I % VOL. I. ■ **irtPn '"> ^ NEW-YORK: PRINTED BY JAMES ORAM*. FOR WILLIAM FALCONER AND EVERT DUYCKINCK, 1S02. • ■■■ ■•■'■ -........ .....'**' ■ ."■ CONTENTS OF THE FIRST VOLUME. Page. Preface - - - - - - ix CHAPTER I. QN THE PELVIS. Sect. I. On the bones of the pelvis i II. On the connexions of the bones of the pelvis - 5 III. On the reparation of the bones of the pelvis - 7 IV. On the reunion of the bones of the pelvis - 13 V. On the pofition and ftructureof the pelvis - 15 VI. On the formation of matter between the loof- ened bones of the pelvis - - - 17 VII. On the form and dimenfions of the pelvis - 19 VIII. On the dimenfions and ftructure of the head of the foetus - - - - 23 IX. On the application of mechanical principles to midwifery - - * - 22 X. On diftortion of the pelvis - - - 23 CHAP. II. ON THE EXTERNAL PARTS OF GENERATION. Sect. I. Defcription of the external parts - - 25 II. On tumours and excrefcences of the external parts - - - - - 27 III. On edematofe fwellings of the external parts - 29 IV. .On the cohefion of the labia - - . - ib- V. On abfcefles of the labu - - - 3° VI. On laceration of the perinaeum - ib. VII. On a peculiar laceration of the perinxum - 33 VIII. On the enlargement of the clitoris - - 34 vi contents. Sect. ?*&- IX. On the difeafes of the bladder and urethra - 34 X. On the pruritus or itching of the external parts of generation - - - ~ 35 XI. On the hymen - . - -3* CHAP. III. ON THE INTERNAL PARTS OF GENERATION. Sect. I. Defcrlptlon of the internal parts » - 38 II. On the contraction of the vagina - - 44 III. On the cohefion of the vagina - "45 IV. On cicatrices of the vagina - - ib* V. On polypi - - - - - . - 46 VI. On fluor albus - - - - 54 VII. On prolapfus uteri - - "5^ VIII. On hydatids of the uterus - - - 59 IX. On the dropfy of the uterus - - 60 X. On the tympany of the uterus - • 61 XI. Of moles - - - 62 XII. On the dropfy of the ovaries - - 63 XIII. On inflammation, fcirrhus, and cancer of the ovaries - - - - 61 CHAP. IV. CN THE PARTS CONTAINED IN THE CAVITY OF THE PELVIS. Sect. I. On the retroverted uterus - - - 71 II. On the retrofledted uterus - - - 78 III. On the dropfy of the perinaeum - - 79 IV. On the elytrocele - - - -81 CHAP. V. ON MENSTRUATION. Sect. I. On the menftrual dlfcharge - _ 83 II. On the efficient caufes of menftruation _ 8-7 III. On the final caufes of menftruation - - 89 IV. On the formation of a deciduous membrane - 90 V. On obftruction of the menfes - - - 02 VI. On exceflive menftruation - - - Of VII. Oi\painful menftruation - - - 06 VIII. On the treatment which may be proper at. the time of the final cefiation of the menfes - 9^ aONTINT*. Vll* Page. Chap. vi. on conception. Sect. I. On the different theories of conception - 102 II. On the growth of minerals, vegetables, and animals - - - _ 106 III. On the ova of animals - - -no IV. On the difference of the ftrudture of the uterus in different animals - - - - 111 V. On the firft ftage of conception - - 112 VI. On the formation and ftrufture of the foetus - 114 VII. On the funis umbilicalis - - - 11 y VIII. On the placenta - - - -118 IX. On the membranes - - -121 X. On the liquor amnii - - - - 122 XL On the changes which the uterus undergoes in confequence of impregnation - - 123 CHAP. VII. ON THE SIGNS OF CONCEPTrON, AND THE DISEASES OF PREGNANCY. Sect. I. On the figns of conception - - - 129 II. On quickening - - - - 133 III. On the fupprefllon of the menfes during preg- nancy - - - - - 134 IV. On the febrile difpofition attending pregnancy - 135 V. On the ufe and abufe of exercife during preg- nancy - - - - - 136 VI. On vomiting - - - - 137 VII. On indigeftion, and depravity or lofs of appe- tite '- - - - - 139 VIII. On heartburn - - - - - 141 IX. On coftivenefs - ib. X. On collections of indurated faeces in the intef- tines - - - - - 142 XL On the hemorrhoids - - - 143 XII. On blotches of the fkin and jaundice - - 144 XIII. On tenefmus, diarrhoea, and dyfenteric com- plaints - - - - - ib. XIV. On the ftrangury and incontinence of urine - 145 XV. On fluor albus - - - - 146 XVL On erratic pains, cramp, and numbnefs of the inferior extremities - - - - 147 XVII. On varices of the legs, thighs, and ajpdomen - ib. XVIII. On inquietude and want of flecp - - \-.M VJI1 contents. Sect. Page. XIX. On the folicitude and anxiety attending a ftate of pregnancy - - - - 149 XX. On headachs, drowfmefs, vertiginous complaints, and hemiplegia - » - - 15a XXI. On anafarcous fwellings of the inferior extre- mities - - - - ib. XXII. On afcites - - - - 151 XXIII. On partial diftention of the abdomen, and um- bilical hernias - - - - 152 XXIV. On the exceffively diftended and pendulous ab- domen - - - ■ - ib. XXV. On the venereal difeafe - - - 153 XXVI. On the fmall-pox.—General remarks on dif- eafes occurring during pregnancy — - 155 CHAP. VIII. on utero-gestation. Sect. I. On the fituationof the foetus in utero - 157 II. On the term of utero-geftation - -158 III. On the caufes of labour - - - 161 IV. On the predifpofing figns of labour - - 163 V. On examination - - - - 166 CHAP. IX. on labour. Sect. I. Claflification of labours - _ - 1-0 II. On natural labour - _ _ ^ III. On the fymptoms accompanying labour - 172 IV. On falfe pains - _ _ -1-8 V. Cautions againft endeavouring to promote the power and effects of pain - 1^Q VI. Fhft ftage of labour - - - I 180 VII. Second ftage of labour - _ .... VIII. Third ftage of labour - _ "_ l%. IX. On tying and cutting the navel-firing _ , Qi X. On the exclufion of the placenta ° _ - 106 CHAP. X. on difficult labours. Sect. I. General reflections - II. Equivocal figns of