ovarium was hard and stony, and weighed 3 ounces. Haller, Disp Med. Tom. IV. p. 419. In this case the tume- faction of the belly could not be caused by the presence of the ovarium, but rather by tlie pressure on the intestines. NOTE 89, p. 114.—Vide case by Fontaine, in Haller, Disp. Med. Tom. IV. p. 485. The patient had tumour of the abdomen, with lancing pains in the left side, extending to the thigh. Tlie left ovarium weighed 10 pounds, the right was as large as the fist, and both consisted of fatty matter. Portal likewise relates a case of this disease, where the right ovarium was as large as a man's head, very hard, and filled with steatomatous matter, weighing altogether 35 pounds. The uterus and bladder were turned to the left side. No water was effused, but the person was cut off by hectic and diarrhoea. Some steatomatous concretions were found in the lungs. Cours d'Anatomie, Tom. V. p. 549. CHAP. XII. NOTE 1. §. 1. p. 121.—Although hysteria be not a diseased state of men- struation, yet, as it is a very general attendant upon deviations of that action, and a very frequent and distressing complaint, to which women are subject, itwillbe proper to notice it briefly at this time. 321 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 sensation of a ball is felt passing along. It mounts upwards, and by degrees reaches the throat, and impedes respiration, so as to give the feeling of a globe in the oesophagus, obstructing the passage of the air, and, as Van Swieten observes, the throat appears sometimes really to be distended. The patient now falls down convulsed, and apparently much distressed in breath- ing, uttering occasionally shrieks, something like the crow ing of a cock, or sobbing violently, or otherwise indicating a spasm of the muscles of respi- ration. She is generally pale, and frequently insensible, at least during part of the fit, and seems to be in a faint; but when she recovers, she is con- scious not only of having been ill, but of many things which passed in a state of apparent insensibility. After remaining for some time in a state of considerable agitation of the muscular organs, the affection abates, and the patient remains languid and feeble, but gradually recovers, and presently is restored to her usual health. This restoration is accompanied with eructa- tion, which indeed often takes place during the paroxysm; and also by the discharge of limpid urine, which, by Sydenham, is considered as a pathogno- monic symptom of hysteria. Head-ache is also apt to follow a fit. Besides producing these regular paroxysms, hysteria still more frequently occasions many distressing sensations, wliich are so various, as not to admit of description. Of this kind are violent head-ache, affecting only a small part of the head, sudden spasms of the bowels, dyspnoea, with or without an ap- pearance of croup, and sometimes attended with a barking cough, irregular chills, and sudden flushings of heat, spasmodic pains, palpitation, syncope, &.c. These, if severe, or frequently repeated, are generally attended with a timid or desponding state of mind. During an hysteric fit, the patient is to be laid in an easy posture, a free admission of cool air is to be procured, the face is to be sprinkled with cold vinegar or Hungary water, volatile salts are to be held to the nostrils, and if she can swallow, 30 drops of tincture of opium arc to be administered, \v ith the same or a greater quantity of ether, in some carminative water; or should there be a tendency to syncope, a drachm of the spiritus ammoniac aroma- ticus may be conjoined. A similar combination of opium is the most powerful remedy in the differ- ent hysterical affections above enumerated. But it is further useful to re- mark, 1st, that local pain is frequently removed by sinapisms, with or with- out the internal use of opium; 2d, that severe affections of the organs of re- spiration sometimes yield more speedily to emetics than to antispasmodics, or may even require the use of the lancet, but this mode of evacuation is to be avoided as much as possible, as it increases a disposition to the disease; 3d, that irregular action of the heart, besides requiring powerful antispasmo- dics, demands, more than any other symptom, during the attack, a state of rest, and the removal of every thing which can agitate the mind; 4th, con- tinued insensibility, or coma, is a very dangerous symptom, as it may end VOX. I. T T 292 fcannot support its condition long. I have never known a woman live twenty-four hours in these circumstances. On