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NATIONAL LIBRARY OF MEDICINE
          Washington 
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	WORCESTER, ^ MASS. ^		
			
 
 
         APHORISMS

               ON THE

      APPLICATION AND USE

               OF THE

     FORCEPS and VECTIS ;

*On Preternatural Labours—on  labours
     attended  with  Hemorrhage—and
     with convulsions.
 By THOMAS DENMAN, M. D
Licentiate in Midwifery of the College of Phyficians, Lor.
    don; and Honorary Member of the Royal
         Medical Society at Edinburgh.


   SECOND AMERICAN EDITION.

                     ■-■•si   •
             Leomiwstsr I m
       Printed by Salmon Wilder,
    For I S A I A H T H O M A S, Jum.
$oldby bim  andly Thomas 1$ Whipple, New-
           buryport.—1&06. 
 
   ,   RECOMMENDATION

 By two eminent PHYSICIANS of Phi-
             ladelphia.
   BEING  requested,  by the American
publisher i to give our opinion of this work,
 we cheerfully mention, that it was written
 by one of the most scientific and experienc-
 ed practitioners in London, ana  that it
 contains in a small compasf,  what  he has
 more diffusely explained  in his  excellent
 Introduction to MIDWIFERY.  It
 is indeed a concise summary of the most
 valuable practical precepts,  and as such
 we may, with safety,  warmly  recommend'
 it to the students in that science which the
author taught for many years, with dis-
tinguished reputation in the  metropolis cf
 Greatbritain.  To say more, in this place,
would perhaps be superfluous,  and incon-
sistent with the spirit of the work we wish
to recommend ; one of whose greatest mer-
its is brevity and precision.
            THOMAS C. JAMES.
            J.  CHURCH.
  Philadelphia, 1803.. 
         Dedication*



                TO

     Dr. THOMAS  SAVAGE.

    DP.AK. SIR,
  TIIE^E Aphorisms, designed for the
use of studentsv I request you v ill per*
nut me to rledicate to you.   I wish also
'« tc'ze this  opportunity of conveying
those sentiments- of respect I have ever
entertained for the integrity  and benevo-
Icice which so eminently  distinguish
your character ; and to express my gratv
itude for that kindness and partiality you
have always shewn to,

    Dear Sir,

      Your obliged, and

         affectionate humble servant,.

            THOMAS  DENMAN.

  Dec. 7, 1792. 
ARRANGEMENT

       OF

LABOURS.
       FOUR CLASSES.
L  Natural.—II. Difficult.—ni.-
  Priternatural.—IV.  Anoma-
  lous, or Complex.
Class 1.—NATURAL LABOURS. t

          Character.
    EVERY labour in which the pro-
     cess is completed within twenty-
four hours, the head of the child present-
ing^ and no adventitious assistance being
required.-
          VarieTies.-

*' 2Je face *ncIined towards the sacrum,  •
2. The face inclined  towards the ossai
  pubis*
              A 2
♦ 
               (   6  )

  3. The  head presenting  with oae or
     both arms.
  4. The face presenting.

  That part of a  child which descends,
lowest into the pchis, is to be esteemed
the  presenting part..

     Circumstances attending labours.
  I. Anxiety.
  2. Rigours..
  3. Stranguary.
  4. Diarrhoea.
  ?>. Mucous discharge, with or without
     a mixture of blood.
  G. Pain.

            Causes of Pain.
   I. Expulsatory  action of the uterus.
  2. Resistance made  to  the effect of
     thab action.

          Distinct'mn of Pain.

   1. True.
   2. False.
 Cmisrs snd signs of £Jse pain,.
 Jvfcansof removing them. 
               (:  *   y

Means by which true pains are supposed
  to be regulated,, and their, effect, pro-
  moted..

  Note. The pains attending labour are
subsequent to the action of the uterus,,
though in common  language the word
pain, and  the action  of the. uterus, are
used synonimously.

      Progress of Natural Laboursi.

  Three periods or stages,
    1st period.              v
     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 placcn*-
     ta.

  Note. It very often happens that the
membranes do not break till the head oi:
the child is on the point of being expel- 
•  -
               (81.

led.   This is the natural and most desir-
able progress of a labour, and it is a ne-
gative proof that the labour has been well
conducted; that is, not interrupted. But
the description given above,  will, an-
swer the purpose  of  impressing a clear
idea of labours in general.
  The two circumstances which princi-i
pally require attention in natural labours
are, to guard iht-perimeum and to extract
theplacenta with discretion.
Class II.-DIFFICULT LABOURS.

            Character.
  Every labour in which the process is
prolonged beyond twenty four hours, the
head of the  child presenting..

  Note. Some objections may be  made
to this definition taken from time,  but it
will be found to apply to practical uses
better than if it was taken from circum-
stances.
  It would often be  extremely  difficult
to say with precision when a labour actu- 
                      3
               (  »   \

ally begins,  because  of the number  of
concurrent changes.    But  in general
some progress must  be made before we
tan allow a labour to be commenced.
         FOUR ORDERS.

              ORDER I.

Labours rendered difficult from  the  inert
    or irregular action of the uterus.

              SAUSES.

  t. 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. 
4
               (  10   )

              ORDER II.

 Labours rendered difficult by the rigidity
        of the parts to be dilated.

   1.  First child.
   2.  Advancement in age.
   S.  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 nteri.
   7.  Uncommon  rigidity of the exter-
    nal parts.

             ORBER III.

'Labours rendered diffiadtfrom dispropor-
  tion between the dimensions oftnecavi-
 ' *y of the pelvis and the headqf the child.
  1. Oiiginal smallness olikit pelvis.
  2. Distortion of the pelvis.
  3. Head of the child unusually Ir.rge,
  . or too much ossified.
 4. Head of Ihe child enlarged by dis-
    ease.
 5. Face inclined towards the ossa pit*
    bis. 
(  11   )
  6. Presentation of the face.
  7. Head presenting with one or botfa
    amis.

             ORDER  IV.

Labours rendered difficult  by disease* of
            the soft parts.

  1. Suppression of urine.
  2. Stone in the bladder.
  3. Excresences 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 natural
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 4i$cult
labours,

  1. By time and patience.
  2. By encouragement  to hope for a
     happy event. 
(  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.   Vectts.
   Three  things are  to be   considered
 with respect to the Forceps or Feetisy 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 aie in the first place to speak of
fee application and use of the forceps. 
(  13   )
directions for, and admonitions  in, tJie
   application and use of tlie 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  m which  they arc used -ail*
therefore to be considered merely as ex-
ceptions 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
forceps 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 be-
fore we think of applying the forceps.
   4.>TheJntention in the use of the for-
ceps is, to preserve the  lives  both of the
mother and child, but the necessity for
using them must be deckled  by the cir-
cumstances of the mother only.
                   B 
(  u   )
   5. It is-meant,  when  the forceps are
 used, to supply with  them  the  insuffi-
 ciency 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-
 joy:* short intervals of refreshing sleep.
   9. A rule for the time of applying tin
forceps has  been  formed  from  this cir-
 cumstance ;  that,  after  the cessation of
 tluj pains, the head of the child should
 have rested for six hours  in such a situ-
 ation as to allow the use of the foraps be-
 fore they are used. 
               (   15   )

  ■10.  But this and every other  rule in-
tended to prevent the rash and unneces-
sary use of the forceps, must be  subject
to the judgment of the person  who  m;: v
have the management of any  individual
case.

  11.  Care is also to be taken that w*
do not, through an aversion to the use oi'
instruments,  too  long  delay  that assis-
tance v/e have the  power of affording with
them.