difficult labours _ _ 2^ PREFACE. B' efore the firft appearance of thefe papers in two volumes* the greater part of them had been feparately printed, and of many of them there had been more than one impreflion. By this mode of publication I had an opportunity of correcting many errors, though, with all that I have been able to do for the amendment of the work in general, I am yet very fenfible of its deficiencies and imperfections. But the reader will difcover, that pains have been taken to render it lefs unworthy of his regard; and the hope of being ufeful to thofe who are engaged in ftudies of this kind, has Converted the trouble into pleafure. Very much ftill remains to be done for the perfection of this branch of the profeflion, not by the fpeculative and prefuming, who are ever mifleading us, but by men of induftrious attention and refearch, capable of re- ducing into order the obfervations they will have many opportu- nities of making, and of converting them to practical ufe and ad- Vantage. In medical writings, ftrict veracity is above all other . things required; and to this I have conftantly adhered, to the beft of my knowledge and judgment. Of the medical treatment of the difeafes peculiar to women, and of the practice of midwifery in particular, we have no ac- counts from the earlieft writers, but fuch as are very imperfect, and involved in works, which the life of one man would fcarcely be fufficient to glean; while after all his labor, though his cu- riofity might be gratified, he probably would not, at this period Of time, gain for himfelf, or afford to others, much fatisfactiom The cultivation of medicine at large, efpecially of that branch, of which we are about to treat, is of a recent date in our own coun- try. This, to one glance of the eye, exhibits a view of the fteps by which human beings, in a courfe of years, emerge from a ftate of abfolute ignorance and barbarifm, become civilized, and arrive at eminence in every art and fcience. In what country medical knowledge was firft cultivated, and Teduced into fcientific order, cannot now be traced ; for, beyond a certain period, the records we have are crowded with fable, and being chiefly fupported by conjecture, are by no means en- titled to uftfeferved confidence. But, long before the eftablifh- mefit of fyftems, there muft have been a time, when means were Vol. I. B * preface. tifed for the cure of difeafes, and the relief of accidents. Thefe muft alfo have been a time, when the rude but well-meant en- deavors of one friend to relieve another in diftrefs, ceafed, and application was made to thofe who were fuppofed to have more information, or greater fkill. This would properly be the origin of the art. By what fteps or means the Greeks became fooner and better' informed in all arts and fciences, than many other nations, we cannot now decide; whether it depended upon the force of their own native genius, to which fomething muft be granted,* or whether this knowledge were communicated by fome preceding or neighboring people. But it is probable that the Greeks were inftructed' by the Egyptians; and thefe, as many contend, by the natives of India: yet, by whatever means they acquired their information, to the Greeks the diftinguifhed glory is due of having conveyed, in their own language, the rudiments not only of medicine,, but of almoft every art and fcience, to all the wefifern world. Though the moderns have availed themfelves of every advantage they could obtain by the ftudy of the ancient writers, it may be truly faid, that they have not-always been too liberal in their acknowledgments. But of this pofthumous repu- tation Hippocrates has had his full (hare,- for his very name feems to have infpired with enthufiafm every fucceeding writer; as all thofe, of whom we have been accuftomed to think with venera- tion, or to fpeak with reipedt, have mentioned him with admira- tion, and held fiim up to our view as an example to be imitated, or as a pattern to be exactly copied. "Whether we confider his writings with regard to the ftrict morality which they inculcate, the liberal conduct which they recommend, the ftrong and ex- tenfive obferVaticiis with which they abound, or the order and method in which thefe are conveyed, it is not poffible to with-- hold our effeem.f He had likewife the good fortune of writing in a language Which was not only known, but fpoken- with claffi- cal purity, for a longer time than any other •, for Hippocrates lived near five hundred years before the Chriftian aera, yet the Grecian Was the popular language at Confilantinople, even at the time when this city was taken by Mahomet the fecond, in the fifteenth cen- tury. The Greeks alfo maintained an acknowledged fuperiority in hterature and arts, for a longtime after their political fovereignty was loft. But if there be any progrefiive power in the human * See Stuarfs Antiquities of Athens. f See a Jhort but elegant abftracl of the medical obfervations and frdclite'of Hippocrates, in //^Hippocrates Contractus of Dr. Burnet, preface. Xl •mind, if any advantage be obtained in the practice of medicine ■by the knowledge of the circulation of the blood, or of an in- finitely more correct- anatomy and phyfiology at large; by the •vail difcoveries, improvements, and application of chemiilry; by a more copious and more efficacious materia medica; by the ■recorded experience of fo many ages ; or by the feveral collateral arts, which medicine calls in to its aid-; we may furely be per- .mitted to fay, that Hippocrates ought not to be confidered as the guide of phyficians at the