the other hand, I grant, that it is possible the woman may die in the act of delivery, or very soon after it; but if she can be supported for two days, we may have hopes of recovery. By a very slow and cautious delivery, and by endeavouring to excite the action of the uterus, so as to pre- vent discharge afterwards, we not only remove the irritation of the distended womb, but we likewise take away a recepta- cle of blood. During the contraction of the uterus, the blood in its sinuses will be thrown into the system, and tend to support it. Part, no doubt, will escape; but by keeping the hand in the uterus, by supporting the abdomen with a com- fltess, and exciting the uterine action by cold applications to the belly, we may prevent a great loss. When to these considerations we add the additional chance which the child has for life, our practice, I apprehend, will, in this very haz- ardous case, be decided. When the pulse becomes firmer and fuller upon the contraction of the uterus, the risk from debility is diminished. A full dose of laudanum ought to be given previous to delivery. The remarks upon the subsequent management of the pa- tient, I shall reserve until I consider the treatment of flood- ing, after delivery. At one time it was supposed, that the placenta was, in every instance, attached originally to the fundus uteri, and that it could only be found presenting in consequence of having been loosened and falling down. This accident was supposed to retard the birth of the child, by stopping up the passage, and also was considered as dangerous on account of the flood- ing which attended it. On this account Deventer endeavour- ed to accelerate the delivery by tearing the placenta, or rup- turing the membranes when they could be found. This was a dangerous practice, and very few survived when it was em- ployed. Mr. Giffard and M. Levret* were among the first * Je m'engage a prouver lmo. que le placenta s'implante quelquefois sur la cireonference de I'orifice de la matrice; c'est-a-dire, sur celui qui du coi 293 who established it as a rule that the placenta did not fall down, but was from the first implanted over the os uteri: and the latter gentleman published a very concise and accurate view of the treatment to be pursued. We know, that during the eighth month of gestation, very considerable changes take place about the cervix uteri. It is completely developed and expanded; and in the ninth month, xery little distance intervenes betwixt the ovum and the lips of the os uteri. These changes cannot easily take place without a rupture of some of the connecting vessels, for either tlie placenta does not adapt itself to the changes in the shape of the cervix; or, which happens more frequently, some slight mechanical cause, or action of the fibres about the os uteri, produces a rupture. ^ This rupture may doubtless take place at any period of pregnancy,* but it is much more frequent in the end of the eighth and beginning of the ninth month, than at any other time. But whether the separation happens in the seventh, eighth, or ninth month, the consequent hemorrhage is always profuse, and the effects most alarming. The quantity, but especially the rapidity of the discharge, very frequently pro- duce a tendency to faint, or even complete syncope, during which the hemorrhage ceases, and the woman may continue for several days without experiencing a renewal of it. In some instances she is able to sustain many and repeated at- tacks, which may take place daily for some weeks. These, however, it is evident, cannot be very severe, and the strength must originally have been great. In other instances, the woman never gets the better of the first attack. It indeed va joindre I'interieur de ce viscere, & non sur celui qui regarde de la vagi n. 2do. Qu'en ce cas la perte de sang est inevitable dans les dernier tems de la grossesse. Et 3tio. Qu'il n'y a pas de voye plus sure pour remedier a cet accident urgent que de fair l'accouchement forc6—L'art des Accouchemens, p. 343. * In some cases, hemorrhage has taken place so early as the third month. By proper means this has been stopped, and the patient has continued well for some months, when the flooding has returned, and the placenta been dis- covered to present. S21 tions; whereas in fowls and quadrupeds, all the vessels enter at one place A similar fact is observed in the ova of frogs, for the umbilical cord in the tadpole goes to the head. The egg of tlie serpent is nearly the same with that of the fisli, and is in- closed in a