["Mil ARMY MEDICAL. LIBRARY WASHINGTON Founded 1836 ANflEX SectioiiOUUl/U^____ Number Fobm 113c, W. D., S. G. O. 3—10543 (Revised June 13, 1936) i ' 1 / APHORISMS L i^ OK™ ^y^i^;i APPLICATION AND USE * *- ' OF THE FORCEPS AND VECTIS ; | ON PRETERNATURAL LAEOUR3, '; I ON LABOURS ATTENDED WITH HEMORRHAGE, ff':, , AND WITH CONVULSIONS. ' - ' THE FIRST AMERICAN EDITIOK. By Thomas Denm'an, M. D. * LICENTIATE IN MIDWIFERY OF THE COLLEGE ' OF PHYSICIANS, LO.vDONJ AND HONORARY MEMBER OF THE ROYAL MEDICAL SO-'"11'- _ C1ETY AT EDINBURGH. ''*.'?> ■*■**# PHILADELPHIA : Printed for Benjamin Johnson, No. 31* High-Street. 1803. ADVERTISEMENT. BEING requested, by the American publisher, to give our opinion of this work, we chearfully mention, that it was written by one of the most scientific and experienced practitioners in Lon- don, and that it contains in a small com- pass, what he has more diffusely ex- plained in his excellent Introduction to Midwifery. It is indeed a concise sum- mary of the most valuable practical pre- cepts, and as such we may, with safety, warmly recommend it to the students in that science which the author taught for many years, with distinguished re- putation in the metropolis of Great Bri- tain. To say more, in this place, would perhaps be superfluous, and inconsistent with the spirit of the work we wish to recommend; one of whose greatest me- rits is brevity and precision. Thomas C. James. J. Church. TO Dr. THOMAS SAVAGE. DEAR SIR, THESE Aphorisms, designed for the use of students, I request you will permit me to dedicate to you. I wish also to take this opportunity of convey- ing those sentiments of respect I have ever entertained for the integrity and benevolence which so eminently distin- guish your character ; and to express my gratitude for that kindness and par- tiality you have always shewn to, Dear Sir, Your obliged, an-.! affectionate humble servant, THOMAS DENMAN. Dec. 7, 1792. ARRANGEMENT OF LABOURS. FOUR CLASSES. I. Natural. II. Difficult. III. Preternatural. IV. Anomalous, or Complex. Class I. Natural Labours. Character. Every labour in which the process is completed within twenty- four hours, the head of the child pre- senting, and no adventitious assistance being required. Varieties. 1. The face inclined towards the sacrum, 2. The face inclined tov, aids the o*-sa pubis. A 2 3. The ( o ) i. The head presenting vrith one or both arms. 4. The face presenting. That part of a child which descends lowest into the pelvis, is to be esteemed the presenting part. Circumstances atte?iding labours. 1. Anxiety. 2. Rigours. 3. Strangury. 4. Diarrhoea. 5. Mucous discharge, with or without a mixture of blood. 6. Pain. Causes of Pain. 1. Expulsatory action of the uterus. 2. Resistance made to the effect of that action. Distinctions of pain. 1. True. , 2. False. Causes and signs of false pain. Means of removing them. Means ( 7 ) Means by which true pains arc supposed to be regulated, and their effect pro- moted. Note. The pains attending labour are subsequent to the action of the ute- rus, though in common language the word pain, and the action of the uterusy are used synonymously. Progress of natural labours. Three periods or stages. 1st period. Dilatation of the os uteri. Rupture of the membranes. Discharge of the waters. 2d period. Descent of the child. Dilatation of the external parts. Expulsion of the child. 3d period. Separation of the placenta. Expulsion or extraction of the pla- centa. Note. It very often happens that the membranes do not break till the head of the child is on the point of being expel- led. ( 8 ) led. This is the natural and most desi- rable progress of a labour, and it is ane- gative proof that the labour has been well conducted ; that is, not interrupted. But the description given above, will answer the purpose of impressing a clear idea of labours in general. The two circumstances which princi- pally require attention in natural labours are, to guard the perinceum and to ex- tract the placenta with discretion. Class II. Difficult Labours. Character. Every labour in which the process is prolonged beyond twen- ty-four hours, the head of the child pre- senting. Note. Some objections maybe made to this definition taken from time, but it will be found to apply to practical uses better than ii it was taken from circum- stances. It would often be extremely difficult to say with precision when a labour actu- ally ( * ) ally begins, because of the number of concurrent changes. But in general •some progress must be made before we can allow a labour to be commenced. FOUR ORDERS. ORDER I. Labours rendered difficult front the inert or irregular action of the uterus. causes. 1. Too great distention of the uterus, 2. Partial action of the uterus. 3. Rigidity of the membranes. 4. Imperfect discharge or dribbling of the waters. 5. Shortness of the funis umbilicalis. 6. Weakness of the constitution. 7. Fever. 8. Want of a due degree of irritabili^ ty. 9. Passions of the mind. 10. General deformity. ( io ) ORDER II. Labours rendered difficult by the rigidity of the parts to be dilated. 1. First child. 2. Advancement in age, 3. Too early rupture of the mem- branes. 4. Oblique position of the os uteri. 5. Fever or local inflammation. 6. Extreme rigidity of the os uteri. 7. Uncommon rigidity of the exter- nal parts. ORDER III. Labours rendered difficult from dispropor- tion between the dimensions of the cavi- ty of the pelvis and the head of the child. 1. Original smallness of the pehis. 2. Distortion of the pelvis. 3~ Head of the child unusually large, or too much ossified. 4. Head of the child enlarged by dis- ease. 5. Face inclined towards the ossapu- bis. 6. Presentation ( 11 ) 6. Presentation of the face. 7. Head presenting with one or both arms. ORDER IV. Labours rendered difficult by diseases of the soft parts. 1. Suppression of urine. 2. Stone in the bladder. 3. Excrescences of the os uteri. 4. Cicatrices in the vagina. 5. Adhesion of the vagina. 6. Steatomatose tumours. 7. Enlargement of the ovaria. 8. Rupture of the uterus. Note. The disturbance of the natu- ral progress of labours, more especially the premature rupture of the membranes, is the most general cause of difficulties in parturition. Women are to be relieved in difficult labours, 1. By time and patience. 2. By encouragement to hope for a happy event. 3. By ( 12 ) 3. By regulating their general con- duct. 4. By lessening the obstacles to the effects which should be produced by the pains. 5. By the assistance of instruments. Intentions in the use of instruments. 1. To preserve the lives both of the mother and child. 2. To preserve the life of the mother. 3. To preserve the life of the child. Instruments contrived to answer the first intention. 1. Fillets. 2. Forceps. 3. Vectis. Three things are to be considered with respect to the Forceps or Vectis, and to the use of instruments in general. 1. To make an accurate distinction of those cases which require their use. 2. Of those" cases which allow their use. 3. Of the manner in which they ought to be used. We are in the first place to speak of the application and use of the forceps. directions ( 13 ) Directions fory and admonitions zn, the application and use of the Forceps. section i. 1. It has long been established as a general rule, that no instruments are to be used in the practice'of midwifery ; the cases in which they arc used are therefore to be considered merely as exceptions to this rule. 2. But such cases can very seldom occur in the practice of any one person ; and when they do happen, neither the for- ceps or any other instrument is ever to be used in a clandestine manner. 3. The first stage of a labour must be completed, that is, the os uteri must be dilated and the membranes broken before we think of applying i\iefcreeps. 4. The intention in the use oi the for- te jj , is, to preserve the lives both of the mother and chi'cl, but the necessity for using them must be decided by the cir- cumsianccs of the mother only. B 5. It ( 14 ) 5. It is meant, when the forceps are used, to supply with them the insuffici- ency or want of labour pains ; but so long as the pains continue, we have rea- son to hope they will produce their ef- fect, and shall be justified in waiting. 6. Nor doth the cessation of the pains always prove the necessity of using the forceps, as there may be a total or a tem- porary cessation of the pains. 7. In the former, the pulse, the coun- tenance, and the general appearances of the patient indicate extreme debility, and resembling those of a person worn out with disease or fatigue. 8. But in the latter there are no alarm- ing symptoms, and the patient often en- joys short intervals of refreshing sleep. 9. A rule for the time of applying the forceps has been formed from this cir- cumstance ; that, after the cessation of the pains, the head of the child should have rested for six hours in such a situ- ation as to allow the use of the forceps before they are used. 10. But ( 15 ) 10. But this and every other rule in- tended to prevent the rash and unneces- sary use o( the forcepSy must be subject to the judgment of the person who may have the management of any individual case. 11. Care is also to be taken tha-. we do not, through an aversion to the use of instruments, too long delay that as- sistance we have the power of affording with them. 12. The difficulties which attend the application and use of the forceps are far less than those cf deciding upon the proper time when, and the cases in which, they ought to be applied. 