prefent time, or as having in any de- gree limited either the perfection or extent of the art, but as an illuftrious fpecimen of ancient medical knowledge and practice. If this obfervation hold good with refpedt to Hippocrates, it will have more force when applied to all his tranfcribers and com- mentators, many of whom feem to have loft, in their attachment to him, the ufe of their own reafon and judgment; conftantly praifing learning at the expenfe of knowledge, and rejecting every improvement, which could not be explained or juftified by his writings. To the Greeks we are indebted for the works of Arif- totle in the time of Alexander the Great; and it was the firft ob- ject of the Romans, who fubdued them, to acquire a knowledge .ofL their fciences, and to poflefs themfelves of examples of their arts. With information of almoft every other kind, the Greeks are to.be confidered as the inftructors of the Romans in medicine; ■and, allowing for fome change in the arrangement, a ftrong in- telligence in his feledtions, the addition of what he had collected from other writers, a few improvements in furgery, and the local application of principles before known, Celfus, Who lived at Rome in the early part of the firft century, may be confidered as an in- -ftructive and elegant abridger of the writingsof Hippocrates. The flourifhing ftate of the Romans was of fhort duration. In the fourth century the empire was divided into the eaftern and weftern. Rome* which was the capital of the latter, was taken by Odoacer, king of the Heru/i, under whofe fubjection it remain- ed ; and the Romans ceafed to fpeak the Latin language in the beginning of the feventh century. But neither the conqueft oi Rome by Odoacer, that of Alexandria, under the Caliph Omar, nor the permanent fubjection of Cotiftantinople by Mahomet the fecond in the fifteenth century, extinguiftied that knowledge, and thofe arts, which had been fo long and fo ftrenuoufly cultivated and ex- ^ercifed. From the deftruction of the library at Alexandria) -which had many bad and fome good confequences, were produ- ced the fchools of Antioch and Haran, -or what may be called the Arabian fchools, the principal medical writers of which were Rhazes* Av'icenna* Avenzoar, and Albttcafs. The fentiments and xn PREFACE. manners of no people could be left favourable to learning than thofe of the Arabians; and we accordingly find in every hiftory, that when they fpoiled Alexandria* the intention of their chiefs was to deftroy all kinds of fcience, by burning the magnificent libraries which had been there collected ; and every book which efcaped the general havoc, was preferved by the care or partiality of private men. The writings of the Arabian phyficians were chiefly, though imperfectly, tranfcribed from the Greeks. Thefe, it will be allowed, are fcarcely ever read; but they are faid to contain little of importance, except that the firft account of the fmall-pox, and of a few other difeafes of lefs confequen.ce, was given by the Arabians; and that Avicenna was the firft who de- scribed the forceps, an inftrument contrived for the purpofe of de- livering women in cafes of difficult parturition, preferving at the fame time the life of the child. After the deftruction of the library at Alexandria* the Grecian manufcripts, which were preferved, were tranflated into the Sy- rian, Perftan, and Indian languages ; and the learned were dif- perfed in different countries. For it appears, that, in the year 767, Almanzur, the founder and Caliph of Bagdat, fent for a fkilful and learned phyfician from India ; which I mention, as it feems to explain an obfervation made by the Raja of Kifhenagur, and re- ported by the learned Mr. Halhed in the preface to his Perfian Grammar, without any violence to other chronologies. Thus wars and apparent devaftation, became, in the hands of Provv* dence, the means of diffufing learning over many countries, which might otherwife have remained in ignorance. But the firft fchools, from which the weftern part of Europe derived knowledge, were eftablifhed in Italy in the eighth century; and the raoft famous of thofe, in which the art of medicine was taught, were at Padua ; whither all, who aimed at excellence, reforted, with the view of purfuing their ftudies, and of qualify- ing themfelves for practice. From the contiguity of the two countries, from the frequent wars carried on between France and Italy, or from other caufes, the French had many opportunities of acquiring knowledge. Schools were eftablifhed among them, encouragement was given to learning, many able men arofe, and France, by its more convenient fituation to Britain and the nor- thern nations, fucceeded Italy in literary reputation; Paris and Montpellier being the places, to which ftudents in medicine as well as other arts, reforted for inftruction, even down to the be- ginning of this century. frkfack. X1U About fifty years before the birth of Chrifi, Julius Cefarmadc a defcent from Gaul into Britain, a country then but little known, the inhabitants of which were in a very uncivilized flare ; if we except thofe who lived on the fouthern coaft of the ifland, per- haps not one degree more enlightened than the Indians, whom their pofterity afterwards difcovered in America. The Romans continued long enough in Britain, to humble and render more tractable the ferocious fpirit of the natives, to prepare them for pivilization, and to teach fome of thofe arts, by which the evils of their ftate might be leflened, and a portion of the comforts of life acquired. On the retreat of the Romans from the