  12.  The difficulties which attend  the
application and use of the forceps are fir
less than those of deciding upon the prop-
er time when, and the cases  in which,
they ought to be  applied.
  13.  The lower the head of  the  child
has descended,, and the longer  the use of
the forceps is deferred, the easier will in
general their application be, the  success
of the  operation more  certain, and  the
hazard of doing nilschiei'less.
  14.  The forceps shou'd a'haavs be ap-
plied over the ears of the child;  it must
therefore be improper to a r! them v. hen
we cannot feel an ear* 
(  1*   )
  15. But when an ear can be felt by a
tvvriirnca examination, the case is always
manaacabie with the forceps j£ the circum-
stances of che mother require their use.

  16. The ear of the child which can be
felt, will be found toward  the ossa pubis.,
or under one of the rami of the ischia.
  17. The  ears r,re not turned to the
sides of the pch'is  till part of the  hind
head has emerged under the arch of the
ossa pubis, when  the use of the forceps
can wy seldom be required.
  IS. When wre have determined on us-
ing the forceps, and explained the neces-
sity of using them to the patieat and her
friends,  she is  to be placed in the usual
position on her left side, near to the edge
of the bed ; and the instruments, wrarm-
ed in water and smeared with some unc-
tious application, are to be laid convenient-
ly by you.
  Note. Women, impelled by their fears
and their sufferings in difficult labours,
wili, very  generally implore you to de-
liver them v\ ith instruments long before
you will  be convinced of the necessity 
               f  IT  }

 of using  thera.  In many cases  I have
 found it expedient and encouraging, 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 some cases of
 great apprehension I have also shewn them,
 upon one of my knees, all that I intend-
 ed to do with the forceps.
   The following rules are given on  the
 presumption  that the head of the child
 presents with the face  inclined or verg-
 ing towards the hollow of the sacrum, and
 that the common short forceps are intend-
 ed to be used;  but if any other kind of
forceps should  be preferred,  the  rules
 must be adapted to the  instrument.
            section  rr.

  .1. Carry the fore finger of the  right
hand to the ear  of the child.
  2. Then take the blade of the forceps
to be first introduced by the handle in
the left hand,  and conduct it between
the head of the child and the finger al-
                 R2 
r  w   )
 ready introduced,  till the  point reaches
 die ear.

    3. The farther  introduction must be
 made with a motion resembling a slight
 degree  of semi-rotation,  and the point
 of the blade must be kept  close  to  the
 head of the child,  by  gently raising the
 handle as the instrument is advanced.

  4. The blade of the forceps must be car-
 ried up till the lock reaches the external
 parts, near the inferior edge of the ossa
 pubis.                          i-

   5. Should any difficulty occur in the
 introduction of either  of the blades, we
 must withdraw them a little, to discover
 the obstacle, and never  strive  to over-
 come it with violence.

   6.  When fche first blade is introduced,.
 it must be held steadily in its  situation,
 as it will be a guide in the  introduction
 and application of the second blade.

  7. The second  blade  of the forceps
mint be  conducted  upon the fore finger
of the left hind, passed  between the
head of the  child and  the perinceum,  in 
(  19   )
the same  cautious manner as the first,
till the  lock  reaches the perinxum, or
even presses it a little backward.
   8. When the second blade is properly
introduced, its situation will  be opposite
to the first.
   9. In order to lock the forceps, the
handles of which arc at a considerable
distance from each other, the blade  first
introduced must  be brought down and
carried  -so far  back that it will lock with
the second blade, held  in  its first posi-
tion.
   10. Care should be taken that nothing
be entangled  in  the  lock of the forceps
by carrying the finger round it.
   11. It is convenient to  tie the handles
of the forceps together, when locked, with
force sufficient to keep  them from slid-
ing or shifting their position.
  12. If the blades of the forceps were
introduced so as  not to  be  opposite to
each other, they could not be locked.
   I3. Should the handles  of the forceps
when applied come close together, pro-
bably the bulk of the head is not included 
(  20   )
between them, and therefore when we
acted with them they would slip.
   14. If the handles when locked are at
a great distance from each other, they
are not well applied, and  will probably
slip.
   15. But in these estimations allowance
is to be made for the different  dimen-
sions of the heads of children.
   16, The forceps will never slip if ju-
diciously applied, if the case be proper
for their  use,, and we act circumspectly
with them.
   Note. The difficulties in the applica-
tion of the forceps arise, from attempting
to apply them too soon ;  from passing
them in a hurry, or in a wrong direction;
or from entangling  the soft parts of the
mother between the instrument   and the'
head of the child.    Of course,  we are
always to be guarded  against these cir-
eumstancesr 
(  21   )
             SECTION III.


  1. There is no occasion, and it would
be hurtful to attempt to change the posi-
tion of  the head,  when the forceps are
applied, before we began to extract.
  2. For if the action with the forceps be
slaw, the head of the  child will turn in
the same m inner,  and for the same rea-
sons, as in a natural labour.

  3, Therefore theforeeps  being fixed
upon the  head must also change their
position according to  its descent,  and
the handles  be gradually  turned from
the ossa pubis and  sacrum, where they
were first placed, to the sides of the^pcl-
vis.
  4. The handles of the forceps likewise,
though originally  placed far back  tow-
ward the sacrum, that is, in the direction
of the cavity  of the pelvis, are to be grad-
ually turned,  as the  child advances,,
more and more  towai'ds the pubes,  that
is» in the direction of the vagina* 
(  22   )
   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 pains 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 theperinceum,  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-  tractioh;  but the  action of
 that blade which was towards the pubes,
 must be stronger and more   extensive
 throughout the operation,  than the ac-
 tion with the other blade which ha# 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
 tothe exigence of the  case, we shall in
 a-short   time  perceive  the head, of the
 child descending. 
(  23   )
  9. 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 to'wards 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
lacer:.I ion of the perinceum or external
partSjWhicU 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 sufficient
to expel the child without their assist-
ance.

   15. In other cases we  are obliged  to
exert very considerable  force, and  to
continue 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 re- 
(  24   )
 peated  exertions of very  considerable
 force.
   13.  In some cases it happens also, that
 the obstacle to the delivery exists at one
 particular part of tlie pchis, and when
 that is surmounted, the remainder of the
 operation is easy; but in other eases
 there is some difficulty through the whole
 course of the pchis.

   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 are not to be re"
 moved before the head is extracted, even
 though we  might have little, or no occa-  ,
 sion 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  hem their abuse:  it  appears, 
(  25   )
however, that necessity will justify the
use of the forceps ;  that when such ne-
ce'ssity exists, their use is not only justi-
fiable, but often  highly  anvantageous ;
that delay to apply  them, and  slowness
in their application and use, will secure,
as fir 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 operation  with
them be performed in a hurry.

   It would bea 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, reflect seriously be-*
fore he determines on performing the o-
pcration, and proceeds slowly Tv.t 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 must
be paid to^he order Of the rule hi  Cclsus,
1, tuto, 2. a to, 3:Jricuncfe. 
(  26   }
             SECTION IV.

On the application and use of the  Feeds.