13. The lower the head of the child has descended, ntia tne i&nger the use of the forceps is deferred, the easier will in general their application be, the suc- cess of the operation more certain, and the hazard of doing mischief less. 14. The forceps should always be ap- plied over the ears of the child; it must therefore be improper to apply them when we cannot feel an ear. 15. But ( 16 ) 15. But when an ear can be felt by & common examination, the case is al- ways manageable with the forceps, if the circumstances of the mother require their use. 1G. The ear of the child which can be felt, will be found toward the ossa pubis, or ucder one of the rami of the icchia. 17. The ears are not turned to the sides of the pcuis till part of the hind head has emerged under the arch of the ccsa pubis, when the use of the forceps can very seldom be required. 18. When we have determined on u- s'mg thefcrccpSy and explained the ne- cessity of using them to the patient end her friends, the is to be placed in the Uouri position on her left side, near to the edge c[ the bed ; and the instru- ments, warmed in water and smeared with some unctuous application, are to be laid conveniently by you. Note. Women, impelled by their fears and their sufferings in difficult la- bours, will very generally implore you to deliver them with instruments long before you will be convinced of the ne- cessity ( 17 ) cessity of using them. In many cases I have found it expedient and encoura- ging to them to fix upon some distant time when they should be delivered, if the child were not before born ; six or eight, or twelve hours, for instance. In seme cases of great apprehension I have also shewn them, upon one of my knees, all that I intended to dowiththe/orc 5. The first action with the forceps must be to bring the handles, firmly grasped in one or both hands, slowly towards the pubes till they come to a full rest. 6. After waiting till the pa'ns return, or an imaginary interval if there should be a total want of pain, the handles are to be carried back in the same slow and cautious manner to the perinaumy using at the same time a certain degree of ex- tracting force. 7. The subsequent actions must be from handle to handle, or occasionally by simple traction ; but the action of ^°t blade which was towards the +>ubpn must be stronger and more extensive throughout the operation, than the ac- tion with the other blade which has no, fulcrum to support it. 8. By a repetition of these actions, al- ways directed according to the position of the handles, with their force increas- ed, diminished, or continued, according to the exigence of the case, we shall in a short time perceive the head of the child descending1/ ,9. Whea ( 23 ) %. When the head begins to descend, the force of the action with the forceps must be abated, and as that advances, the direction of the handles must change by degrees more and more to each side, and towards the pubes. 10. The lower the head of the child descends, the more gently we must pro- ceed, in order to prevent any injury or laceration of the perhiazum or external parts, which are likewise to be supported in the same manner as in a natural labour. 11. In some cases, the mere excite- ment occasioned by the application of the forceps, or the very expectation of their being applied, will bring on a re- turn or an increase of the pains suffici- ent to expel the child without their as- sistance. 12. In other cases we are obliged to exert very considerable force, and to con inue it for a long time ; so that one operation may be safely and easily finish- ed in twenty minutes, or even a less time, and another may require more than an hour for its completion, and the repeated ( 24 ) repeated exertions of very considerable force. 13. In some cases it happens also, that the obstacle to the delivery exists at one particular part of the pelvis, and when that is surmounted, the remainder of the operation is easy ; but in other cases there is some difficulty through the whole course of the pelvic. 14. Before the exertion of much force we are always to be convinced that a small or a moderate degree of force is not equal to our purpose. 15. In every case in which the forceps have been applied, they ?re not to be removed before the head is extracted, even though we might have little or no occasion for them. 16. When the head of the child is born the forceps are to be removed, and the remaining circumstances are to be ma- naged as if the labour had been natural. Note. The general arguments a- gainst the use of instruments have been drawn from their abuse : it appears, however, 4 t 25 ) however, that necessity will justify the use of the forceps ; that when such ne- cessity exists, their use is not only justi- fiable, but often highly advantageous ; that delay to apply them, and slowness in their application and use, will secure, as far as is possible, both the mother and child from untoward accidents; but that mischief cannot be prevented if they are applied too soon, or the opera- tion with them be performed in a hurry. It would be a very desirable thing that every student should have an opportuni- ty of seeing the operation with the for- ceps performed before he goes into prac- tice ; but that is not always possible. Yet if he has been properly instructed in the principles of the application and use of the forceps, reflects seriously be- fore he determines on performing the o- peration, and proceeds slowly -but not timidly in it, he can hardly fail to suc- ceed. Hurry, in any operation, is a ve- ry common sign both of want of infor- mation, and of fear; and attention is be paid to the order of the rule in Celsus, 1. tutOy 2. citOy Z.jucunde* C SECT. X 26 ) SECTION IV. On the application and use of the Vectis. 1. We shall have a just idea of the vectis by considering it as one blade of the forceps a little lengthened and en- larged, with the handle placed in a di- rect line with the blade. 2. The general condition and circum- stances of labours before stated, as re- quiring and allowing the use of the for- cepSy will hold equally good when the vectis is intended to be used. 3. In the application of the vectis two fingers, or the fore finger of the right hand is to be passed to the ear of the child. 4. Then taking the vectis by the han-. die, or with the blade shortened in the left hand, conduct it slowly till the point of the vectis reaches the ear, how- ever that may be situated. 5. The instrument is then to be ad- vanced, as was advised with the forceps, till according to your judgment the ex- tremity C 27 ) tremity of the blade reaches as far, cr a little beyond the chin of the child. 6. Then grasping the handle of the instrument firmly in the right hand, wait for the accession of a pain. 7. During the continuance of the pain raise the handle of the instrument gent- ly but firmly towards the pubeSy drawing at the same time with some degree of extracting force. , 8. When the pain ceases let the in- strument rest, and on its return repeat the same^kind of action, alternately rest- ing and acting in imitation of the man- ner of the pains. §. By a repetition of this kind and manner of action the head of the child is usually advanced, and the face turn- ing gradually towards the hollow of the sacrum, the position of the handle of the vectis will be altered, and the direction of the action with it of course be chan- ged. 10. When the head is perceived to de- scend we must proceed more slowly and carefully, according to the degree of de- scent, in order to prevent any injury to the ( 28 ) the external parts, which is to be pre- vented, as was directed, when the for- ceps are used. 11. But. if by the continuance of the moderate force before recommended, the head should not descend, it must be gradually and cautiously increased till it becomes sufficient tty bring down the head. 12. In the action with the vectis the back part of the instrument must rest upon the symphysis of the ossa pubisy or upon the ramus of the ischium according to its position, as upon a.ful€rumy for its support. 13. By passing the flat part of the hand to the back of the blade of the in- strument when in action,.we shall be oc- casionally able to lessen or take off this pressure which must otherwaysbemade upon the parts of the mother. 14. Some have recommended the vec- tis to be used when the head of the child was higher up in the pelvis than is be- fore stated, as justifying the use either of this instrument or the forceps. 15. They have also recommended the vectis ( 29 ) vectis when the head of the child was firmly locked in the pelxtisy and have as- serted that by its use there is often ob- tained a very good chance of preserving the life of a child, which 'must other- wise be inevitably lost. 16. Others have by frequent use ac- quired such dexterity as to be able to extract the head of a child in the, situa- tion first stated, with a single sweep of the instrument. 