flexible membrane. The foetus is coiled up spirally within it, and the chorion is vascular, as in the egg of the fowl. The alder is a viviparooa animal; its viterus is membranous, and divided, I find, into eight or nine cells, each of which, in September, contains an ovum as large as a chesnut. This consists of an exterior membrane, which incloses a foetus about six inches long, and coiled up. About an inch from the tail, the umbilical cord passes out, which consists of vessels that go to ramify on the exterior membrane, which resembles the chorion of the sow. There is also a connection with a vitellus, which is as large as a hazel nut. The coluber natrix is said, by Valmont-Bomare, to have a placenta and cord within the egg, but this is contrary to the general structure of eggs; most likely the chorion has been taken for the placenta. The eggs of reptiles are often deposited in packets, the eggs being glued together. T^e egg of the turtle is as large as a hen's, and is inclosed in a covering like parchment. Tt is deposited in the sand, and is hatched in about 24 days. The egg of tlie alligator is similar in structure to that of the turtle ; it is rather larger than a goose's egg, and covered with a thin skin, so transparent, how- ever, that the foetus may be seen through it. Those animals which are called oviparous hatch their eggs out of the body either by sitting on them as we see in fowls, or by exposing them to the heat of the sun, as the turtle, crocodile, and many serpents. Oviparous fishes, which comprehend all those called osseous, expel their ova into the water, where they are fecundated by the male, but without copulation. Many fishes leave the sea, and come up the rivers to spawn. Others remain in the ocean; and the eggs, specifically lighter than the water, float on the surface. Many fishes attach them to marine plants, and in some cases the ova are fixed to the body of the parent. The ova are covered with a kind of mucus, which has been supposed to defend them from the water. The ova of frogs, &c. are likewise fecundated and hatched out of the body. They are enveloped in a glary matter, which perhaps contributes to their increase; for during incubation, the egg both enlarges and changes its shape. Those animals which hatch their eggs within the body are called ovo- viviparous, such as cartilaginous fishes, as the shark, skate, and torpedo, &c. The scorpion and venomous serpents also belong to this class. Ovo-viviparous animals expel the young fully formed, and therefore have been sometimes considered as having uteri hke quadrupeds, and a cord attached directly to it. Spallanzani at first supposed that the foetus of the torpedo was attached directly to the uterus, but afterwards found that it was contained in a distinct ovum. Experiences, p. 294. See also Cuvier Lecons d'Anat. Comparee, Tom. V. p. 142. The shark is said to have an uterus like the bitch, and Bclon says he saw a female dehvered of eleven young, attached by a cord. Its mode 325 of gestation most likely is similar to the torpedo. This class expel their young often very quickly. A female syngnatus hyppocampus was observed to ex- pel at least a hundred in a very short time. Analogous to ovo-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 metamor- phosed in these cells. The opossum tribe has a modification of this gesta- tion; for in them the foetus, when very small, is expelled into a bag situated on the belly, and immediately attaches itself to a nipple. The utero-gesta- tion of the opossum of North America lasts only from 20 to 26 days, and tlie embryo when expelled does not exceed a grain. It remains in the sac about 50 days, and acquires the size of a mouse. In other animals, as for instance the bat, the young after birth attach themselves to the nipple, partly for tlie convenience of being transported or carried about. In plants, we find likewise a placenta or structure, intended for the nourishment and respiration of the foetus. To take the kidney bean for an example, we find within the membranous covering two parenchymatous lobes, or cotyledons; and at the margin betwixt these, there is the corculum or cicatricula. During incubation, we find that this sends up a small shoot called the plumula, and down a radical into the earth. But to support the plant until the root and leaves are capable of maintaining it, we find the cotyledons rise up out of the earth, on each side of the plumula, forming what are called seed leaves. These both serve for the respiratory organs, and also supply pabulum, which