ifland, about the year 426, fuch of the natives as, after an impotent op- position to their arms, and a rejection of their government, had been driven to the diftant parts, poured with irrefiftable fury on thofe who had fubmitted to the dominion of Rome. Thefe called in the Saxons, to aflift and to protect them, about the mid- dle of the fifth century. Subjection is ufually the lot of thofe who claim or receive political protection; and the Saxons afTumed the government of Britain. Being but little more civilized than thofe they came to defend, they could furnifh few means of im- provement ; and the Danes, in their fubfequent invafions, checked and reduced the fmall advancement, which the Britons had made towards learning, notwithftanding the encouragement afforded by Alfred, about the year 900. The Norman conqueft took place1 in 1066, and the change, with all its difadvantages, was produc- tive of fome general good to the nation : but the great profpeft of literary improvement arofe towards the conclufion of the twelfth century, when Richard the Firft undertook his crufade to the Holy Land. It appears, however, that there was not a fingle man in his whole army, who underftood the Grecian or Sy- rian language; fo that, without any advantage to balance the loft of his fubjefts, or the expenditure of his wealth, in all likelihood, he and his people returned to England almoft as ignorant as they departed. During all this barren and dreary time, that is, for the fpace of nearly thirteen hundred years, the excellence of the Britons feems to have been in the ftrength of their arms, for they were conftantly engaged in wars foreign or domeftic, and men- tion is fcarcely made of any man, who had a claim to be confi- dered as learned in any l'cience, before Roger Bacon, who lived in the thirteenth century. He was a man endowed with a very fuperior and excelling genius, who, among other branches of philofophy, applied himfelf to chemiftry, which he earned to higher degrees of perfeaion than his predeceflbrs of any age or nation, as well as laid the foundation of many modern improve- sciv preface. *nents. A few other names of medical men indeed are recorded, as Richardus Anglicus, Nicholas de Ferneham, Johannes de Sanfo JEgidio or Giles, Hugh of Evejbam, and Gilbertus Anglicus; but John a Gaddefden was the firft Englifhman, according to Dr. Friend, who acquired fufficient reputation to be appointed Phyfi- cian to the Court, which Gaddefden was, in the reign of Edivard the Second. His work, which he called the " Rofa Anglicana," •was never printed in England: and if it be compared with thofe of the Greeks, and .perhaps of fome other phyficians of his time, lie may deferve the feverity of that cenfure, which has been un- iparingly paffed upon him. But furely much allowance is to be made, and fome :honor muft be given, to the firft man in any country, who, by diftinguifhing himfelf, was preferred to a place of fuch high truft and importance. About the fame time lived John Ardern, a Surgeon of ,great reputation at Neavarke in Not- iingham/hire, who compofed many works, none .of which have been printed, except his treatife on (the " Fiftula in Ano." In every country knowledge -muft be acquired by the mere in- duftry and genius of the natives ; or by communication with other countries* in which it already exifts ; or the rudiments, de- rived from fome other nation, may be carried to greater perfection •by the induftry and genius of thofe, who originally received their inftruction from foreigners. If knowledge were conveyed from die Babylonians or Indians to the Egyptians, thofe would probably afford an example of the firft; the Greeks of the fecond ; and aM Europe of the third. But the progrefs of knowledge would in the (beginning be exceedingly flow,in every nation; and even fuppofing the powers of the mind were not diverted from the purfuit by more favorite objects., it would be long before men thus circumftanced could be put into competition with a people already informed. The abilities of particular men would very often be loft by their death ; and, if they were difpofed to convey their knowledge by writing, the number .of copies would be comparatively fmall, full of the errors of tranfcribers, and difficult to be underftood, from (Unavoidable changes -in the meaning of words, and the conftruc- tion of the language in which they might be written. Nor would a people defeive the name of fkilful and learned, becaufe there were a few men of diftinguifhed abilities among them, hut be- caufe the generality were fo well informed, as to be able to. exe* cute with aptitude and intelligence what was required of them for the good of fociety. All or the greater part of the impediments to the acquifition or * See Aikirts Biographical Memoirs. preface. xr dlffufion of knowledge in general, were happily removed in the fifteenth century, by the difcovery of the art of printing, by John FauJl, ox Fuji, a German, about the year 1432. This art wa9 introduced into Britain in the year 1470, by William Caxton, who hired himfelf as a fervant at Cologn, for the purpofe of qualifying himfelf as a working printer. There are two books, which, it is faid, were printed by him before his return, of one of which we fhall have occafion to take notice. Another event, extremely favorable to the improvement of medisine, took place earlv in the next century, that is, in the year 1518. This was the eflablifh- ment of the College of Phyficians in London, by the charter of King Henry the Eighth. The words of the charter of the col- lege denote its view ; Improborum