   1. We shall have  a  just idea  of the
vtctis 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 circit'm-
stances of labours before stated,  as re-
quiring and allowing the use of the for-
ceps, 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-
dle, or with the  blade shortened  in the
left hand, conduct it slowly till the point
of the vectis reaches the ear,however 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- 
(  27   )
tremity of the Made reaches as far, or a
little beyond the chin of the ehild.
   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 pubes, 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  manner
 of the pains.
   9,  By a repetition of this  kind and
manner of action the head of  the  ehild
 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 
(  28   )
the external parts,  which is to be pre-
vented, as was directed, when the forceps
aie used.
   11.  But if by the continuance of the
moderate  foree  before  recommended,
the head should not descend, it must be
gradually and cautiously increased till  it
becomes  sufficient  to bring down  the
head.
   12.  In the action with  the. vectis ike
back  part of the instmment must  rest-
upon the symphysis of the  ossa pubis, or
upon the ramus of the ischium according
to its position, as upon afultrum, 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 otherways be made
upen-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 pchis than is "before
stated, as justifying  the use either of this
instrument or the forceps.
   15. They have also recommended the 
(  29   )
Vectis when the head of the child was
firmly locked hi the pelvis, 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 otherwise
be inevitably lost.
   16. Others have by frequent use ac-
quired such dexterity as to be able to ex-
tract the head of a child  in the situation
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  havjng 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  front
these principles, or enter upon a discus-
sion of points of practice, of which, as far
as I  am competent to judge,  1 cannot
approve.
  Note. Before, and  immediately  after 
(  30   )
the publication of my  second Essay  on
Difficult Labours,- several  gentlemen,
with a\ horn  I converse, and to v. horn I
ought to pay great respect,  reprehended
in very  decided terms  what I have ad-
vanced  with  regard tothe  forceps  and
vectis,   Some maintained that the forceps
is an instrument far superior to the  vec-
tU, of which I was accused of speaking
too favourably.    Others  of equal  re-
spectability, accused me of speaking with
timidity, or restraint, of those advanta-
ges which,  they asserted, tKe 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 '
workj and  kaving frequently used both 
(  31   )
the instruments,  I stated  the  matter e-
quitably, according to the best  of my
abilities,and in such a way that, 1 thought;
students, who were principally concern-
ed in the discussion, being  left with the
choice of either instrument, according to
the doctrines of the particular professors
whom they might attend,  could not be
misled.    It  is not  to be expected that
men versed in practice,  should change
their opinions or alter their .practice, or,
in short, pay much regard to disputes
about instruments, if any  were disposed
to raise them..

   It then was, 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 tothe
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 assistnnce
which is required in  cases of difficult
parturition, allowmg and justifying  their 
              (  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 prefer
the forceps, or if  the known properties
of the forceps be  not allowed  by  those
who do not use  them, because they pre-
fer the vectis, the proper inference would
not be,  that  either  of the instruments
ought to be condemned ; but that we are
in possession  of  two  instruments  well
adapted to answer the  same purpose, if
they are prudently used.


 Class III.  PRETERNATURAL
            LABOURS.
            Character.

  Labours in which any ptfrt of the child
presents, except the head.
         TWO ORDERS.
             ORDER I.
Presentations of the  Breech,  or  inferior
            Extremities. 
c  &   )
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.
tematural presentation   of children are
very uncertain, nor €iul it ever be deter- 
(  34   )
rriined 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 th© want of a thumb;
and the hand by its flatness,by the thumb,
and the length of the fingers.
             SECTION II.

6n thefrst Order  of Preternatural Prt-
              sentations,
   1. In this  kind of  presentation  the
breech, one hip, the  knees,  and one or
both legs, are to be included. 
(  «   )
   2. In these presentations  it  was for-
 merly supposed necessary,  as , soon as
 they were discovered, to introduce the  ,
 hand to bringdown 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, Rut allowed to proceed as if the
 presentation was natural; unless the nec-
 essity of'giving assistance should  arise
 from seme 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 distended
 to allow the body and head to follow with-
 out 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 coula* 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. 
(  3«   )
  •6. In cases of this kind there is also
equal reason, when the  breech is on the
point of being excluded, for our guard-
ing theperinceum from the hazard of lac-
eration as in presentations of the head.

  7. In first labours, the child,  unless it
be  very  small,  will not unfrequently he
bom dead when the breech, or inferior •
extremities, present; but in subsequent
labours they will usually be bom living,
if there be no other impediment than that
which is  occasioned by the  presenta-
tion.

  8. The injuries  which the presenting
part of the child, especially the penis, and
scrotum, may sustain, will often be alarm-
ing, and appear dangerous, but by sooth-
ing and gentle treatment, they  are soon
recovered.
  9. Should there be reason to think the
child dead, or the powers of the mouier
insufficient to expel it, wre must then give
such assistance as  may be required.
  10. This assistance must be given with
the hand, or with a-blunt hook or crotch-
et, hitcfied in the groin of the chikl; or, 
(  37   )
   which  I prefer, by passing  a ligature,
   round  the  bent part  of the child at the
   groin,  with which we can hardly fail to
   extractit.
     11. But  every assistance of this 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
be 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-
D 
(  38   )
ers lately discharged, a superior extrc-
nity being perceiv ed to present, before
he uterus is contracted.
 4.'—2.  When the membranes break in
ie beginning of labour, the  os  uteri be-
ig little dilated.
 5..—3.  When the os uteri has been fu I-
' .dilated,  the  membranes broken, and
ie   waters long  discharged,  the uterus
eing at the same time strongly cOntract-
d,  and the body of the child jammed at
ie  superior aperture of the pelvis.
 6—4.  When,  together  with  any of
lese circumstances,  there is  a  great
isproportion between the size  of the
*ad of the child, and the dimensions of
ie cavity of the pelvis.
          . SECTION  It.
n the Gases which come under the first
            Distinction.

 1.  Whenever there is a necessity of
rning a child, the patient is to  be pla-
d upon her left side,  near the edge of. 
(  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 hands : the situation of the  child
not being altered  by the position of the
patient.

   3.  The os externum is then to be dib ■
ted with the fingers reduced into a couK
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 wrk,t
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 uteri, which  being whol-
\for sufficiently  dilated, we  mu.-r  break 
(  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
child, till we come to the feej.
   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 begin 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 slow waving m.Qt*on,into the pel-
vis ; when we are to rest and wait till the
nterus begins to contract,  still retaining
them in our hand.
  11. When the action *f the uterus comes
on, the  feet are to be brought lower at
each return of pain, till they are extract-
ed through the external orifice, and the
labour may then be finished partly  by
the efforts of the mother, and  partly by
art. 
■(  il   )
   12.  If the toes are turned towards th«
pubes, 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*
crums 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 ehild in a
cloth, and wait till there is a contraction
of the uterus, or a pain* during the con-
tinuance of which gendy draw down the
feet.
   16,  When  the pain  ceases we  must
rest, and proceed in this manner through
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 sfowly through h, and in the proper'
                 2D 
(  4S  J
direction, or there will be danger^of lacer-
ating1 the perinneum.
   18. When the child is brought so low-
that the funis reaches die os^oxternafn, a
small portion of it is to be drawn out;, to
slacken  it to lessen the chaftce of com-
pression, or to prevent the seperation 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. Biut if the  circulation in the funis
be undisturbed there is no  occasion for
haste, as the child, we are then assured,
is in safety.
   &0. The child may Fie 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
shoulder's, 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 
f. ■*  ).
 flhoujd 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 sid*
 ©f the neck.                    » HJ*
    24.   Then placing the right hand over
 the shoulders, and.pressing with our fin-
 ders 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 tthiid, by*which'the  position 'of the
 head Will be rendered more convenient.'
  '  26. When the head begins to 'enter
 the -os externum, w'e must  proceed  very
 slowly,  and support the perineum,   by
 spreading the fingers of the left hando-'
 Wit.  ;  .           \  ■**  v
  .  27. Inswnecasesthei^ra&ybeaneces-
 sjgr of i^eedily extracting the  child ix.
 order to preserve its.Jiife^to W* mustaU 
(  "  0
 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 vesy soon and very easily ;  but in
the management of this we are to be guid-
ed by the general rules.
             section  v.
                                      j

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 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  reqnired, whatever  is done by  art
should be done slowly, and in imitation
of nature.
  5. The os uteri is always to be consid-
ered as completely dilated  when  we
judge it will allow of the easy introduction
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
pehis 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 betweeu the  body  qf th* 
(  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*
cd 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.