is absorbed by proper vessels, and in con- sequence thereof they presently are destroyed. When there are more lobes than two in tlie seed, there are a corresponding number of seed leaves. In many cases these cotyledons do not rise out of the ground, but the plumuLi alone appears. This is the case with the garden pea, but the cotyledons still perform their functions below the ground, and exist until the fohage of the plant, or adult organs, be formed. The greatest part, then, of a vegeta- ble seed or ovum, consists, like the eggs of fowls, of an apparatus intended for the nutriment and respiration of the foetus, wliilst the embryo itself is very small. The cotyledon consists, in many cases, of a farinaceous sub- stance. In other seeds it is oily and farinaceous, and in some is almost all oily. Vegetable ova sometimes are contained in a dry pericarpium, and are shed into the earth when it bursts. But others have an apparatus provided not only for their present growth, but also for accelerating their incubation in the earth. In stone fruit and nuts, we find that vessels pierce the shell at the bottom, and pass on toward the top, and reach the kernal or lobes, which are contained within the shell, enveloped in a soft membrane. They are in- serted very near the embryo. Now, for the farther support of these parts we find that stone fruits are covered with a quantity of nutritious matter. The almond, for example, has its ligneous nut covered with a fleshy sub- stance about an inch thick, inclosed in a proper membrane. The rhamnus lotus has the stone surrounded with farinaceous matter, whirh tastes like 326 gingerbread. Other seeds are contained in a parenchymatous or succulent substance, as the apple or pear, or in a firm white substance like cream or marrow, or in a mucilaginous matter as the gooseberry, or in an organized pulp as the orange and garcinia mangostona. Some are deposited in a luscious fluid at first, which ultimately becomes farinaceous, as the plantain. CHAP. XVII. NOTE 1, p. 169.—In Dr. Clark's case the morning sickness, and other signs of pregnancy, appeared very regularly. At the end of nine months, attempts were made to expel the foetus. These were followed by inflamma- tion and decline of health. Then suppuration took place, and the patient sunk. Transactions of a Society, &c. Vol. II. p. 1. In Mr. Mainwaring's case, in the same work, p. 287, the patient suffered much from morning sickness, and pain at the groins. NOTE 2, p. 169.—In the Journal de Seavans for 1756, we are told of a woman at Louvain, who at first had so dreadful pain when she went to stool, that she thought her bowels were coming out.—In Pouteau's case, the woman suffered great pain till after the second month. Melanges, p. 333. NOTE 3, p. 169.—Bianchi mentions a case, in which, in the first months, the woman complained of great pain in the lower belly, with nausea and fainting fits. The motion of the child ceased in the fifth month, and then milk was secreted. De Nat. in Hum. Corp. Vitioso Morbosoque Gener. p. 166.—In Dr. Mounsey's case, the pain, vomiting, and fainting fits, continued till the woman quickened. Phil. Trans. Vol. XhX. p. 131.—In Dr. Fern's case, the person complained of great pain till the third month ; and from that period till the eighth month, was subject to convulsions and syncope. Phil. Trans. Vol. XXI. p. 121. NOTE 4, p. 169.—In Dr. Perfect's case, no labour pains came on, but the motion of 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. 170.—Vide cases by Longius, in his Epistols, Tom. II. p. 670. Tulpius Opera, lib IV. c. 39, p. 358.—Pouteau in his Melanges, p. 373.— Mr. Shiever,in Phil. Trans. Xo. 303, p. 172.—Winthrop, Phil. Trans. Vol. XL1II. p. 304, and Simon, p. 529.—Lindestaple, Vol. M.IV. p. 617. Morley, Vol. XTX. p. 486. Gordon, in Med. Comment. Vol. XVIII. p. 323. Cammel, in Lond. Med. Jour. Vol. X. p. 96. Case by M. Bergeret, in the Recueil Pe- riodique, Tom. XIV.p.289. NOTE C, p. 170.—Vide Marcel. Donatus, De Med. Hist. Mirab. lib. IV. c. 22.—Horstii Opera, Tom. II. p. 536. In this case, the foetus was discharged both by the vagina and rectum.—Benevoli, in his Dissert, p. 104, gives an in- stance where the greater part of the child was expelled by the vagina, but the woman died before the process was completed.—Mr. Smith's case, in Med. 327 Comment. Vol. V. p. 314.