hominutn qui medicinam, &c. audaciam cdmpefcere,- the kind of inftittttion, injlittdarum civitatum in Italia exemplam imitati; and the perfons to whom it was grant- ed, gravium virorumdoBorum,tkc.preeibus imslinafi. For certain purpofes, intending or promoting the good of fociety, thefe men were directed to form a college,, with powers for their internal regulation, as forcible as thofe ever granted to any other univer- fity or college; provided fuch regulations, and fuch only, were made and executed>. as preferved and promoted thofe interefts of fociety, which were committed to their truft. I mention thefe circumftances, becaufe the felecting power of the Fellows of this College, though; allowed to all others, has been difputed by fome very able and worthy men, who, perhaps, did not reflect, that before its eftablifhment, no fchool, or even ledturefhip for medi- cine, had been founded in this country, nor had a fingle book of any eftimation beea written by a native of it, but that the art was then practifed without reftraint, by men as bold as they were ignorant; or forefee, that, if the college were to be fupprefied* or the exercife of its powers perpetually checked and contefted, the art would, in all probability, decline into its primitive ftate of ignorance and confufion. It would, moreover, be eafily proved, that, fince the year 1518, there have been, at every pe- riod of time, phyficians of diftinguifhed abilities and eminence, and that the general literature of this country has been in many inftances very effectually affifted by the members of this college*' There can fcarcely be a doubt, but that very important benefit;* have accrued to fociety from the eftablifhment of the College ot Phyficians, and that the rank and dignity of the profeffion have been raifed and fupported by it. As early proofs of the firft, I may mention the difcovery of the circulation of the blood, by Harvey; the doctrine of irritability, firft cultivated by Gliffbn,-. the reduction into order, and more accurate anatomical knowledge, *vi PREFACF. Of the brain and nervous fyftem, by Willis ; the difcovery, or at leaft the great improvement of our knowledge of the glandular and lymphatic fyftem, by Jolliffe, Wharton, Needham, Willis, and many other very able men of their time ; and the difcoveries of Mayoiv, whom I am proud of having contributed to refcue from Oblivion. The fecond pofition is felf-evident. Even thofe Who are not members, eventually partaking of its advantages, and profiting by its eminence, are interefted in its fupport. In the courfe of time, the rules of this, like thofe of many other foun- dations of a fimilar kind, may require alterations, according to the progrefs and improvement of fcience : but the powers already granted might be effectually exerted, to prevent the frauds, hinder the impofitions, and curb the audncioufneis of ignorant and un- principled men; and the exercife of this authority was never more neceflary, than at the prefent time. It is probable, that this im- portant purpofe would be anfwered, if nO patent for any medi- cine were to be granted, or any noflrum allowed to be fold, with- out a teftimonial of its efficacy and fafety from the College of Phyficians ; and by compelling every perfon pradtifing medicine in any form, to become a member of the College of Phyficians, of the College of Surgeons, or the Company of Apothecaries. Nor does it feem difficult to make regulations fo ftrict, that they mould refill any claims to the privileges of the college by the prefumptuous, yet fo liberal as not to withhold them from the deferving; and thus improve both its public and profeffional benefits. One of the firft books printed by Caxton was " Bartholomew de Proprietatibus Rerum." He is named in the firft tranflation, which was made under the protedion of one of the earls of Berkley, as B. Glanville; but the title of the copy of the book which I have, probably Caxton's, is this—" Incipit prohemium de proprietatibus rerum Fratris Bartholomd, Anglici, de Ordine Fratrum Minorum." This is in the nature of a Cyclopedia . and bemg a book not much known, I allow myfelf the liberty of making an extrad from it, which will fhew the nature of the work. His obfervations on fire, which will exhibit his philofo- phy, are m this order—De forma—De elemento—De igne—De flamma—De fumo---De carbone---De fctntilla~De favilla—De einere .The following, from his chapter de infirmitatibus, will fhew his medieme-Defebre-De febre efymera-De ethica-De febre putnda---De ftgnis putrid* febrls—De febre cotidiana—Dt febre terciana et ejus ftgnis et cura—De quartana et ejus fanis ef remedns—De febre ftmplici et compoftta. He has a chapter de obfle- trice, and another de umbilico, but they both relate almoft wholly PREFACE. xvii to die management of the child. A book like this promifed to' be of great fervice; but, though the circle was cOmprehenfive and regular, it was filled, not with the obfervations of a man of real knowledge or experience, but with popular opinions ; and thefe collected, without much difcrimination, from other writers. A tranflation of this work, by John Trevifa, was printed by Wynkin de Worde in 1507, another edition by Berthelet in 1535^ and I believe feveral others. Very few medical books feem to have been printed about this time ; and, from the examples, their lofs is not to be regretted. The " Judycyall of Vryns," was printed in 1512—"Alitel boke for the infirmities and grete Sicknefle called Peftilence," which pafTed through many editions! —and " A little treatyfe called the Gouernail of Helthe." But