Qti the cases which come under the  third
              Distinction.


   I. 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 it*.
a longitudinal  form. 
(  47  )
   3.  It is always easier with an equal de-
gree of contraction to turn the child when
the uteris is contracted in a globular, 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.        N
   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 die  child
lie, if we consider whether it be the right
or left hand which presents,  which may
be known by. the  directon of the thumb
and of the palm of the hand.
   7. But the  contraction of the uterus  is
die principal difficulty to be surmounted,
and die danger in turning die child is in
proportion to the difficulty,
  8. The danger in turning a child when
there is a strong contraction of the uterus? 
t
              (  48   )

is a single danger, that of rupturing the
UWUS.
  9. The contraction of the uterus is of
two kh cii,; first, the permanent contrac-
tion, m consequence  of the waters ha-
ving been long  drained off, vLich may
occur  when there has been httle or no
pain.
   10.  Second,  the extraordinary  con-
traction  arising from the  action  of  the
uterus, returning, at intervals, and  always
 attended ^ ith pain*
   11. The hand must  be  introduced
with a degree of force sufficient gradual-
ly to overcome the permanent contraction
of the uterus, or the operation could nev-
er 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 ihe hand would  be cramp-
 ec>, and we should be unable to proceed
 with the operation. 
(  W   )
   ■14. The deduction is therefore clear,
mat we ought not to proceed in our at-
tempts to turn the child wliile the uterus
is acting vv ith violence.
   15. The action of the uterus is render-
ed more frequent and strong by the gen-
erally increased irritability of the pa-
tient.
   16, Before  we attempt to deliver, it
will be prudent  to endeavour .to  lessen
this irritability, in many cases by bleed-
ing, by clysters, and by an opiate, which,
to answer this purpose*, should be  ^iven
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 extremely
favourable, and proceed without loss of
time to the delivery.
   18. There never can be  occasion to
separate the arm which presents from 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 introduc-
   A            e           -    .. 
               (  50  )

 ed in die manner before directed,  and
 conducted slowly into the uterus if there
 be sufficient room,
   20. But 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  pushmg  the
 shoulders towards the head and towards
 the fwidus 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 fiat du-
 ring the continuahceof 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 tothe feet of the child.
  .25. In this manner we are to proceed,
alternately resting and exerting ourselves, 
(  51   )
till we can lay hold of ojpe or both feet.
  26. There  is sometimes  much diffi-
culty in getting to the feet,  and some-
times  in  extracting  them,  especially
when the uterus is contracted in a # longi-
tudinal form.
 • 27. In such eases  it is often conven-
ient, when we can reach the knees, to
bend them cautiously, and to bring down
the legs and feet together.

  58. But before-we begin to extract we
should examine the  parts we hold, an'I
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^here be difficulty in extracting them,
we must endeavour to. slide a rioose, first 
(  52   )
formed upon our*wrist, over the hand to
secure the feet, by which the  hazard of
their return  will be prevented, and  the
succeeding part of the  operation much    m
facilitated.
  32, When the noose is fixed over the
ancles, we must puH  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
fingenand thumb  as directed at 21, to
raise the shoulders and body of the child
towards the  fundus  of the  uterus, with,
one hand, and with the other extract at
the same time  with the noose.
  35. When the breech of the child  has
entered the pelvis, we must proceed with
deliberation, but there will be little  far-.
ther difficulty, except from  the smallness.
of the pc^xis, of which we shall speaj| in,
the next section. - 
               (  55   )            *


            SECTION VII.

  On those Cases which come under the-
          fourth Distinction.


  1.  The  disproportion  between  the
Read of the child and the dimentions  of
the pelvis, may be added to any of the
circumstances mentioned under  the pre-
ceeding distinctions.
  2. But as die management of these has
been already directed, there is now occa-
sion to speak only of the peculiar difficult
ties arising from that cause.
  3. The degree  of difficulty if these is
greater or less according to the degree of
disproportion ;. but the  difficulty of ex-
tracting any part of the body of the child
is little,  compared with that which at-
tends 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 any
©f the methods before recommended.
  5. The force with  which we endea- 
J   54  )
vour to extract must then be increased,
till it is sufiicientto overcome the difficul-
ty or resistance.
   6. But as the necessity of  using great
force can only be 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, controuled or 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 c xtract.                 ^

   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- 
C  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 peh is.
   12. But should  the head  rest in this
 situation for several hours, no  addition-
 al inconvenience would thence arise to
 the mother, and die longer it rested tJie
 greater advantage we should  probably
 gain when we  renewed our  attempts to
 extract it.
   13. It may be presumed when the head
 of die 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  littlo reason  to  expect
 the child should be bom  alive ;  yet in-
 stances  of this are said to have  occurred
 m.practice.
   14. When wt; 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 '. 
(  56   )
   15. But we must not extract with so
much force  as to incur the  hazard of    j
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 mtention, 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,the
utmost care must  be  taken  that we do
no injury to the mothes.
   20.   Under  these  circumstances
should it be absolutely necessary to les-
sen the head of the child, the  perforation 
(  57   )
may be conveniently made behind either
of the ears, and the general  rules of the
operation must be followed.
  21. By the force used should the neck
bf 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  0
the head by  the force we have used, or
should we, be called to a case of this kind,
there  will be no occcasion 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^ 
(  53   )
SECTION  VIII.
       Miscellaneous Observations.


   1. It sometimes happens that no part
of the child can be perceived before the
membranes break, though the os uteri be
fully dilated.
  2. In such[cases we should not be ab-
sent when the: membranes break, lest it
should prove a  preternatural presenta-
tion, requiring the child to be turned.
  S. Li  SGTne cases even when the os
uteri is dilated, the membranes broken,
and the waters discharged, no part of th©
.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 
(59   ),
present,  we may brmg 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
contrasted 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 introduee the hand into the uterus, the
shoulder of the child being pushed low
down into the pelvis.
   10. -Under  such  cicumstances  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 
( ■ «9 .  )
 breech is the first  part  delivered,  and
 the head the last, die 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 satisfactoiy manner by many cases
 which  have been recorded, in  some of
 which die 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- 
(  61   )
jaring the mother, and we have general-
ly a better  chance  of preserving  the
child.
   16. But  when there is no chance of
preserving the ehild,  and yet it  cannot
be turned  without  the greatest  danger
to the mother,, knowing  the pc-sibilrty
of its being expelled, in this  position, it
is necessary to consider the propriety oi'
the operation before we perform it.

   17. It remains, however, to be proved
by future experience, how  far, and  in
what  cases the preceeding  observation
ought to be a guide in practice.