—In Mr. Colman's case, pains came on, and the head was felt in the pelvis at the time of her reckoning, and long afterwards, but the os uteri could not be perceived. In some time, hectic fever, with diarrhoea and sore mouth, appeared Six months after her attempts at labour, an open- ing was felt in the vagina, but very unlike tlie os uteri. The hand was in- troduced, and a putrid child was extracted. Some fxces continued to come by the wound, but at last she got well Med. and Phys. Jour. Vol. II. p. 262.— See also Camper's case, in his Demonst. Anat. Path. lib. II. p. 16, and Dr. Fo- thergiIPs case, in Mem. of Med. Society, Vol. VI. p. 107. NOTE 7, p. 170.—Vide Stalpart Vander Wiel, Opera, Tom. I. p. 305. In this case, bones came away with the urine.—In the case of Ronseus, the child was discharged 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 case, the child was found altogether in the bladder. Med. and Phys. Jour. Vol. XIV. p. 519. NOTE 8, p. 170.—Vide case of Mrs Stag, in Lond. Med. Obs. and Inqui- ries, Vol. II. p. 369; and cases by Mr. Jacob, Dr. Maclarty, and others. NOTE 9, p. 170.—In Mr. GhTard's case, the child was expelled entire by the anus, and even the cord was found hanging out of the intestine. Phil. Trans. Vol. XXXVI. p. 435.—See also Mr. Goodsir's case, in Annals of Me- dicine, Vol. VII. p. 412. NOTE 10, p. 170.—In Dr. M'lvnight's case, although the caesarean opera- tion was performed before any bad effects were produced on the health, no part of the placenta could be found. NOTE 11, p. 170.—In Dr. Clark's case, the tube burst in the second month, and the woman died from loss of blood. Transactions of a Society, Vol. I. p. 216.—Vide case by Duverney, in his works, Tom. II. p. 353, and by M. Littre in the Memoirs of the Acad, of Sciences, for 1702, and by Riolan, in his works. See also Med. Comment. Vol. 1. p. 429.—In Mr. T. Blizard's case, rupture took place at a very early period, for the woman had miscar- ried only five weeks previous to this event. Vide Edin. Phil. Trans. Vol. V. p. 189—Mr. Tucker's case, Med. and Phys. Journal, XXIX. 448. NOTE 12, p 170.—I have known the foetus retained for twenty years; and there are some instances, where it has been retained thirty, forty, or fifty years. Mrs. 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 XLIV. p. 617. Mounsay's thirteen years, Vol. XLV. p. 121. Steigertahl's forty-six years, Vol. XXXI. p 126. Broomfield's nine years, Vol. XLI. p. 696. Sir P. Skippon's patient discharged it by suppuration at the groin, after retaining it twenty years, Vol XXIV. p. 2070. See also cases by M. Grivcl, in Edin. Med. Jour. Vol. II. p. 19, and Dr. Caldwell, p. 22. Some- times no attempt is made to expel, but the foetus is converted into a sub- stance, which Fourcroy finds to resemble the gras des cimetieres. System, Tom. X. p. 83. Sandifort relates a case, where, after attempts at labour, no further inconvenience was sustained, but the child was found after twenty. 328 two years to be indurated. Observationes, lib. II. p. 36. He quotes Nebel for a case, where it was retained fifty-four years. Chcscldcn found it con- verted into earthy matter. The late Mr. Hamilton of this place had a pre- paration of a foetus, covered with calcareous matter, which w as retained 32 years. This woman had pains at the end of nine months, after which the belly decreased in size. NOTE 13, p. 170.—Iilthe 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.—Seelalso Primrose de Morb. Mul. p. 326.—Mr. Hope, in the 6th Vol. of the Med. and Phys. Jour. p. 360, details a case, where the woman in the seventh month of pregnancy had pains, which continued for three weeks, and then went off, leaving a hard tumour on the left side, which was somewhat painful; she then had another pregnancy, and a fortnight after dehvery, began, after taking a laxative, to vomit, and continued to do so, ultimately throwing up feculent matter. The case ended fatally.—See also Turk, in Haller, Disp. Chir. IV. 793. NOTE 14, p. 170—In Mr. White's case, related in Med. Comment. Vol. XX. p. 254, the symptoms were very 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 re- moved, and the uterus felt in situ. She continued well till the ninth month, when labour ineffectually came on; but in process of time, the child was discharged by the anus. Med. and Phys. Jour. Vol. XI. p. 293. NOTE 15, p. 171.