17. Some have also advised the intro- duction of the vectis between the sacrum, or sacrosciatic ligaments, and the head of the child, from a belief that it could be equally or more advantageously used in this position than in that first stated. 18. But having ever considered the use of all instruments as a thing to be lamented, and when I did use them, es- teemed the safety of using them as my principal object, I cannot deviate from these principles, or enter upon a discus- sion of points of practice, of which, as far as I am competent to judge, I can- not approve. Note. Before, and immediately af- C 30 ) ter the publication of my second Essay on Difficult Labours, several gentlemen, with whom I converse, and to whom I ought to pay great respect, reprehended in very decided terms what I have ad- vanced with regard to the forceps and vectis. Some maintained that the forceps is an instrument far superior to the vec- tisy of which I was accused of speaking too favourably. Others, of equal res- pectability, accused me of speaking with timidity, or restraint, of those advanta- ges which, they asserted, the vectis had over the forceps. This very strong evi- dence could only be invalidated by its contradiction, but the very respect which I bear to the witnesses, compelled me to pass over their evidence, and to rely up- on my own experience and judgment. I did not speak of the mechanism of the instruments, or of the operation per- formed when we had applied, and acted with them, as these have hitherto been very imperfectly and often erroneously explained. The subject came under con- sideration in the ordinary course of the work, and having frequently used both the ( 31 ) the instruments, I stated the matter e- quitably, according to the best of my a- bilities, and in such a way that, I thought, students, who were principally concerned in the discussion, being left with the choice of either instrument, ac- cording to the doctrines of the particu- lar professors whom they might attend, could not be misled. It is not to be ex- pected that men versed in practice, should change theiropinions or alter their practice, or, in short, pay much regard to disputes about instruments, if any were disposed to raise them. It thenwas, and yet remains my opin- ion, founded, as I before observed, on my experience with both instruments, that the superior excellence which has been attributed to each of these instru- ments, ought chiefly to be ascribed to the dexterity which may be acquired by the habit of using either of them. It is also my opinion that we may, in general, ei- ther with the forceps or vectis, effectual- ly and conveniently give that assistance which is required in cases of difficult parturition, allowing and justifyingtheir use. C 32 ) use. In particular cases it may perhaps be proved that one instrument is more commodious than another. But if the vectis be depreciated by those who have never used it, and are not expert in its use, because they pre- fer the forceps, or if the known proper- ties of the forceps be not allowed by those who do not use them, because they prefer the vectis, the proper inference would not be, that either of the instru- ments ought to be condemned ; but that we are in possession of two. instruments well adapted to answer the same pur- pose, if they are prudently used~ Class. III. Preternatural Labours. Character.—Labours in which any part of the child presents, except the head. TWO ORDERS. ordi:r i. Frescntati&ns of the Breech, or inferior Extremities. ORDER, ( 33 ) ORDER II. Presentations of the Shoulder, or superior Extremities. section i. 1. The presentation of children at the time of birth may be of three kinds. 1. With the head. 2. With the breech, or inferior extremities. 3. With the shoul- der, or superior extremities. 2. Presentations of the first kind are called natural, those of the second and third kind, preternatural. 3. Preternatural presentations have been subdivided into a much greater va- riety, but without any practical advan- tage. 4. The presumptive signs of the pre- ternatural presentation of children are very uncertain, nor can it ever be deter- mined ( 34 ) mined what the presentation is, till we are 'able to feel the presenting part. 5. When any part of a child can be felt, we may form our judgment of the pre- senting part by the following marks. 6. The head may be distinguished by its roundness, its firmness, and its bulk. 7. The breech may be known by the cleft between the buttocks, the parts of generation, and by the discharge of me- conium. 8. The foot may be distinguished by its length, by the heel, by the shortness of the toes, and the want of a thumb ; and the hand by its flatness, by the thumb, • and the length of the fingers. section II. On the first Order of Preternatural Pre- sentations. 1. In this kind of presentation the breech, one hip, the knees, and one or both legs, are to be included. 2. In ( 35 ) 2. In these presentations it was for- merly supposed necessary, as soon as they were discovered, to introduce the hand to bring down the feet, and to ex- tract the child with expedition. 3. But, according to the present prac- tice, such labours are not to be inter- rupted, but allowed to proceed as if the presentation was natural; unless the ne- cessity of giving assistance should arise from some circumstance independent of the presentation. 4. By acting on this principle, when the breech of the child is expelled by the pains, the parts are sufficiently distend- ed to allow the body and head to follow without any danger from delay. 5. But if the feet of the child were to be brought down in the beginning of la- bour, the difficulty with which it would be expelled or could be extracted, in- creasing as it advanced, the child would probably die before the woman was de- livered, and she would be in danger of suffering mischief. 6. In ( 36 ) 6. In cases of this kind there Is also equal reason, when the breech is on the point of being excluded, for our guards ing the perineum from the hazard of la- ceration as in presentations of the head. 7. In first labours, the child, unless it be very small, will not unfrequently be born dead when the breech, or inferior extremities, present; but in subsequent labours they will usually be born living, if there be no other impediment than that which is occasioned by the presen- tation. 8. The injuries which the presenting part of the child, especially the penis, and scrotumy may sustain will often be alarming, and appear dangerous, but by soothing and gentle treatment, they are soon recovered. 9. Should there be reason to think the child dead, or the powers of the mother insufficient to expel it, we must then give such assistance as may be required. 10. This assistance mustbe given with the hand, or with a blunt hook or crotch- et, hitched in the groin of the child; or, which ( ^7 ) which I prefer, by passing a ligature, round the bent part of the child at the groin, with which we can hardly fail to extract it. 11. But every assistance of thi3 kind must be given with discretion, and we must first be convinced of the necessity before we interfere. section III. Of the second Order of Preternatural Presentations. 1. In this kind of presentation are in- cluded the shoulders, the elbows, and one, or both arms. 2. In all these presentations we shall "he under the necessity of turning the child, but as they may be attended with circumstances widely different, it is ne- cessary to make the following distinc- tions. 3.—1. When the os uteri is fully dila- ted, the membranes unbroken, or the wa- ters D C 38 ) ters lately discharged, a superior extre- mity being perceived to present, before the uterus is contracted. 4.—2. When the membranes break in the beginning of labour, the os uteri be- ing little dilated. 5.—3. When the os uteri has been ful- ly dilated, the membranes broken, and the waters long discharged, the uterus being at the same time strongly contract- ed, and the body of the child jammed at the superior aperture of the pelvis. 6.—4. When, together with any of these circumstances, there is a great disproportion between the size of the head of the child, and the dimensions of the cavity of the pelvis. section IV. On the Cases xvhicb came under the first ' Distinction. 1. Whenever there is a necessity of turning a child, the patient is to be pla- ced upon her left side, near the edge of the ( 39 ) the bed ; or sometimes, when we ex- pect to find much difficulty, in a prone position, resting upon her elbows and knees. 2. All the advantage to be gained from any particular position of the patient is, to allow us the free and dexterous use of our hand's ; the situation of the child not being altered by the position of the patient. 3. The os externum is then to be dila- ted with the fingers reduced into a coni- cal form, acting with a semi-rotatory motion of the hand. 4. The artificial dilatation of all parts must be made slowly, in imitation of the manner of natural dilatation. 5. The os externum should be amply distended before the hand is carried far- ther, or its contraction round the wrist will be an impediment in the subsequent part of the operation. 