   18.  In  cases of  presentation  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 lias 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
jtidge, having never tried it.
   ■20.'  I therefore refer to the &oi«xed
                   F 
.  (   «2  )
note for an explanation  and history of
the method to which I allude.
  Note. Hoorneus, sajpe laudatus, ad-
huc  peculiarum, novum eumque brevi-
orem modum,  foetum  morteum cum
brachio arctissime in vagina  uteri has-
rente extrahendi, invenit atque descrip-
sit,  qui  in eo consistit,  ut quando ad
pedes pervenire  nequit,  collum, utpote
quod in fcetibusvalde adhuc tenerum est,
vel scapello a reliquo trunco resceet,  vel
unco idoneo  quam cautissime  auferat.
Hoc enim  facto, vel sponte  mox pro-
rampitex  utero foetus, vel tamen, dum
brachium propendens   attrahitur, quod
medico loco habenje  inservit, quain fa-
cillime  excutitur.  Caput  vero deinde
seorsim mox vel manu,  vel aliis propo-
situs artificiis, si manus parum  esset,
cjiciendum.
           HEisTER.cap. cliii. sect,  ix.
  The latter part of this description  is
further, c*plained in the  seventh section. 
              (  63   >


  I AM induced to reprint the  folio w-
Srioyas 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 proceeding 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-
t 
             v(  64   )

nal parts  ::i  such  a manner, that the
shoulder nearly reached  the  per'wcetim.
Tfe woman struggled vehemently with
' cr pains, and during their continuance,*
I perceived the shoulder of the child to
<\r. .->cend.  Concluding that the child was
small and would pass,  doubled, through
the pelvis, I desired one of the gentlemen
to sit down to receive it,  but  the friends
of the woman would not permit me to
move.  I remained by the bed-side  till
the child was  expelled, and I was very
much surprised to find, that  the breech
and inferior extremities were  expelled
before the head, as if the case had origin-
ally been a presentation of the inferiorrex-
trcmities.                    .■;>-,  »  tt
   The child was dead,  but the another
recovered as  soon  and as well  as she
could have  done after the most natural
labour.
              CASE II.

  Lithe  year,1773, I was called  to a*
woman in "Castle  Street, Oxford Mar- 
               C   6t  )                  1

fret,  who-was  attended  by  a midwife.    ||
Many  hours after,  it  was  discovered    g
that  the  arm  of the  child  presetted.*  II
Mr.  Burosse, surgeon, in Poland Street,
was sent for, and I was called into co.i-    I i
sultation.  When 1  examined,  I  fot' id
the  shoulder  ofthechUd  pressed-1 into    .i
the snperior aperture of the pelvis*   1 he    R
pains  were  strong,  and returned  «it   Jj,
short  intervals.   Having agreed upon    ;
the necessity of turning, the  child, ant
extracting it by the feet, I sat down and    (j;
made  repeated  attempts to raise■  tiie   ;<
shoulder,  with  all  the force which  I   j.;!
thought could  be safely used ;  but  the   ».,
action of the uterus was so powerful that   |j
I was  obliged ic desist.  I then called to    j
mind the circumstances of the caseioe-    j
lore related, mentioned them to Mr. Bu-
rosse, and proposed that we  should wait    ;'
for the effect,  which  a  continuance of    |
the  pains might produce,  or  till they    jj
 were abated,  when  the  child might  be    j •
turned with less  difficulty.  No further     j
 attempts were made to  turn the child:    j»
Then every pain propelled it lower infc>    }'
 the pdvis, and in a little more than owe    ; 
('.«•  )
hour the child was b orn, the  breech be-
ing expelled, as in the first case.
  This child was also dead, but the mo-
ther  recovered ih the most favourable
manner.                ,
  Having been prepared for observing
the progress of thi s 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 knowl.
edge of the fact might be rendered" use-
ful in practice;  but with great circum-
spection.
             (»ASE III.


  January the 2d; 1774, I was called t»
Mrs. Davis, who keeps a Toy-shop,  in
Crown Court,  Windmill Street.   She 
(  «7   )
 fcadbeenalong time in labour, and the
 arm of the child presented^.

    Tlie 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 perinozum.   The exer-
 tions of  the  modier were  wonderfully
 sUong^   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 sud-
  den  change, 'but I assured him that I
  could claimno. other merit on account of
  this  delivery, except that I had  not im-
  peded an effect which was wholly produ-
 ' ced by the pains.    i           >\ •: ;
     This child was also dead, .fyit the mo-
 ' tfier recovered in the most favourable
  "mariner.
     In all these cases, the women  were at 
C  68   )
 the  full period of utero-gestationv and
 the children were of the usual size.
   Many other  cases of the same kind
 Kave occurred 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 knowledge of
 this fact, I may be permitted to repeat,
 that the custom of turning and deliver*
 ing by the feet  m presentations of the
 arm, will remain necessary and. proper,
 in all cases, in which the  operation  can
 be performed with safety to die  mother,
or give a chance of preserving  the life
of the child. But wen the  child is dead,
and when we  have no other view but
merely to extract the child,  to  remove 
(  69   )
the danger thence arising to the mother,
it is  of great importance to know  the
.child may be turned spontaneously, by
the action of the uterus.   If we avail our-
selves of that knowledge, the  pain  and
clanger which sometimes attend the op-
peration of turning a child may be avoid-
ed.   Nor would  any person,  fixing up-
on a preternatural presentation, in which.
he might expect  the Child to be turned
spontaneously, be involved  in difficulty,
if, from a defect of the pains, or any oth-
er cause, he should be disappointed in his
expectations.  Nor would the suffering,
or chance qf danger to the patient be in-
creased by such proceeding, an the usu.il
methods of  extracting  the child could,
under any such circumstances,, be  safely
 and successfully j ractis.-d* 
(   70  )
CLASS IV.  Anomalous ox  Com-
          flex Labours.



   .\'» FOUR ORDERS.

             OR»EX I.
  Labours attendedwith Hemorrhage.
            ORDER II.
  Labours attenjed with Convulsions.

            ORDER I IT.
  Labours with two or more Children.
            ORDER IV.
Labours in which the Funis Umbilicalifc
       presents before the Child. 
(  7i   )
On Labours attendedwith 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-gestation.
  3, 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 toeachdther.
^They arc brought together merely to pre-
vent the multiplication of classes. 
(  72   )
ON ABORTIONS.
             SECTION I.

   l.With respect tothe  time of preg-
nancy,  all expulsions of the foetus may
be reduced under two distinctions.
   2. In the first will be included all those
which occur before the uterus is suffi-
ciently distended to allow of any manual
operation, and these may be properly cal-
led 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  say
that all expulsions of the foetus, before the
end of the sixth month, are to be consid-
ered as abortions. 
(  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.

       Qn the causes if abortions.
   1. The predisposing causes  of abor-
tion are, 1st. general  indisposition  of
the constitution; 2d. infirmity of the ute-
rus.
   2. The general state of women who arc
disposed to  abortion is very  different,
some being weal^ and r«duo*4, ami oth-
ers plethoric. 
(  74   )
  3. Weakly women become more lia-
ble to abortion, because they are suscept-
ible of violent  impressions from slight
external causes.
  4. Plethoric women are more liable to
abortion, from the disposition v hich the
vessels of the uterus have, from structure
and kabrt, to discharge their contents.
   5.  Every action  in  common life has
been assigned as a  cause of abortion.
   6. But it is the excess of these actions
that we are to attribute their  effects,  for
women in  health seldom abort, unless
from violent external causes.
            SCTION III*

     On the Prevention of Abertion.