—Boehmer long ago observed this ; and Dr. Baillie, in the 79th Vol. of the Phil. Trans, mentions, that Dr. Hunter had a preparation of tubal pregnancy, in which the uterus was found enlarged to double its na- tural size, and containing decidua. He also states, that in an ovarian case, the uterus was enlarged, thick, and spongy, and its vessels enlarged. Dr. Clarke found the uterus, in the second month of an extra-uterine pregnancy, exactly of the same size as if the embryo had been lodged within it. The decidua was formed, and the cervix filled with gelatinous matter. Trans- actions of a Society, Vol. I. p. 216. See also a case by Saviard, in Phil. Trans. No. 222, p. 314. A case, similar to Dr. Clarke's is related by Mr. T. Blizard, in the Edin. Phil. Trans. Vol. V. p. 189. Sae also Annals of Med. Vol. HI. p. 379. NOTE 16, p. 171.—In Mr. Houston's case, the cervix was so closed up that it would not admit a probe. Phil. Trans. Vol. XXXII. p. 387. The decidua would appear sometimes to enlarge, and form a mass like placenta, wliich in Mr. Turnbull's case was expelled with hemorrhage. Mem. of Med. So- ciety, Vol. HI. p. 176. NOTE 17, p. 171.—In a case related by Varocquier, the ovarium did not acquire a larger size than an egg. The woman died, after suffering violent pain in the left side, low down. The viscera were slightly inflamed. Mem. 329 de I'Acad. de Sciences, Tom. CXI1I, p. 76. In the case by L'Eveille, the foetus was apparently betwixt three and four months old. Rapport de la Societe Philomatique, Tom. I. p. 146. See also a case in the Recueil Period. Tom. Xni. p. 63; and in the Recueil des Actes de la Societe' de Lyon NOTE 18, p. 171.—Vide Chambon, Malad. de la Grossesse, Tom. II. p. 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, after violent colic pains, voided blood by the anus. The hemorrhage and fainting fits proved fatal. The foetus was found in the ovarium. Annals of Medicine, Vol. HI. p. 379. NOTE 19, p. 171.—Vide Roederer, Elemens, c. 15. §. 758. In Mr. Dumas' case, a fluid hke chocolate was drawn off by tapping, which was twice per- formed. The ovarium contained hair, bones, &c. La Med Eclaree, Tom. IV. p. 65. Mr. Bell's tubal case excited ascites. NOTE 20, p. 172.—Vide Dr. Kelly's case, in 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 vertebrse. In the history by La Coste, it was placed under the stomach and colon. Vide CEuvres de Duverney, Tom. H. p. 863. In Mr. Turnbull's case, it was very thin, and adhered to the intestines. Mem. of Med. Society, Vol. HI. p. 176. A case of ventral pregnancy, complicated with hernia, is related by M. Martin in the Recueil des Actes de la Societe de Sante de Lyon. Courtial found it adhering to the stomach and colon. NOTE 21, p. 173.—Dr. Maclarty relates the case of a negress, where the breech of the child protruded through an ulcer, at the lower part of the abdominal tumour, and the arm at the upper part of tlie tumour. The in- termediate portion of skin was divided, and the foetus extracted. The head of the child stuck firmly, but was brought out with the forceps. There was no placenta, but putrid matter was discharged with the child. The woman, recovered. Med. Comment. Vol XVII. p. 481. Another case is related by Duverney, where the child was extracted from the groin; and this is one of the rare instances where the placenta was not destroyed. It was ex- tracted with the child. CEuvres, Tom II. p. 357. Cyprianus gives an in- stance of the child being removed, after having been retained twenty-one months. Histor. Foetus Hum. Salva Matre, ex Tuba Excisi. Mr. Brodie en- larged 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 inci- sion four inches in length was made, and the bones of two children extracted. Med. Comment. Vol. H. p. 72. Dr. Haighton relates an interesting case, where some bones were discharged by the vagina, but the tumour also pointed above the pubis, and through this one of the ribs appeared. The practitioner made an incision, but so great hemorrhage came on, that he VOL* T. r ' 330 was obliged to apply a bandage till next day, when he extracted the bones The woman recovered. Med. Records, p. 260. Dr. M'Knight performed the operation in the twenty-second month, although the woman enjoyed tolerable health; very dangerous symptoms supervened, but the woman, who certainly was brought into a very hazardous state by the premature operation, did recover. No placenta was found. Mem. of Med. Society, Vol. IV. p. 342. NOTE 22, p. 173.—in Dr. Morley's case, this happened two years after the original abscess had healed. Phil. Trans. Vol. XIX, p. 486. Mr. Moyle details a history, where the abscess first of all burst, in consequence* of leap- ing over a hedge. Bones continued to be discharged for a year, without much injury to tlie health. The abscess then healed, but three years after- wards a tumour again appeared, and, in consequence of exertion, burst; when about a yard of intestine protruded. Some days elapsed before Mr. Moyle saw her. The intestine was then gangrenous, but she lived 12 days longer, and the portion was thrown off before death. Med. Jour. Vol. VI. p. 52. CHAPTER XIX. NOTE 1, p. 207.