6. When the hand is passed through the os externum, it must be slowly con- ducted to the os uteriy which being whol- ly or sufficiently dilated, we must break the ( 40 ) the membranes by perforating them with a finger, or by grasping them firmly in the hand. 7. The hand must then be passed a- long the sides, thighs, and legs of the ehild, till we come to the feet. 8. If both the feet lie together we must grasp them firmly in our hand; but if they are distant from each other, and we cannot conveniently lay hold of both feet, we may deliver by one foot without much additional difficulty. 9, Before we negin to extract we must be assured that we do not mistake a hand for a foot. 10. The feet must be brought down, with a clow waving motion, into the pel- vis ; when we are to rest and wait till the uterus begins to contract, still re- taining them in our hand. 11. When the action of the uterus comes on, the feet are to be brought lower at each return of pain, till they are extracted through the external ori- fice, and the labour may then be finish- ed, partly by the efforts of the mother, and partly by art. 12. If ( 41 ) 12. If the toes are turned towards the pubesy the back of the child is towards the back of the mother, which is an un- favourable position. 13. But if the toes are towards the sa- crum, the back of the child is towards the abdomen of the mother, which is pro- per ; and all other positions of the child must be gradually turned to this as the body is extracting. 14. Yet this position of the child is on- ly advantageous when the head comes to be extracted. 15. Wrap the feet of the child in a cloth,*and wait till there is a contraction of the uterus, or a pain, during the con- tinuance of which gently draw down the feet. 16. When the pain ceases we must rest, and proceed in this mannerthrough the delivery, assisting the efforts of the patient, but not making the delivery wholly artificial. 17. When the breech comes to the os- externum, the child must be extracted very slowly through it, and in the pro- per D2 ( 42 ) per direction, cr there will be danger of lacerating the perinamm. 18. When the child is brought so low that the funis reaches the os externum, a small portion of it is to be drawn out, to slacken it to lessen the chance of com- pression, or to prevent the separation of it from the body of the child, or of the placenta from the uterus ; and from this ,time the operation should be finished as speedily as it can with safety. 19. But if the circulation in the funis be undisturbed there is no occasion for haste, as the child, we are then assured, is in safety. 20. The child may be extracted with- out much difficulty if we act alternately from side to side, by making a lever of its body, and sometimes by pressing it from the ossa pubis with the fingers. 21. If the child should stick at the shoulders, the arms must be successive- ly brought down. 22. This is to be done by raising the body the opposite way, and by bending them at the elbow very slowly, lest they should ( 43 ) should be broken, and the hand must be cleared toward the pubes. 23. When both the arms are brought down, the body of the child must be sup- ported upon our left hand placed under the breast, and the fingers on each side of the neck. 24. Then placing the right hand over the shoulders, and pressing with our fin- gers the head towards the sacrum, we must ease the head along, gradually turning the body of the child as it advan- ces toward the abdomen of the mother. 25. If the head should not come easi- ly away, we must introduce the fore fin- ger of the left hand into the mouth of the child, by which the position of the head will be rendered more convenient. 26. When the head begins to enter the os externum, we must proceed very slowly, and support the perinceum, by spreading- the fingers of the left hand o- ver it. 27. In some cases there may be a neces- sitv of speedily extracting the child in order to preserve its life, but we must al- so ( 44 ) so recollect, that the child is often lost by endeavouring to extract it too hastily. 28. When a child has been extracted by the feet, the placenta usually sepa- rates very soon and very easily ; but in the management of this we are to be guid- ed by the general rules. section v. On the Cases -which come under the second Distinction. 1. We are first to ascertain the pre- senting part, and if, together with the arm, the head is perceived by a common examination, there may be no occasion to turn the child, such case only consti- tuting the third variety of natural labour. 2. But if the case should be such as to require the child to be turned, it might be doubted whether it were proper to di- late the os uteri by art, or to wait for its spontaneous dilatation. 3. Perhaps ( 45 ) 3. Perhaps neither of the methods can be constantly followed, but we may gen- erally say, that there is 'under these circumstances neither danger or increase of difficulty, from waiting for the spon- taneous dilatation, which is therefore in general to be preferred. 4. But if more speedy dilatation should be required, whatever is done by art should be done slowly, and in im- itation of nature. 5. The os uteri is always to be consid- ered as completely dilated when we judge it will allow of the easy introduc- tion of the hand. 6. When we have fixed upon the pro- per time and begin the operation, the os externum must be dilated in the manner before advised. 7. The hand must always be introdu- ced into the uterus, or that side of the pelvis where it will pass most conveni- ently ; and there is usually most room at that part which will lead to the feet. 8. It is generally most convenient to pass the hand between the body of the child ( 46 ) child and the ossa pubis, the feet being most commonly found lying toward the belly of the mother. 9. In cases which come under this distinction the uterus is seldom contract- ed very strongly upon the body of the child, but always in some degree. 10. But the difficulties which occur in the operation of turning the child, in these cases, will be fully explained under the following distinction. SECTION VI. On the cases which come under the third Distinction. 1. The difficulty in the management of these cases depends upon the degree of contraction of the uterus, and upon the distance or awkward position of the feet of the child, but chiefly upon the former circumstance. 2. The uterus is in some cases con- tracted into a globular, and in others in a longitudinal form. 3. It C 47 ) 5. It is always easier with an equal de- gree of contraction to turn the child when the uteris is contracted in a globu- lar, than in a longitudinal form. 4. When we are called to a case of this kind it is better not to form, or to give a hasty opinion, nor to attempt to deliver the patient immediately, but to deliberate upon it, and then to make a second examination. 5. If the second examination should confirm our first opinion, we may pre- pare for the operation. 6. We shall be able to judge in what part of the uterus the feet of the child lie, if we consider whether it be the right or left hand which presents, which may be known by the direction of the thumb and of the palm of the hand. 7. But the contraction of the uterus is the principal difficulty to be surmount- ed, and the danger in turning the child is in proportion to the difficulty. 8. The danger in turning a child when there is a strong contraction of the ute- rus ( 48 ) rus, is ft single danger, that of rupturing the uterus. 9. The contraction of the uterus is of two kinds ; first, the permanent contrac- tion, in consequence of the waters ha- ving been long drained off, which may occur when there has been little or no pain. 10. Second, the extraordinary con- traction arising from the action of the uterus, returning at intervals, and al- ways attended with pain. 11. The hand must be introduced with a degree of force sufficient gradual- ly to overcome the permanent contrac- tion of the uterus, or the operation could never be performed. 12. But if we were to attempt to over- come the extraordinary contraction, it must follow, that we can, or cannot o- vercome it. 13. In the first instance we should be in danger of rupturing the uterus, and in the second the hand would be cramp- ed, and we should be unable to proceed with the operation. 14. The ( 49 ) 14. The deduction is therefore clear, that we ought not to proceed in our at- temps to turn the child while the uterus is acting with violence. 15. The action of theutcrus is render- ed more frequent and strong by the gen- erally increased irritabiiitj- of the pa- tient. 16- Before we attempt to deliver it will be prudent to endeavour tj lessen this irritability, in many cases by bleed- ing, by clysters, and by an opiate, which, to answer this purpose, should be given in two or three times the usual quantity. 17. When the opiate takes effect, and the patient becomes disposed to sleep, we must consider this state as extreme- ly favourable, and proceed without loss of time to the delivery. 18. There never can be occasion to separate the arm which presents frcm the body of the child, and when this has been done, instead of facilitating, it has impeded the operation. 