  1. As every disease to  which women
are  liable may dispose to abortioh, the
method instituted to prevent it must be
accommodate, to the  disease,or tothe
atateofthe constitution. 
           '  (  71   )

  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 invigoratmg  diet
and medicines, by hark, by wine,  espe-
cially claret, and often by cold bathing.
  4. But it will be prone;, .in every caM.%
to avcil all vinlttu': cxerosa, to "kceptnt;
mmd  composed,  and to rest frequently
in an horizontal position.
  5. Women  seldom  abort while they
hive the vc* lit ing 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. 
(  76   )
            SECTION  IV.


        On the Signs of Abortion,


   1. The signs of abortion are,  frequent
micturitions, 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 cvum is separated from the
uterus.
   3. It has been supposed when this last
sign appears, thatthere 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 apj*_arance, once or
oitener, to a considerable degree,  the
discharge has ceased, and  no ill conse-
quences have followed.
   5. We are therefore  to  persevere in
{lie use of those means which are thought
reasonable and proper,  till the  abortion=
has actually happened. 
(  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.

Of the treatment ofW'omen 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 abortions take 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  sorne the ovum has  been
soon  and  perfectly  expelled,  in others
after a long time, in small portions, or
                 G 2 
(  78   )
fery much decayed ; but the only alarm-
ing symptom is the hemorrhage;
  3. The hemorrhage in abortion is not
always  in  proportion  to the period of
pregnancy, this being in some  advanced
cases very small:  and in others, though4
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^ofthe
 body, are applicable to those of the ute-
 rus, regard being had to the structure o ■
 the utcrks.

    G. 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.
 e':ds of a.-iy kind, may be  given in a«?
 Jarre a Quantity,  aftd'as  often  as the  sto-
 mach will bear. 
f  7$   )
  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 used with great -propriety, and
it is the custom in Italy to sprinkle ice
oyer the body of the patient if the dan-
ger of the case is imminent.

  9.  Every  medicine  or application
which has the  power of slackening the
circulation of the blood, eventually be-
comes an astringent, but astringents, pro-
perly 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 cf the coats of the blood
vessels.
   11. These effects are  produced more
favourably during a state  of faintness. 
(  80   )
Which though occasioned by .the doss of
felood, becomes  a remedy in stopping
hemorrhages.
   12. Cordials are not therefore to be
hastily given to those who are faint from
loss of blood ; unless the faintness should
continue so long  as to make  us 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 vagina have 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, f «-
pecially when there  is a chana-: of  pn
venting the abortion, or afterthe accident
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 uterus 
(  81   )
and the  action of the uterus producing
and favouring' the contractile  power of
the blood vessels, if by opiates the action
of the uterus should be  prevented  or
checked, they may contribute to the con-
tinuance 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 consequence
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 re-
tained in the uterus  for  many  months
after the symptoms of abortion  had ap-
peared, and  when  k  had lost theprinci-"
pie of increasing.
  21. Put it is not now thought necessa-
ry oi' proper in abortions, to  use any
means for bringing away  the  ovum,  or
any portion of it which may be  retained. 
C  82   )
              SECTION  VI.

On Hemorrhage's at the full  Period of
            Utero-gestationf

   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 t  secondly, by  the  separation of a.
part, or of the whole placenta* which hed
been attached to  some oilier 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 dis-
charged, and of the effect of the loss of
blood, which will  vary in different  con-
stitutions..
i  ' 
(  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
inquietude, by continual 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 die patient is always
relieved,  and  it contributes  to the sup-
pression of hemorrhages.
   9. Near the full period of utero-gesta-
tifln, women are  always  in greater dan- 
(  84   )
ger in those hemorrages  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 ex-
hausted, the danger in hemorrhages may
often be estimated by the absence or de-
gree of pain.
            SECTION W.

On those Hemorrhages  which are occa-
   sioned by the Attachment of "tf/ta 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 early
part of pregnancy without any inconven-
ience,  or  symptom  which -denotes the
circumstance.
   2. But when  the changes previous to
labour ccraes on,  there must  be an he- 
(  85   )
 morrhagc, because a separation of a part
 t>f the placenta is thereby occasioned, and
 as the disposition  to labour advanceth,
 the hemorrhage is generally, tho not uni-
 versally, 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
 r.ever free from daifger till she is deliv-
 ered.
   5. The powers of  the constitution are
 undermined  by hemorrhage profuse or
 •often returning, so that  no  efforts, or
only 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  deliverv,
in cases of dangerous hemorrhage, tliere
 is no doubt, or can be any dispute,  ex-
cept as  tothe precise time  when the pa-
tient ought to be delivered.
                  II 
(  86   )i
     8. On the first appearance of the  bum-
   orrhage,  unless  it  be  prodigious in
   quantity or unusually  terrifying in its ef-
\ . feet, it is seldom either requisite or  prop-
   er to attempt to deliver by art.
     9. Nor does it often happen that a sec-
   ond or a third return of the  discharge
   compel us tothe delivery by art.

      10.  But as a patient  with this circum-
   stance cannot be secure till she is deliv-
   ered, and as the deliver)- ;j 'seldom  com-
   pleted by the natural  efforts, and as the
   artificial delivery, though performed he-
   fore it be absolutely necessary,  is not
   dangerous,  if performed  with care, we
   must be on our  guard not to delay thfe
   delivery too long.

      11.  In some cases in which it might
   be thought eligible to deliver  on account
   of the hemorrhage, the  parts are so un-
   vieldirig as not to allow of the operation
   k&elf without some hazard.

     12. Yet when the parts requiring dila-
   tation rrai'.e no resistance t© the. passage
   •f the har.d, the "event of the  operation 
              ((  8-7   )

is alwrys more precarious,  tlie operation-
having been deferred too long.

   13. But though it may be proper in
r.omc cases to determine  on immediate    ;
delivery, the  operation must always be
performed v.ith  the ut»nost'"deliberation.    ,
   14. The first r rt of the operation has    ;
been described under  preternatural pre-    |
?ie: \;\\ox\h.                            .    j

   IS. Whtti  t/.t Karris tan^'Ui'x
ftaccnut  attached  over the w trtm, i* ifi    j
ofhitic  consequence whether we pevfo.
rate the phicenta with our nc-gcrs, or se-
parate it on  o;;c  side  tiU wc tome to the    ,
edge, though the latter is generally pre-    j
fcrable.

   1G. If the hand he passed through the    j
fluent u,  we  sh ill come  directly to trie    j
part of tf.e clrid which prescnls.            *
   17. But if we separate the placcnta to    "
the edge, the hand will be on the outside-    I
of tli.; membranes,  v.hi:h must be rup-
tured before we'lay  hold of the feet of    j
the ehild.

   18. No regard is to be paid to the part'    I


                                          ii 
               '(  88   )

the child, which may present, as it mu^t
always be delivered by the feet.
   19. The feet of the childbeing brought
slowly into the pchis,  we must wait till
the uterus is contracted to the  body o!
the child,  which will  be  indicatee! by
pain, and known  by  the application of
•>ur hand to the abdomen.

   20.  The delivery must then be finish-
ed very slowly, to give the uterus time
to  contract as  the  child  is  withdrawn
from its cavity ; but this part of the ope-
ration has likewise been described under
preternatural presentation.
   21.  An assistant should make a mode-
rate pressure upon the abdomen  during
the operation,'  to aid the  contraction or
the i.teruc, and to prevent ill consequen-
ces from  the sodden emptying of the ab-.
 domen.
   2-2.  When  the  child "is born,  the he-
morrhage will be generally stayed, if the
operation has been performed slowly.
   23. But if the hemorrhage should cor^
tinue or return, the placenta is to be man-
aged as will be afterwards directed.. 
(  8&   )'
  2-i.  Should no uncommon dimculty
attend the delivery, children will be of-
ten be>rn living,  in cases of hemorrhage
which are attended with the utmost dan-
ger to the mother ;  or, as it has some-
times happened, after die 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  vu.
Ci those Hemorrhages  which are 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 dangerous as
the  preceding.
  2. But if the separation of the placenta'
he sudden anej extensive, the danger may
                 H2 
(  90   )
be equai, and the same mode of proceed-
ing required.