—Mr. Pearson relates a case, where the uterus was re- troverted, in consequence of being scirrhous. Vide Pearson on Cancer, p. 113. Dr. Marcet gives an instance where the uterus was retroverted, with- out pregnancy, producing constipation and vomiting. Vide Cooper on her- nia, part II. p. 60 NOTE 2, p. 207.—M. Baudelocque relates a case, where the fundus uteri protmded at the os externum, the patient at the same time having violent incUnation to expel sometiiing. He was, however, able speedily to reduce the womb to the. proper state. Vide l'Art, &c. §. 125. In Dr. Bell's case, a portion of the rectum was protruded by the uterus. Med. Facts, Vol. VHI. p. 32. NOTE 3, p. 208.—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. 388. In the same volume, p. 382, Dr. Garthshore relates an instance of semi-retroversion. NOTE 4, p. 208.—In the case described by Dr. Hunter, Med. Obs. and Inq. Vol. IV. p. 400, the bladder after death was found to be amazingly dis- tended, but not ruptured NOTE 5, p. 208.—In Mr. Lynn's case, the bladder burst, and immediately afterwards the woman miscarried, but the uterus after death was found to be still displaced. Med. Obs. and Inq. Vol. V. p 388. Dr. Squire relates an instance in which the bladder also gave way. Med. Review for 1801. 331 NOTE 6, p. 208.—In Mr. Wilmer's case, the belly was greatly distended; six pints of urine were drawn off, but the woman soon died. On inspecting tlie 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 wedged in the pelvis, that it could not be raised up till the symphysis pubis was sawed away. Wilmer's Cases, p. 284. NOTE 7, p. 208.—In Dr. Ross's patient, after the uterus was reduced, abor- tion tookpbice; and the woman dying, tlie bladder was found to be thickened, and adhering to the navel. Annals of Medicine, Vol. IV. p. 284. NOTE 8, p. 209.—This is illustrated by Dr. Garthshore's patient, who, notwithstanding these symptoms, ultimately did well. After the reduction of the womb she miscarried, and foetid lumps were for some time discharged from the bladder. Med. Obs. and Inq. Vol. V. p. 382. NOTE 9, p. 209.—In Mr. Croft's case, the disease was of a month's stand- ing, the woman was oedematous, and she was supposed to have dropsy; but by introducing tlie catheter, seven quarts of urine were drawn off. The in- troduction was daily repeated for some time, and then occasionally, as cir- cumstances required, for three weeks. The swelling of the legs went off, and the uterus gradually rose. Med. Jour. Vol. XI. p. 381. NOTE 10, p. 209.—A case is related by Mr. Ford, in which the catheter being allowed to shp into the bladder, produced a sinuous ulcer. Med. Facts, Vol. I. p. 96. NOTE 11, p. 209.—In Mr. Cooper's case, whenever the tumour was pressed back, the woman called out that she could now make water. Med. Obs. and Inq. Vol. V. p. 104. NOTE 12. p. 209.—This was done by Dr. Cheston. The woman remained long very ill, but she carried her child to the full time, and recovered. 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. 210.—Dr. Hunter mentions a case, in which the uterus re- covered itself immediately after the bladder was emptied. Med. Obs. Vol. IV. p. 408. And in Mr. Croft's second case, the water having been .drawn off for six days, the uterus suddenly rose. Lond. Med. Jour. Vol. XI. p. 384. NOTE 14, p. 211.—Both Dr. Ross's patient, and Dr. Cheston's patient, the latter of whom recovered, complained of uneasiness in the throat, which Dr. C. considers as a mark of slow peritoneal inflammation. NOTE 15, p. 211.—This circumstance has been mentioned by different writers, and a distinct case is related by Mr. Merriman, in the Med. and Phys. Jour. Vol. XVI. p. 388. Mrs. F. being about five months pregnant, was suddenly terrified, and felt as if her inside were turned upside down. The symptoms, however, were not very acute, for she voided the urine in the last month of gestation, though with pain and some difficulty. On the 16th of June, she had some pains, and a discharge of serous fluid; no os uteri could be felt, but a large sem>-globular tumour at the back part of the vagina, bearing down toward the perinscum. The pains brought on fever, 332 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 regu- lar, 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 natural situation The substance was found to be the scalp of the child, co*|ajning loose bones. The child-and placenta were delivered, and the mother recovered. NOTE 16, p. 213.