19. Without regarding the arm, the right or left hand, as may be most con- venient to ourselves,- must be introdu- E ced ( 50 ) ced in the manner before directed, and conducted slowly into the uterus if there be sufficient room. 20. B-ut if the child be jammed at the superior aperture of the pelvis, the hand cannot be introduced. 21. We must then fix our forefinger and thumb in the form of a crutch in the armpit of the child, and pushing the shoulders towards the head and towards the fundus of the uterus, we must by de- grees raise the body of the child till there be room for the introduction of the hand. 22. If while we are introducing our hand we perceive the action of the ute- rus come on, we must not proceed till that ceases or is abated. 23. The hand is also to be laid flat du- ring the continuance of the action of the uterus, lest the uterus be injured by its own action on the knuckles. 24. When the action ceases or is aba- ted, we must renew our attempts to car- ry up our hand to the feet of the child. 25. In this manner we are to proceed alternately resting and exerting our- selves, ( *1 ) Selves, till we can lay hold of one of both feet. 26. There is sometimes much diffi- culty in getting to the feet, and some- times in extracting them, espechiily when the uterus is contracted in a lon- gitudinal form. 27. In such cases it is often conveni- ent, when we can reach the knees, to bend them cautiously, and to bring down the legs and feet together. 28. But before we begin to extract we should examine the parts we hold, and be assured they are the feet; and we must extract slowly and steadily. 29. If we hurry to bring down the feet they may slip from us, and return to the place from which they were brought. 30. We must then carry up the hand again, and grasping the foot or feet more firmly, bring them down in the cautious manner before advised. 31. When the feet are brought down, if there be difficulty in extracting them, we must endeavour to slide a noose, first ( 52 ) first formed upon our wrist, over the hand to secure the feet, by which the hazard of their return will be prevent- ed, and the succeeding part of the opera- ration much facilitated. 32. When the nocse is fixed over the ancles, we must pull by both ends of it with one hand, and grasp the feet with the other. 33. When there is afterward much difficulty in extracting the child, it is probably owing to the body of the child being jammed across the superior aper- ture of the pelvis. 34. It will then be proper to pass the finger and thumb as directed at 21, to raise the shoulders and body of the child toward the fundus of the uterus, with one hand, and with the other ex- tract at the same time with the nocse. 35. When the breech of the child has entered the pelvis, we must proceed with deliberation, but there will be little far- ther difficult}', except from the smallness of the pelvis, of which we shall speak in the next section. SECTION C 53 ) SECTION VII. On those Cases which come under the fourth Distinction. 1. The disproportion between the - head of the child and the dimensions of the pelvis, may be added to an}- of the circumstances mentioned under the pre- ceding distinctions. 2. But as the management of these has been already directed, there is no-,v occasion to speak only of the peculiar difficulties arising from that cause. 3. The degree of difficulty in these is greater or less according to the de- gree of Oproportion; but the difficult y of extracting any part of the body of the child is little, compared with that which attends the extraction of the head. 4. We will therefore suppose the bo- dy of the child to be brought down, but that the head Cannot be extracted by a- ny of the methods before recommended. 5. The force with which we endea- vour E 2 ( 54 ) vour to extract must then be increased, till it is sufficient to overcome the diffi- culty or resistance. 6. But as the necessity of using great force can enly he known by the failure of a less degree to produce the desired effect, we must begin our attempts with moderation, and gradually increase our efforts according to the exigence of the case. 7. The force exerted should also be uniform, controuledor commanded, and exerted by intervals, in the manner of the natural pains. 8. If the head should not descend with the force which we judge can be safely exerted, we must rest, and give it time to collapse. 9. We may then renew our attempts, extracting from side to side, or back- wards and forwards, as may best con- duce to ease the head through the dis- torted pelvis, alternately resting and en- deavouring to extract. 10. But if the head should descend in ever so small a degree, the force is not to be increased with the view of finish- es ( 55 ) ing the delivery expeditiously, but we must be satisfied with our success, and proceed circumspectly. 11. When the head Once begins to de- scend there is seldom much subsequent difficulty in finishing the delivery, as the cause of the difficulty usually exists at one particular part of the pelvis. 12. But should the headrest in this situation for several hours, no addition- al inconvenience would thence arise to the mother, and the longer it rested the greater advantage we should probably gain when we renewed our attempts to extract it. 13. It may be presumed when the head of the child has been wedged for a long time in the position we are supposing, and great force has been used to extract it, that there is little reason to expect the child should be born alive ; yet in- stances of this are said to have occurred in practice. 14. When we can hook a finger on the lower jaw of the child, the direction of the head may be changed to one more favourable, and the delivery thereby fa- cilitated. 15. But C 56 ) 15. But we must not extract with so much force as to incur the hazard of breaking or tearing away the jaw. 16. Pressing the head of the child from the ossa pubis to the sacrum, with the fingers carried up as high as we can reach, will often be of great use in these cases. 17. If the difficulty of extracting the head arises from its enormous size, oc- casioned by some disease, as the hydro- cephalus, &c. these methods steadily pur- sued will answer our intention, as by a prudent use of the force in our power, the integuments will burst, or even the bones be broken. 18. I have never seen a case of this kind, in which it seemed expedient to use either one, or both the blades of the forceps, or to lessen the head. 19. But if such cases should occur, th« utmost care must be taken that we do no injury to the mother. 20. Under these circumstances- should it be absolutely necessary to les- sen the head of the child, the perforation. ma*y ( 57 ) may be conveniently madebehind either of the ears, and the general rules of the operation must be followed. 21. By the force used should the neck of the child give way, we are not to se- parate the body from the head, but we must rest longer and act moderately. 22. Should the body be separated from the head by the force we have used, or should we be called to a case of this kind, there will be no occasion for this reason alone to act hastily or rashly, as the head may even then be expelled by the pains. 23. But if this should be impossible, or if it be absolutely necessary to extract the head speedily, on account of the state of the mother ; 24. Then the general rules for lessen- ing the head must be accommodated to the exigencies of this particular case, and the head may be confined to a pro- per situation by compressing the abdo- men. SECTION ( 58 ) SECTION VIII. Miscellaneous Observations. 1. It sometimes happens that no past of the child can be perceived before the membranes break, though the os uteriht fully dilated. 2. In such cases we should not be ab- sent when the membranes break, lest it should pro\e a preternatural presenta- tion, requiring the child to be turned. 3. In some cases even when the os Uteri is dilated, the membranes broken, and the waters discharged, no part of the child can be felt. 4. It will then be prudent to introduce the hand into the uterus in the cautious manner before directed, to discover the part which does present. 5. If the head be found to present we should withdraw our hand, and suffer the labour to proceed in a natural way. 6. If the inferior extremities should present, ( 59 ) present, we may bring down the feet, and then suffer the labour to go on un- interruptedly. 7. But if the shoulder or superior ex- tremities should present, we may pro- ceed to the feet, and turn the child as was before directed. 8. By this conduct we shall guard a- gainst the danger of turning a child in a contracted uterus. 9. If we should be called to a case in which the arm presented and much force had been used to extract the child in that position, the arm having perhaps been mistaken for a leg, and the pains being at the same time violent, it may be impossible to turn the child, or even to introduce the hand into the uterus, the shoulder of the child being pushed low down into the pelvis. 10. Under such circumstances it is improper to attempt to introduce the hand into the uterus, or to turn the child, as it will be expelled by the efforts of the mother. 