  3. Our conduct must be guided  by a
consideraUon 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
 f.v  uteri.
    5.  If the quantity of blood lost in these
 ^ises be very  considerable  when the os
 :.t-:ri U sufficiently dilated,  the  greater
 the degree the  better,  the  membranes
 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 abateel or
 removed.
    7. After the abatement or suppression
 of the hemorrhage, the action of the utr-
 r:is will become stronger, so that the de
 livery will, in general, be then complex
 *?<l without further assistance.- 
t  9*   I
  8. But if the hemorrhage  should con-
tinue after  the  discharge  of the waters
in sush a degree as. to threaten danger ;
or if it should commence in the second
period of the lalxmr, the interposition on
our part must vary according to the cir-
cumstances, 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  b>
profuse, and we despair of the  child be-
ing expelled by the natural efforts.
   10. The proper management of all sucl
cases may be collected from  what wil
be generally saiel on  the subject,  beint
always on our guard to distinguish be-
tween fear and real danger- 
(  92   )
            section viii.


 On those Hemorrhages which occur when
   tlie Placenta is 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.
   3. But  sometimes the placenta istre
 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 tothe
 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 placent<%
 must have been  previously separated,
 and  the hemorrhage  usually continues,
or returns till the placenta is expelled or
extracted out of the cavity of the uterus. 
<  M   1
SEG-TION IX.
 On the Retention ofthePlacenta from the
   Inaction or insufficient Action  of the
   Uterus.


   1. Thou all the placenta  be retained
 after the birth of the child, if there be
 no hemorrhage,  we are to wait, without
 any interposition on our part, in expec-
 tation of the action of the uterus.
   2. The time which  it may be proper
and expedient to wait  will depend upon
the previous circumstances  of the la-
bour,         r
   o. But no patient  ought to be left be-
fore the pit, urn a is brought away, be-
cause a  dangerous hemorrhage may at
any time come on.
   4.  When the patient  complains  of
pain, the expulsion of the placenta  may
be safely forwarded,  by aiding the 'con-
traction of the uterus by moderating pres- 
                (  94   )

sure with the  hand  upon .the abdomen,
and by pulling gently by the funis.

   5. But if the first pain,  with the aid
we think it prudent to give,  shouhl not
bring down the placenta, we are to wait
for the return of the pains, proceeding in
the sanu cautious manner.

   6. When that part  of the  placenta into
which the  funis  is inserted cm  be felt,
little danger or difficulty is  to be appre-
hended, and we are to extract it slowly.

   7. But if a hemorrhage "was to come
on, the placenta being retained, it vvauld
l>? equally necessary  tocstrac*.  tn • plj-
tents as it would oi to eKtM.ct thi child,
praykl.'d fch-i degree of hernonhh.*; was
equally profu -:e or sudden.

   8. After the bVrth of the child,  the ex"
traction  of the placenta is? therefore t>
be considered  as the  only method  !>y
which an  apprehended or prese-it h$-
rfp'rhige is to be prevented or avoided.
   0. Yet all ells-:h erges  of blool  d > n:>t
rcrutirc  a soeeclv extraction ofth?6/j-
   i        i.                    ,  i
centa, but such only as by their violence 
(  05   I
or  continuance,  or frequent  returns,
threaten danger.
   10. If mue«h force  be used in pulling
by the funis, there  \\ ill  be danger ; 1st,
oiUearing.it  from the  placenta;  2d,  of
inverting the uterus ; 3el, of injuring the
uterus by the violence ; 4th, of increasing
the hemorrhage.
   11. The danger of these consequences
is greater when  force is used to extract
the placenta  by the funis, than by the
prudent  introduction  of. the hand into
the uterus for that purpose.
   12.  By attending  to  the  respiration
you will  sometimes- be able  to bring
down the placenta in cases in which the
uterus acts insufficiently, just using so
much force as will prevent the retroces-
sion of it in the act of inspiration.

   13. But in whatever manner the pla-
centa  may be brought  into the pelvis, it
should be suffered to  remain there  till
the action  of the uterus comes on, or so
long as there is reason to fear a return
of the hemorrhage, and it must then be
carefully withdrawn. 
(  96   )
              SECTION  X.


On the Retention ofthe Placenta from the
     irregular Action of the Uterus.

   1. When all the parts of the uterus
act  with equivalent  force,  and at  the
same time, the combined  power  will
contribute to the expulsion of whatever
is contained in its cavity.
   2. But if the uterus should act irregu-
larly,  the contrary effect might  be  pro-
duced.
   3. If the fundus  uteri should not  act
when the other parts are in action,  the
longitudinal  contraction   of the uterus
would be produced ;  but if the central
parts should only act, the uterus would
then be  contracted in the form- of an
hour glass.
   4. As the placenta, cannot be excluded
when the uteris acts in  this  irregular
manner,  it must be extracted by intro-
ducing the hand into  the uterus, provi-
ded the state of the hemorrhage  should 
(  97   )
requiring it, or when it cannot be extrac-
ted by using the means before mention-
ed.

   5. The hand ought never to be intro-
duced into the uterus except in cases of
real necessity, and then with the utmost
care ;  and the  hand when  introduced
should not be withdrawn  until the pla-
centa is  detached  and  brought into the
pelvis.

   6. If  the whole placenta be loosened
 this is easily  effected, but if a portion of
 it should be  found adhering, this must
 be separated by bending it back from the
 uterus, or by pressing gently the fingers
 between it and the uterus.

    7. When the uterus is found  contact-
 ed in the form of an hour-glass,  the con-
 tracted parts must be dilated in  the man-
 ner  recommended for  the dilatation of
 tlie os uteri, and the contracted part must
 be amply dilated,  or it  will immediately
 contract again around the wrist.

    8.  we must  then proceed as is before
 advised.
                    I 
(  98   )
SECTION XI.
 On the. detention of the Placenta from the
    scirrhous Adhesion of it to the Uterus.


    1. Should there be a degree of hemorr-
 hage  sufficient to make  it necessary to
 introduce the hand to extract the placen-
 ta, a part of it must be separateel, though
 there may be a scirrhous adhesion of the
 remainder to the uterus.
   2, Then the  method advised in the
 last section must be put in practice,  and
 the firmer the  adhesion the slower the
 separation ought to be made.
   3. But if there should  be no hemorr-
 hage of importance,  and merely a reten-
 tion of the placenta beyond its  due  time,
 we may  say,  for example,  more  thpn
 four hours, and thq means  before recom-
 mended  are insufficient to bring down
 the placenta ;
  4. It may then be necessary to intro-
duce the hand carefully  to separate  and 
               (  99   )

extract tlie placenta, and the  difficulty
will not be encreased by the delay.
  5. Following the. naval  string as  our
guide, we must then  pass  the. hand to
the placenta ;  and if it should  be found
wholly adhering,  we must  begin with
great caution to  separate  at the edge,
and gradually proceed^ as before direct-
eel until the separation is completed.
   6. Then  grasping the placenta, we
must  slowly  withdraw-our hand, that
' '• ie uterus may contract -ace onla • l, '.y, v r.d
the chance of a-subsequent  hemorrhage
be prevented.
   7. The irritation made by the  intro-
duction of the hand, will generally occa-
sion a return of the action of the uterus>
before dormant,  that will greatly facili-
tate the separation.
   8. Yet it i;3  possible that   a rortVn of
the placenta  may adhere so firmly as to-
make  it unsafe to  separate it  v. it hour
fingers.
   y.   Shculel this circumstance  occur
notwithstanding the most c\eiiberate and
firm  proceeding, it may sometimes be
more  justifiable  to leave  the  adhering; 
(  ioo   ).
part remaining than to use  violence in
separating it.
   10.  But though  hemorrhages  are
stayed when the greater  portion of pla-
centa is brought away, it is  ahvays a de-
sirable thing to bring away the placenta
and membranes in a perfect state.
              SECTION XII.
  On those Hemorrhages which follow tlie
  Expulsion or Extraction of the Placenta.