in the year 1522, Linacre, who was the firft prefident of the college, publifhed, when fixty-two years of age, a tranflation of different parts of Galen, which he thought molt ufeful to be known. The ability and elegance with which this tranflation was made, are univerfally acknowledged, and great honor was juftly given to Linacre, on this and many other occafions. But the Englifh practitioner did not reap much advantage from the work ; for, though there might not have been fix men in the nation at that time able to read or tranflate Greek, and probably fome hun- dreds who underftood Latin, yet the bulk of the people were ftrangers to both the languages; and of this Linacre himfelf feems to have been fenfible, for he immediately afterwards pub- lifhed his " Rudimenta Grammatica Lingua Latina." Nor can I here help lamenting two defects even in Linacre's plan ; one, when the college was eftablifhed, that he did not encourage the publication of papers on medicine, under the aufpices of the col- lege ; a defect feen by the eftablifhers of the Royal Society, who publifhed fuch papers in their tranfadtions, a place not the mod proper for them ; the other, that he did not print his works in Englifh i in which they would have been generally read, have af- forded immediate inftruction, flood as good examples, and taught a proper method of writing. It is amongft the moft remarkable things I have met with, that no writer in any other language, than that of the country in which he lives, ever feems to be ge- nerally underftood by the people of that country, of which I could adduce feveral proofs. But this not being done by Linacre, the Englifh medical writers returned to their former ftyle; and for many years little real progrefs in knowledge was made, or any ti- tles heard of but thofe of Urynals, Judgment of Urynes, Anatomies tf Urynes, Trefuries of Helth, Mirrours af Helth, Anthidotaries, Breuiaries of Helth* the Trefures of poore Men, Herbals, and the Vol. I. C xvm PREFACE. like, by medycyners and aftronomers. But about the year 154c fome attempts were made to tranflate books of reputation into the Engli/h language ; as Sir Ulrich Autten on the wood called Gua- iacum that healeth the French Pockes, by Paynell, Canon of Mar- ten Abbey, who had alfo tranflated many other books about 1533 ; the Cajlell of Helthe by Sir Tho. Elyot, who was not a phyfician ; Albertus Magnus; Prognoflicacions out of the books of Tpocras, Auicen, &c. and the $$uejlionarie of Cyrurgyens, with the formu- larie of lytcll Guydo in Cyrurgie. In the year 1540 was alio pub- lifhed the firft book on the fubject of midwifery in England,* call- ed " The Byrth of Mankynde," otherwife named the " Woman's Booke," by Thomas' Raynold, Phyfition; the fecond edition of which was' imprinted at London, by Thomas Ray, whofe name is not mentioned either by Ames or Herbert, in their hiflory of prin- ters. This was alfo the firft medical book which has prints rea- sonably well executed from neat drawings. As every one of thefe books went through feveral editions, we may conclude they were in high eitimation. Then (1545) came forth alfo an abridg- ment of Vefalius, of which the copies are not fcarce, under the title of, " Compendium tctius Anatomise delineatio aere exarata, per Thomam Geminum Londini." Geminie was an engraver. The knowledge of Vefalius was more extenfively fpread from his book being ftudied by painters and artifls. In the original work of Vefalius, a great part of the engravings, it is faid, were defigned by Rubens. But one of the firft Englifh medical books, of any value, properly fpeaking, I t^ke to be " a fhort and profitable treatyfe touching the cure of the difeafe called Morbus Gallicus; withe aim account of the nature of Quickfilver, by G. Baker, Maifter of Chirurgerie, 1 5 79," and the firft book in furgery, called, " An Excellent Trea- tyfe of wounds made with Gunfhot, &c. by Thomas Gale, Maifter in Chirurgerie, (1563.)" The dedication to Ambrofe Pore's work is dated Feb. 8, 1379-, and it was tranflated into Englifh in 1634 by Thomas Johnfon ; fo that it may be doubted whether Gale did not precede Pare in the recommendation of a more fimple method of treating gunfhot wounds. The fame Thomas Gale, who was a very meritorious and indefatigable man, alfo printed " An En- cherridon of Chirurgerie," and many other works relating both to * Dr. Combe has in his poffejfton the identical manufcript copy of this work, which was prefented to Catherine, Queen of Henry the "VIHth. This copy is ftgned with the name of----- Jonas, but it does not appear why the book was afterwards publifhed in the name of Raynold. PREFACE. XIX furgery and medicine, together with the "Inftitution of a Chirur- geon." Near the fame time John Halle publifhed what he calls the " Chirurgeon Parva Lanfranci;" and John Bannijler " a Treatyfe of Chirurgerie;" and foon afterwards William Clowes "A breife and neceflarie treatyfe touchynge the cure of the difeafe called Morbus Gallicus, or Leus Venerea, by unctions and other approved waies of curing." There had been publifhed in the year 1577, a profytable treatyfe of the anatomie cf man's bodie, com- pyled by that excellent Chirurgeon, M. Thomas Vicary, Efq. Sar- jaunt Chirurgeon to Edward the Sixth, Queen Marie, and Queen Elizabeth, and alfo chiefe Surgeon of 5/. Bartholomew's Hofpitall. There was alfo printed in 1597, "The whole courfe of Chirur- gerie," by Peter Lowe, a Scotchman, Aurelian Doctour in the facultie of chirurgerie at Paris, which is quoted in the Critical Enquiry publifhed about fifty years ago by Samuel Sharp, one of the moft expert and able furgeons this country ever produced. I find a few books publifhed by phyficians about this time.