11. Yet in these cases the body of the child does not come doubled, but the breech ( 60 ) breech is the first part delivered, and the head the last, the body turning, as it were, on its own axis. 12. Nor is this observation made with regard to a small child coming prema- turely, as it will apply to a child of a common size, and when a woman is at her full time, provided the pelvis be well formed. 13. This fact, of the possibility of a child .being expelled in this position, though originally contradicted with great confidence, is now confirmed in the most satisfactory manner by many cases which have been recorded, in some of which the children have even been born living. 14. From these it might be inferred that a woman in a state of nature, or in perfect health, would not die undeliver- ed, though the arm of the child might present, supposing that she was not as- sisted by art. 15. Yet it is always requisite and pro- per to turn children when the superior extremities present, if the operation can be performed without the hazard of in- juring C 61 ) juring the mother, and we have general- ly a better chance of preserving the child. 16. But when there is no chance of preserving the child, and yet it cannot be turned without the greatest danger to the mother, knowing the possibility of its being expelled in this position, it is necessary to consider the propriety of the operation before we perform it. 17. It remains, however, to be proved by future experience, how far, and in what cases the preceding observation ought to be a guide in praci.ee. 18. In cases of preset tat'.on. of the superior extremities, in which the dif- ficulty of turning the child would be ve- ry dangerous, and great or insurmount- able, another method has been recom- mended. 19. But of this method, which has been practised by one gentleman to whose knowledge and experience I pay great respect, I am not a competent judge, having never tried it. 20. I therefore refer to the annexed not>* F ( 62 ) note for an explanation and history of the method to which I allude. Note. Hoorneus, saspe laudatus, ad- huc peculiarem, novum eumque brevi- orem modum, foetum mortuum cum brachio arctissime in vagina uteri hse- rente extrahendi, invenit atque descrip- sit, qui in eo consistit, ut quando ad pedes pervenire nequit, collum, utpote quod in fcetibus valde adhuctenerum est, vel scapello areliquo trunco resecet, vel unco idoneo quam cautissime auferat. Hoc enim facto, vel sponte mox pro- rumpit ex utero foetus, vel tamen, dum brachium propendens attrahitur, quod medico loco habense inservit, quam fa- cillime excutitur. Caput vero deinde seorsim mox vel manu, vel aliis propo- situs artificiis, si manus parum esset, ejiciendum. Heister. cap. cliii. sect. ix. The latter part of this description is further explained in the seventh section. I AM C 63 ) I AM induced to reprint the follow- ing, as they were the very cases which first gave me an opportunity of observ- ing the spontaneous evolution. case i. In the year 1772, I was called to a poor woman in Oxford Street, who had been in labour all the preceding night, under the care of a midwife. Mr. King- ston now living in Charlotte Street, and Mr. Goodwin, surgeon, at Wirksworth, in Derbyshire, who were at that time students in midwifery, had been sent for some hours before I was called. The arm of the child presenting, they attempted to turn and extract it by the feet, but the pains were so strong as to prevent the introduction of the hand in- to the uterus. I found the arm much swelled and pushed through the exter- nal ( 64 ) parts in such a manner, that the shoul- der nearly reached the perinceum. The woman struggled vehemently with her pains, and during their con- tinuance, I perceived the shoulder of the child to descend. Concluding that the child was small and would pass, doubled, through the pelvis, I desired one of the gentlemen to sit down to re- ceive it, but the friends of the woman would not permit me to move. I re- mained by the bed-side till the child was expelled, and I was very much surprised to find, that the breech and inferior ex- tremities were expelled before the head, as if the case had originally been a pre- sentation of the inferior extremities. The child was dead, but the mother recovered as soon and as well as she could have done after the most natural labour. CASE II. In the year 1773, I was called to a woman in Castle Street, Oxford Mar- ket, C 65 ) ket, who was attended by a midwife. Many hours" after, it was discovered that the arm of the child presented. Mr. Burosse, surgeon, in Poland Street, was sent for, and I was called into con- sultation. When I examined, I found the shoulder of the child pressed into the superior aperture of the pelvis. The The pains were strong, and returned at short intervals. Having agreed upon the necessity of turning the child, and extracting it by the feet, I sat down and made repeated attempts to raise the shoulder, with all the force which I thought could be safely used ; but the action of the uterus was so powerful that I was obliged to desist. I then called to mind the circumstances of the case be- fore related, mentioned them to Mr. Ba- rosse, and proposed that we should wait for the effect, which a continuance c.f the pains might produce, or till they were abated, when the child might be turned with less difficult)-. No further attempts were made to turn the child. Then every pain propelled itlower into the pelvis, 'and in a little more than one • Y 2 hoar ( 66 ) hour the child was born, the breech be- ing expelled, as in the first case. This child was also dead, but the mo- ther recovered in the most favourable manner. Having been prepared for observing the progress of this labour, I understood it more clearly, and attempted to ex- plain both in my lecture on the subject, and in the aphorisms which were print- ed for the use of the students, my opin- ion of the manner in which the body of the child turned as it were, upon its own axis. I also pointed out the circumstan- ces, in which, I supposed, the know- ledge of the fact might be rendered use- ful in practice ;. but with great circum-. spection. ' CASE III. January the 2d, 1774, I was called to Mrs. Davis, who keeps a Toy-shop, in Crown Court, Windmill Street. She had ( 67 ) had been along time in labour, and the arm of the child presented. The late Mr. Eustace had been cal- led on the preceding evening, and had made attempts to turn the child, which he had continued for several hours with- out success. I was sent for about one o'clock in the morning, and on examina- tion found the arm pushed through the external parts, the shoulder pressing firmly upon the perinasum. The exer- tions of the mother were wonderfully strong. I sat down while she had two pains, by the latter of which, the child was doubled and the breech expelled. I extracted the shoulders and head, and left the child in the bed. Mr. Eustace expressed great astonishment at the sudden change, but I assured him that I could claim no other merit on account of this delivery, except that I had not impeded an effect w,hich was wholly pro- duced by the pains.. This child was also dead, but the mo- ther recovered in the most favourable manner. In all these cases, the women were at the ( 68 ) the full period of utero-gestation, and the children were of the usual size. Many other cases of the same kind have occured to me, and with the histo- ries of several, varying in the time or manner in which the evolution of the child was made, I have lately been fa- voured by gentlemen of eminence in the profession, and many others have been published, in different countries. But these are sufficient to prove the fact, that in cases in which children present with the arm, women would not necessa- rily die undelivered, though they were not assisted by art. With respect to the benefit we can, in practice, derive from the knowdedge of this fact, I may be permitted to repeat, that the custom of turning and deliver- ing by the feet in presentations of the arm, will remain necessary and proper, in all cases, in which the operation can be performed with safety to the mother, or give a chance of preserving the life ofthe child. But when the child is dead, and when we have no other view but merely to extract the child, to remove the ( 69 ) the danger thence arising to the mother, it is of great importance to know the child may be turned spotaneously, by the action of the uterus. If we avail ourselves of that knowledge, the pain and danger which sometimes attend the operation of turning a child may be avoided. Nor would any person, fixing upon a case of preternatural presentation, in which he might ex- pect the child to be turned sponta- neously, be involved in difficulty, if, from a defect of the pains, or any other cause, he should be disappointed in his expectations. Nor would the suffering, or chance of danger to the patient be in- creased by such proceeding, as the usual methods of extracting the child could, under any such circumstances, be safely jind successfully practised, ( 70 ) CLASS IV. Anomalous or Com- plex Labours. FOUR ORDERS. ORDER I. Labours attended with Hemorrhage. ORDER II. Labours attended with Convulsions. ORDER III. Labours with two or more Children. ORDER IV. Labours in which the Funis Umbilicalis presents before the Child. C n ) On Labours attended with Hemorrhage. Hemorrhage. A discharge of blood from the uterus, inordinate with res- pect to time or quantity. Varieties. 