     1.  The hemorrhage  in  these  cases
.j. may  be either  a continuation  of that
  which existed  before the exclusion  of
  the placenta,  or it may only  follow  the
  exclusion of the placenta.
     2. When it is of the former  kind, we
  may presume that it was not  within our
  power to prevent it, but the latter kind
  may often be attributed to the violence
  or  hurry with which  the placenta has
  teen extracted.
     3. This is  not so dangerous  as either
  r. f the varieties  of hemorrhage of which
  we have last spoken,, though with iaa- 
(-  ftl   )
prudent management,  or under particu-
lar circumstances, it has sometimes prov-
ed fatal.
   4. All the cautions given with respect
to the management  of the placenta, relate
to the prevention of this kind of hemorr-
hage.
   5. When the  strength  of women is
much reduced by any cause which ex-
isted  previous to labour, or when they
have gone through much fatigue in the
Course of it, there is usually great  heat
and  a rapid circulation of the blood at
the time of delivery.

   6. While they  are iii this situation, if
tlie placenta were to  be  brought  away
hastily,  an extraordinary  quantity of
blood must of necessity be discharged.

   7. Tlie interval of time  which jJasseth
between  the birth of the  child and the
expulsion of the  placenta, should there-
fore be employed-in cooling the patient
and recovering her  from her fatigue.
   8. Even when the placenta is excludeel
©Ut of the cavitv of the  uterus, it should1
             •    12 
(  102   )
be suffered to remain there till all tumult
is quieted, and then with the membranes
slowly extracted.
  ■9, The quantity of blood  discharged
m consequence  of the separation of the
placenta will vary in different  women, or
in the same women at different labours,
independently of the manner in which
the placenta may come away.

   10.  The less quantity of  blood  dis-
charged the better women in general re-
  over, provided there b»no morbid cause
of its diminution.

   11. Some women are always prone to
a great discharge of blood after the separ-
ation of'theplacenta, whatever care may
be tai-:en in extracting it.

   12. This may often  be prevented by
keepiog the patient  out of bed till the
membranes are  broken and the waters
discharged to the  very moment of the
child being born.

   13. In all cases of dangerous hemorr-
hage after the extrrction of the placenta, 
{*  103   )
it is first necessary that we should be as- ,
sured by an  examination per vaginam,
that the uterus is not inverted.
   14. Should there be  an alarming  he-
morrhage after the separation and exclu •
sion of the placenta, notwithstanding all
the care which can be taken according to
die methods before mentioned.

   15. The doctrine of  hemorrhages be-
fore given, and the general treatment al-
ready recommended, will enable you to
fix upon the line of conduct it will be ex-
pedient to pursue, and to restrain or sup-
press them as far as they are under the
influence of art.

   16. In eases  of hemorrhage so very
profuse as to occasion frightful faintings*
continuing so long as to raise great soli-
citude for the  immediate safety  of the
patient, it was generally said, that cordi-
als ought not to be given.

   17.  But  this  requires explanation.
When the patient has continued faint so*
long  as to give  time,  according to our
judgment, for the vessels cf the  uterus 
('  104   )
to contract, then cordials and nourisfi-
ment in small quantities,  very often re-
peated, are really heedful.
   IS. Other means are also to be used
for the purpose of recovering women
from this  long continued fainting ; and
one  of the  most effectual is  sprinkling
the face freely with cold water.
   19.  After a profuse  hemorrhage  the
patient will frequently have a disposition
to'sleep, which has generally  been con-
sidered as dangerous.
   *20. But short sleeps are very refresh-
ing, though long  ones in a very  weak
state are,   under every  circumstance,
found t© be injurious.
   21. When there has been a dangerous
hemorrhage, the  patient should remain
for many  hours undisturbed,  and in an
horizontal  position ;: and our- attention
must be continued as long as any danger-'
is to be apprehended. 
(  105   )
On Labours attended with Convulsiom.
  1. The convulsions  which occur 4n
pregnancy very much resemble the epi-
lepsy, but to the symptoms,, which these
have in common, may be added, to pe-
culiar hisping noise which women make
with their lips during the convulsions.

  2. When convulsions  happen to wo-
men with child, they are  generally, but
not universally, accompanied or follow-
ed with symptoms of labour.

  3. These convulsions are indicated by
a piercing pain in the head, by giddiness
and, other  vertiginous  complaints, by
blindness, by vacillation of the  mind or
a slight  delirium, by violent cramp  or
pain at the stomach, by a fulness or ap-
parent strangulation of tlie neck and fau-
ces, and  other  affections of the vascular
and nervous ay stem,
   A The means to  be used for the pr«« 
(  106:  )
vention or  cure  of  convulsions  when
thrcateneel or existing, must be regulat-
ed ^according to the  constitution  of thfc
patient and.  the violence  of  the symp-
toms.
                   4

  9. In  general it will be necessary' tQ,
take away some blood, or, sometimes to-
repeat tlie bleeding, and it has been found
particularly  serviceable to open the ju-
gular veiri.   Emetics, when they  could
be given, have been  Useful, as has also
the  warm  bath.    Clysters may be fre-
quently exhiulted.  Opiates, joined with.
nervous  medicines," may be given ;  and
the patient is, by all tlie  means iti our
power, to be soothed and restrained from
violent exertions..
                                •/
   6. During the convulsions  the means
by which contrary irritations may be ex-
oited are to be  used; and of these the
most powerful is,  the dashing of cold
water in the face, which has been known
to prevent, or even  to-cure convulsions.  *

  7. Some writers have recommended'
&e speedy delivery of the patient, as the 
(  A07   )
most eligible, and only  effectual method
of removing puerperal convulsions;  but
others  have insisted  that  the labour
 should be uninterrupted.

 ■  8. Prom the  histories of all the cases
of  puerperal • convulsions  which  have
been recorded,  it appears, that a greater
number have died of those who werede-
 liverd by art, than when the labours were
resigned to nature.

   9. As far  as  my  experience enables
me to judge, we ought not to attempt to
deliver  women  in, convulsions  before
some progress is made in the labour.

   10. But when the os uteri becomes di-
lated sufficiently, or to a certain degree,
the patient safely  may, and ought to be
delivered by art, if from the urgency of
the convulsions, and the general danger
of the case, delivery should appear neces-
sary.
   11. The manner of delivering women
in these cases, whether the  operation be
performed with the forceps or vectis, or
by turning and extracting  the child by 
(  108   )
the feet, has already been fully explain-
ed.
   12. The event of the operation,  both
to the mother and child,  will also  very
much depend upon the skill and circum-
spection with which it may be perform-
ed.
THE EtfD. 
 
 
 no
1)317*
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