—" A fliort difcourfe of the moft rare and excellent Virtue of Nitre"— A Greene Foreft, or a natural Hiflorie," by John Mapler, M. A. and ftudent at Cambridge—" The Hammer for the ftone," by Walter Carie; and a briefe treatyfe called " Caries Farewell to Phificke"—" Stirpium Adverfaria Nova perfacilis inveftigatio luculentaque acceffio ad prifcorum Materiam Medicam"—"The Benefit of the auncient Bathes of Buckftone, and the Bathes of Bathes ayde; by John Jones, Phyfician"—" Hygeina, &c. authore Timotheo Brighto, Cantabrigienfi Medicinae Doctore :" and a Trea- tyfe of Melancholie, by the fame author; " Praxis Medicinae Univerfalis" (1598), and many others in number, but not of much value, though they fhew very fatisfactorily the pains taken by die Englifh to acquire knowledge by their own induftry, and by tranf- lating many of the works, which were then held in particular efteem. But it appears alfo, that the progrefs made by the En- glifh phyficians and furgeons, for the improvement of the refpec- tive branches of the profeffion, had not been very rapid, and that much remained to be done at the commencement of the feven- teenth century; and particularly that the practice of midwifery had not been yet attended to, unlefs as a part of furgery. It is neceflary to obferve, that this order, in which we are fpeaking of different writers, is not meant as recommending an order of ftudy ; becaufe it feems to be univerfally agreed, that it is beft for learners to begin with acquiring a knowledge of thofe authors who have written on the principles and practice of the prefent time, and thence to proceed to the ftudy of former writers and of the ancients. XX PREFACE. In the year 1560, Francis Bacon, afterwards Lord Verulam, was born, a man whofe fame will receive no addition from any applaufe which it is in my power to give. He was a meteor, from whofe lufire all nature received fome light. Though he did not apply himfelf particularly to the ftudy of medicine, he has left many ufeful obfervations relating to it; and he promoted-this, and almoft every other branch of knowledge, by teaching and practifing the only effectual method of acquiring it. The more profound works of this writer are perhaps to be fludied with ad- vantage only by men who have a greater fhare of genius than common, or by thofe who have been bleffed with a learned edu- cation ; but his tractate de Augmentis Scientiarum may be of ufe to all, as, if read with care, it is not difficult fo underftand, and abounds with the moft acute obfervation and profitable inftruction, though he himfelf fpeaks of it in lowly terms. In the year 1578 William Harvey was born at Follfion, In Kent t and, having completed his fludies at Cambridge, he went to Padua, where he was admitted to the degree of Doctor in un- ufually flattering terms of approbation, in 1602. In the year. 1615 he was appointed by the College of Phyficians to read the lectures on anatomy and furgery ; and in thefe he firft promul- gated his difcovery of the circulation of the blood, a difcovery fo complete, that no perfon has ever controverted one pofition, or amended his explanation. With all the fagacity and perfeverance of a truly great man, he applied himfelf to form an entire hiftory of the generation of animals, with that of the preceding and accompanying changes; but his fludies were interrupted, and many of his papers loft, in the time of the civil war. It does not appear, that he had determined to publifh the reft, though finifhed with admirable correctness, till he was prevailed upon by the So- licitations of hi§ intimate friend feir George Ent, who fupervifed the printing of them in Engli/h, in the year 1653 ; Dut * ^avC no other authority for this fact, than the preface to that edition^ written by Sir George. By inclination, or the neceffity of his affairs, Harvey was engaged in the practice of Midwifery, by which means he got that information which enabled him to write his " Exercitatio de partu," and the many excellent obfervations upon that fubject, with which his works abound. He clearly entertained an opinion, that the knowledge of the circulation, the conftituent parts, and properties of the blood, would enable phy- ficians to cure all difeafes; but experience has not confirmed its. truth. The difcoveries which Harvey made, the many fubjects which he illuftrated, and the delicacy and patience which he ex- ercifed in his investigations, then unknown in this country, entitle PREFACE. XXI him to the higheft honor as an anatomift, and as a man of Science. He died at eighty years of age, honored and beloved for the great- nefs of his abilities, the ingenuoufnefs of his difpofition, and the mildnefs of his manners. His character is ftrongly marked in a fine picture of him, taken in his old age, now in the mufeum of the late Dr. Hunter. From the gradual progrefs of Science, from the encouragement it received, or from the example of the two illuftrious men juft mentioned, Harvey and Bacon, a happier profpect dawned upon Britain, to which I muft beg leave to call your particular atten- tion.