1. In abortions. 2. At the full period of utero-gesta- tion. 6. After the birth of the child. 4. After the expulsion of the placenta. Note. No general description or character can be given to Anomalous Labours as a class, because the different orders bear no resemblance to each o- ther. They are brought together merely to prevent the multiplication of classes. on ( 72 ) ON ABORTIONS. SECTION I. 1. With respect to the time of preg- nancy, all expulsions of the fetus may be reduced under two distinctions. 2. In the first will be included all those which occur before the uterus is sufficiently distended to allow of any manual operation, and these may be properly called abortions. 3. In the second may be classed all those which allow of manual assistance, if required, and which are therefore to be esteemed as labours, premature or at the full time. 4. But no precise period of pregnan- cy can be fixed as a line for these distinc- tions. 5. We may, however, in general saj* that all expulsions of the fetus, before the end of the sixth month, are to be considered as abortions. 6. But ( 73 ) 6. But all expulsions of the foetus, af- ter the expiration of the sixth month, are to be esteemed as labours, and, if attend- ed with the same circumstances, should be managed upon the same principles. 7. Yet expulsions of the foetus some- times happen so critically, as to make it doubtful to which distinction they should be ascribed. 8. When manual assistance is thought needful, the longer the time wanting to complete the full period of pregnancy. the more difficult must be any operation. SECTION II. On the Causes of Abortions. 1, The predisposing causes of abor- tion are, 1st, general indisposition of the constitution; 2d, infirmity of the uterus. 2. The general state of women who are disposed to abortion is very different, some being weak and reduced, and o- thers plethoric. 3. Weakly G ( 5T4 ) 3. Weakly womenbecome more liable to abortion, because they are susceptible of violent impressions from slight exter- nal causes. 4. Plethoric women are more liable to abortion, from the disposition which the vessels of the uterus have, from struc- ture and habit, to discharge their con- tents. 5. Every action in common life has been assigned as a cause of abortion. 6. But it is to the excess of these ac- tions that we are to attribute their ef- fects, for women in health seldom abort, unless from violent external causes. SECTION III. On the Prevention of Abortion. 1. As every disease to which women are liable may dispose to abortion, the method instituted to prevent it, must be accommodated to the disease, or to the state of the constitution, 2. In C 75 ) 2. In some constitutions abortions may be prevented by repeated bleeding in small quantities, by antiphlogistic me- dicines, and sometimes by warm bath- ing. 3. In others, abortion may be prevent- ed by nourishing and invigorating diet and medicines, by bark, by wine, espe- cially claret, and often by cold bathing. 4. But it will be proper, in every case, to avoid all violent exercise, to keep the mind composed, and to rest frequently in an horizontal position. 5. Women seldom abort while they have the vomiting which usually attends early pregnancy. 6. In women who have no spontane- ous vomiting, this may be excited with safety and advantage by frequently gi- ving small doses of Ipecacuanha. 7. Pregnant women are usually cos- tive, and abortions have been often oc- casioned by too great assiduity to re- move this costiveness, which is a natu- ral and proper state, in the early part of pregnancy. section ( re ) SECTION IV. On the Signs of Abortion. 1. The signs of abortion are, frequent micturition, tenesmus, pain in the back, abdomen, and groins, with a sense of weight in the region of the uterus. 2. But the most certain sign is, a dis- charge of blood, which proves that some part of the ovum is separated from the uterus. 3. It has been supposed when this last sign appears, that there is scarcely a pos- sibility of the patient proceeding in her pregnancy. 4. But I have met with an infinite number of cases in practice, in which, notwithstanding this appearance, once or oftener, to a considerable degree, the discharge has ceased, and no ill conse- quences have followed. 5. We are therefore to persevere in tne use of those means which are thought reasonable and proper, till the abortion has actually happened. 6. It ( 77 ) 6. It is not always prudent to give a decided opinion of the probable event of those cases which may be attended with the symptoms of abortion, as their termination is very often different from what might have been expected from the symptoms. SECTION V. On the Treatment of Women at the Time of Abortion. 1. The treatment must vary according to the nature and degree of the symp- toms. 2. There is an endless variety in the manner in which abortion takes place. Some women abort with sharp and long- continued pains, others with little or no pain ; some with a profuse and alarming hemorrhage, others with very little dis- charge. In some the ovum has been soon and perfectly expelled, in others after a long time, in small portions, or very G 2 ( 78 ) very much decayed; but the only alarm- ing symptom is the hemorrhage. 3. The hemorrhage in abortions is not always in proportion to the period of pregnancy, this being in some advanced cases very small ; and in others, though very early, abundant. 4. The hemorrhage usually depends upon the difficulty with which the ovum may be expelled, and upon the state of the constitution of the patient naturally prone to hemorrhage. 5. The general principles which should guide us in the treatment of he- morrhages, from any other part of the body, are applicable to those of the ute- rus, regard being had to the structure of the uterus. 6. If the patient be plethoric, some blood should be taken from the arm at the commencement of the hemorrhage, and the saline draughts with nitre, or a- cids of any kind, may be given in as large a quantity, and as often as the sto- mach will bear. 7. These ( 79 ) 7. These may also be given during its continuance, and cloths wet with cold vinegar may be applied to the abdomen and loins, and renewed as they become warm. The patient should be exposed to, and suffered to breathe, the cold air. 8. Every application or medicine, ac- tually or potentially cold, may be used. A large draught of cold water or ice may be given with great propriety, and it is the custom in Italy to sprinkle ice over the body of the patient if the dan- ger of the case be imminent. 9. Every medicine or application which has the power of slackening the circulation of the blood, eventually be- comes an astringent, but astringents, properly so called, can have no power in stopping hemorrhages from the uterus. 10. Hemorrhages are stayed by the formation of coagula, plugging up the o- rifices of the open blood vessels, or by the contraction of the coats of the blood vessels. 11. These effects are produced more favourably during a state of faintness, which, ( 80 ) which, though occasioned by the loss of blood, becomes a remedy in stopping hemorrhages. 12. Cordials are not therefore to be hastily given to those who are faint from lossof-blood; unless the faintness should continue so long as to make u-s appre- hensive for the immediate safety of the patient. 13. The introduction of lint or any soft substance into the vagina, has been recommended, and sometimes used with advantage, by favouring the formation of coagula. 14. Cold or astringent injections into the vaginahave also been recommended. 15. Opiates have been advised in a- bortions attended with profuse discharg- es, and they may sometimes be proper to ease pain, or to quiet the patient, es- pecially when there is a chance of pre- venting the abortion, or after the acci- dent has happened. 16. But when there is no hope of pre- venting the abortion, the degree of pain proving the degree of action of the ute- rus ( si ) rus, and the action of the uterus produ- cing and favouring the contractile pow- er of the blood vessels, if by opiates the action of the uterus should be prevented or checked, they may contribute to the continuance of the hemorrhage. 17. Hemorrhages in abortions, inde- pendent of other complaints, though ve- ry alarming, are not dangerous. 18. But if women abort in conse- quence of acute diseases, there will be very great danger. 19. For they abort because they are already in great danger, and the danger is increased and accelerated by the abor- tion. 20. The ovum has been sometimes retained in the uterus for many months after the symptoms of abortion had ap- peared, and when it had lost the princi- ple of increasing. 21. But it is not now thought necessa- ry or proper in abortions, to use any means for bringing away the ovum, or any portion of it which may be retained. SECTION ( 82 ) SECTION VI. On Hemorrhages at the full Period of Utero-gcstation. 1. Under this section will be included all those hemorrhages which may hap- pen in the three last months of pregnan- cy. 2. These are occasioned first by the attachment of the placenta over the os uteri ; secondly, by the separation of a part, or of the whole placenta, which had been attached to some other part of the uterus. 