—In Mr. Bird's case, the acciden^succeedcd to stooping, in washing clothes. Med. Obs. and Inq. Vol. V. p. 100. In Mr. Hooper's case, the woman was frightened by an ox, and in attempting to escape, fell down, after whicli 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 sud- denly terrified; and Mr. Wilmer's patient had tlie uterus retroverted, after being fatigued with weeding. NOTE 17, p. 214.—Vide Chambon, Malad. de la Grossesse, p. 16. M. Baudelocque relates a case from the practice of Choppart, where it was pro- duced in the second month of pregnancy, by the action of an emetic. L'Art, &c. § 255. NOTE 18, p. 214.—Sometimes the hemorrhage proves fatal. A singular case is to be met with in tlie 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. NOTE 19, p. 214.—A twin case is related by Dr. J. Hamilton, where the uterus was so thin, that even the sutures of the head could be felt through the abdominal parietes Violent pains were produced by the motion of the child, the uterus felt very light, and the woman had been exposed to a de- gree of violence. This case had a very considerable resemblance, in some respects, to a ruptured uterus, but she was delivered safely of two children. Cases, p. 124. NOTE 20, p. 214.—Sometimes the tumour rather increases. In Dr. Per- cival'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 recumbent posture. Med. Comment. Vol. II. p. 77. NOTE 21, p. 214.—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 tiie opening. Phil. Trans. Vol. XLV. p. 121.— A washerwoman at Brest had the uterus ruptured by a fall in the seventh month, and idtimately expelled the foetus at the navel. Mem. of Acad, of Sciences 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. 215.—In the Journ. de Med. for 1780, there is a case of a woman, who had the uterus ruptured in the fourth month of pregnancy. The 333 accident was followed by uterine hemorrhage, which continued for sonic time The menses returned, but the belly did not subside. In the ninth month she died. The uterus was found of the natural size, but the rent was still perceptible. The uterus for some time does not return to its unimpregnated state, as is evident from the following case, which I lately saw . Anne Neilson, aged 24 years, fell on the ground about a month ago, Deing then in the ninth month of her first pregnancy. She felt at the time as if something had burst near the navel, and perceived more fluttering of the child than usual. This continued in a certain degree for two days, after which, she felt no more motion. In the course of two or three days after the accident, she was seized with irregular pains, chiefly about the belly, and these are rather increasing than diminishing in severity. The belly has subsided considerably in size, is hard, particularly above the navel, toward the stomach. The umbilicus itself, is soft and prominent. The bowels are regular, urine proper, tongue clean, heat natural, pulse 84, has occasional shivering. On examining, per vaginam, the lower part of the uterus is felt soft and tubulated, very unlike either the gravid or unimpregnated womb. It hangs into the vagina, like a fleshy inverted cone. By some degree of attention the os uteri is discover- ed at tlie lower part, or rather a little backward. It has no distinct project- ing lips as in the unimpregnated state, but by pressure with the finger, the aperture is felt with thin margins, and the point of the finger may be in- troduced a very little way within it. The head of the child is discovered between the uterus and pubis. No distinct member can be felt through the abdominal parietes. Dr. Jeffray possesses a preparation of a foetus contained in a kind of cyst taken from a woman who had carried the child above 20 years : the rupture was occasioned by a fall. NOTE 23, p. 215.—In the Journal de 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 vagina, which continued in variable quantity for six weeks. The strength gradually sunk, and in June she began to vomit, and continued to do so for several days, when she died. The abdomen was found inflamed, and con- tained the remains of a putrid child. The rent was visible in the womb. NOTE 24, p. 215.—In Mr. Wilson's patient, the accident was produced by being kicked. She complained of pains all night after the injury, and ne:*W.' ','**"'*-", M >"'£ .-?'■?■ ,V-.W..a V N V.