3. Hemorrhages arising from the first cause are more dangerous than from the second ; but those from the second have sometimes proved fatal. 4. The danger attending hemorrha- ges is to be estimated from, a considera- tion of the general state of the patient, of their cause, of the quantity of blood discharged, and of the effect of the loss of blood, which will vary in different constitutions. 5. Hemorrhages C 83 ) 5. Hemorrhages are infinitely more dangerous with sudden than with slow discharges of blood, even though the quantity lost may be equal. 6. The danger arising from hemorr- hages is indicated by the weakness or quickness of the pulse, or by its becom- ing imperceptible, by the paleness of the lips, and a ghastly countenance, by in- quietude, by continued fainting, by a high and laborious respiration, and by convulsions. 7. The two last symptoms are usually mortal, though when women are ex- tremely reduced, they are liable to hys- teric affections of a similar kind, that are not dangerous. 8. The vomiting which generally fol- lows violent hemorrhages indicates the injury which the constitution has sus- tained by the loss of blood, but by the action of vomiting the patient is always relieved, and it contributes to the sup- pression of hemorrhages. 9. Near the full period of utero-gesta- tion, women are always in greater dan- ger C 84 ) ger in those hemorrhages which are not accompanied with pain. 10. For the pain proving the contrac-. tion of the uterus, and this proving that the strength of the constitution is not exhausted, the danger in hemorrhages may often be estimated by the absence or degree of pain. SECTION VII. On those Hemorrhages -which are occa- sioned by the Attachment of the Placen- ta over the Os Uteri. 1. Though the placenta, which may easily be distinguished from the mem- branes as soon as the os uteri is a little opened, be attached over the os uteri, the woman usually goes through the ear- ly part of pregnancy without any incon- venience, or symptom which denotes the circumstance. 2. But when the changes previous to labour come on, there must be an he- morrhage, ( 85 ) morrhage, because a separation of apart of the placenta is thereby occasioned, and as the disposition to labour advan- ceth, the hemorrhage is generally, though not universally, increased. 3. With this circumstance very slight external causes are also apt to occasion hemorrhage. 4. When a hemorrhage from this cause has once come on, the patient is never free from dangertill she is deliver- ed. 5. The powers of the constitution are undermined by hemorrhages profuse or often returning, so that no efforts, or on- ly very feeble and insufficient ones, are commonly made for the expulsion of the child. 6. We are therefore often obliged to free the patient from the imminent dan- ger she is in by artificial delivery. 7. Of the propriety of this delivery, in cases of dangerous hemorrhage, there is no doubt, or can be any dispute, ex- cept as to the precise time when the pa- tient ought to be delivered. 8. On H C 86 ) 8. On the first appearance of the he- morrhage, unless it be prodigious in quantity or unusually terrifying in its effect, it is seldom either requisite or proper to attempt to deliver by art. 9. Nor does it often happen that a se- cond or a third return of the discharge compel us to the delivery by art. 10. But as a patient with this circum- stance cannot be secure till she is deli- vered, and as the delivery is seldom completed by the natural efforts, and as the artificial delivery, though perform- ed before it be absolutely necessary, is not dangerous, if performed with care, we must be on our guard not to delay the delivery too long. 11. In some cases in which it might be thought eligible to deliver on ac- count of the hemorrhage, the parts are so unyielding as not to allow of the ope- ration itself without some hazard. 12. Yet when the parts requiring di- latation make no resistance to the pas- sage of the hand, the event of the opera- tion C 87 ) tion is always more precarious, the ope- ration having been deferred too long. 13. But though it may be proper in some cases to determine on immediate delivery, the operation must always be performed with the utmost deliberation. 14. The first part of the operation has been described under preternatural pre- sentations. 15. When the hand is carried to the placenta attached over the os uteri, it is of little consequence whether we perfo- rate the placenta with our fingers, or se- parate it on one side till we come to the edge, though the latter is generally pre- ferable. 16. If the hand be passed through the placenta, we shall come directly to the part of the child which presents. 17. But if we separate the placenta to the edge, the hand will be on the outside of the membranes, which must be rup- tured before we lay hold of the feet of the child. 18. No regard is to be paid to the part of ( 88 ) the child which may present, as it must always be delivered by the feet. 19. The feet of the child being brought slowly into the pelvis, we must wait till the uterus is contracted to the body of the child, which will be indicated by pain, and known by the application of our hand to the abdomen. 20. The delivery must then be finish- ed very slowly, to give the uierut time to contract as the child is withdrawn from its cavity; but this part of the ope- ration has likewise been described under preternatural presentations. 21. An assistant should make a mode- rate pressure upon the abdomen during the operation, to aid the contraction of the uterus, and to prevent ill consequen- ces from the sudden emptying of the ab- domen. 22. When the child is born, the he- morrhage will be generally stayed, if the operation has been performed slowly. £3. But if the hemorrhage should con- tinue or return, the placenta is to be ma- naged as will be afterwards directed. ( 89 ) 24. Should no uncommon difficulty attend the delivery, children will be of- ten born living in cases of hemorrhage which are attended with the utmost dan- ger to the mother ; or, as it has some- times happened, after the death of the mother. 25. Before, during, or after delivery in cases of hemorrhage, the means and applications before recommended, may be occasionally used with advantage. SECTION VII. On those Hemorrhages which arc occa- sioned by the Separation of a Part, or of the-whole Placenta, before or in the Time of Labour. 1. Hemorrhages arising from this cause are seldom so alarming or danger- ous as the preceding. 2. But if the separation of the placen- ta be sudden and extensive, the danger H2 C 90 ) may be equal, and the same mode of proceeding required. 3. Our conduct must be guided by a consideration of the degree and effect of the hemorrhage, and of the state of the labour when it occurs. 4. Should the hemorrhage from this cause occur in the first period of labour, the action of the uterus will be weaken- ed, but it may be sufficient to dilate the os uteri. 5. If the quantity of blood lost in these cases be very considerable wdien the os uteri is sufficiently dilated, the greater the degree the better, the mem- branes containing the waters may be ruptured. 6. By the discharge of the waters the distention of the uterus will be lessened, and by the consequent contraction, the size of the vessels being diminished, the hemorrhage will of course be abated or removed. 7. After the abatement or suppression of the hemorrhage, the action of the ute- rus will become stronger, so that the delivery will, in general, be then com- pleted without further assistance. ( 91 ) 8. But if he hemorrhage should con- tinue after the discharge of the waters in such a degree as to threaten danger ; or if it should commence in the second period of the labour, the interposition on our part must vary according to the circumstances, and chiefly according to the situation of the child. 9. It may in some cases be necessary to deliver by art as in the preceding sec- tion, and in others to deliver with the forceps or vectis, if the hemorrhage be profuse, and we despair of the child be- ing expelled by the natural efforts. 10. The proper management of all such cases may be collected from what will be generally said on the subject, being always on our guard to distinguish be- tween fear and real danger. SECTION ( 92 ) SECTION VIII. On those Hemorrhages which occur when the Placenta /* retained after the Birth of the Child. 1. The placenta is generally expelled by the spontaneous action of the uterus in a short time after the birth of the child. 2. But sometimes the placenta is re- tained, 1st, from the inaction or insuffi- cient action of the uterus ; 2d, by the ir- regular action of the uterus ; 3d, by the scirrhous adhesion of the placenta to the uterus. 3. Sometimes there is a profuse dis- charge of blood, when no action is ex- erted by the uterus to expel the placenta. 4. Whenever there is a hemorrhage, the whole or a portion of the placenta must have been previously separated, and the hemorrhage usually continues, or returns till the placenta is expelled or extracted out of the cavitvof the uterus. SECTION C 93 ) SECTION IX. On the Retention of the Placenta/r