* Thomas Sydenham was born in the year 1624, an^ graduated at Oxford. He applied himfelf to the practice of medicine, and wrote his account of the continued fever of 1661, and the three following years; which fever he probably then fuppofed to be the only one in nature. But farther experience convinced him, that there were many kinds of fever; and of thefe he has given an account to the year 1683, together withdiffertations on the fmall- pox, dropfy, gout, hyfteric, and many fporadic difeafes. Some notice is alfo taken of the difeafes incident to women in child- bed, and of many of the complaints of children. His works, originally written in Englifh, and afterwards tranflated into Latin by his friend Dr. Mapletoft, were publiflied in diflindt parts, and at different times, as the occafions occurred to him. The writ- ings of Sydenham, whether we confider the Sagacity and order with which the obfervations are made, or the fidelity with which they are recorded, have been held by all fucceeding phyficians in the higheft efteem ; and, from the time of Hippocrates to the prefent, he has been defervedly confidered as the beft example of a faith- ful obferver of difeafes, and practical phyfician. Though it muft be acknowledged, that he was often wrong in his theory, and in fome inftances in his practice, his descriptions of difeafes are al- lowed to be excellent; but his omitting to fpecify the precife times or Stages of difeafe, when his method of treatment was to be applied, very much leffens the value of his work. He died in the year 1689. Francis Gliffon was educated at Cambridge, where he became Regius Profejfor. He was one of the phyficians to Queen Eliza- beth, and to James the firft. In 1654 he publifhed his " Anat- ome Hepatis," on the internal Structure of which vifcus he made feveral new obfervations ; in 1659, his " Tradtatusde Rachitide," * The greater part of this Preface was given as an hit rod nil ory Leclure. xx:i PREFACE. which difeafe he was the firft who defcribed; and after fome years (in 1676) his book "De Ventriculo & inteftinis," in which he firft took notice of the irritability of the fimple fibre ; fo that he has an undoubted right tothe credit of being the father of all the doctrine of irritability, fince unjuftly attributed to Holler, and on which fo many volumes have been written without the men- tion of Gliffon''s name. This could not have happened, if his works had been printed in the Englifh language. He alfo pub- lished a treatife " De Natura Vita, vel fubftantia energetics," which he calls the prodromus of his treatife de ventriculo & inteflinis, but of this I have never feen a copy. Gliffon lived to be upwards of one hundred years of age,* and died at Streatham, to which place he had retired. Thomers Willis, Sedleian Profeflbr at Oxford, was born in the year 1621, and publifhed, as the foundation of a large defign, his " Cerebri-Anatome, cui acceffitNervorum Defcriptio &Ufus," in 1663. In this work he was much affifted by Dr. Lower, who was in fact his diffector and demonftrator, and the drawings were taken by the famous Sir Chriflopher Wren. The terms in which Willis Speaks of Lower, feem deferiptive of both their characters —eujus culteHi is? ingenii aciem, lubens agnofco—emicttit viri folertia plane admiranda, nee non indefatigabilis indtiflria, nulloque obicefiflen- ius labor. In 1672 he publifhed his work "De Anima Brutorum,* which is to be confidered as a fequel to the former. It is a work of infinite labor, reflection, and ingenuity, in which he defcribes the caufes and effects of the difeaSes arifing Srom nervous influ- ence. There are in this book four plates, three extremely fine, reprefenting a diffected oyfter, a loblter, and an earth-worm.—- In 1673 he publifhed the firft part of his " Pharmaceutice Ra- tionalis, five Diatriba de Medicamentorum Operationibus in Hu- mano Corpore," a work compoSed of anatomical, phyfiological, and practical observations, with many curious plates of the lym- phatics, vafa vaforum, and other finer parts of anatomy. He died before the fecond part of this work was printed ; and in the preface to it there is an account of his life and writings. The works of Willis are very numerous and ufeful, and bear indu- bitable marks of great learning, genius, and induftry, but they are Seldom Studied. Perhaps his medical works may be too philo- sophical for practical phyficians, and his philofophical works too much blended with medicine, to pleafe philofophers; and it does Seem * poffible, by the ftudy of arrangement and fubtleties of ^ * See the general Biographical Diftionary; or the Annual Regifter for the year 1767. PREFACE. XMll Science, to lofe fight of practice, as by the prefent Syftems of botany, its relation to medicine is become almoft forgotten. But there is Scarcely a Subject connected with the Science or practice of medicine, which has not been cultivated by Willis. His chap- ter on the puerperal fever, when Simply inflammatory, is judicious and good. He died in the year 1675, having founded a lecture- fhip in the church of St. Martin in the Fields, where prayers are read at an early hour chiefly for the convenience of medical men. His practical works were badly tranflated into Englifh in 1685, and afterwards all his writings, but in a language never very good, and now become obfolete. Nathaniel Highmore wrote his " Difquifitiones Anatomicae," in 1651, and " A hiftory of the Generation of Plants and Animals," in which it appears, that he made many difcoveries, particularly of the antrum in the upper jaw, to which his name has ever fince been given. Contemporary with thefe was Walter Needham, educated at Cambridge, then appointed phyfician to the Charter-houfe in Lon- don, but who afterwards refided at Shrew/bury. He wrote " Dif- quifitio Anatomica de Formato Faetu ;" a work of defervedly high estimation, in which he takes the opportunity of treating not only upon the contents and economy of the gravid uterus, but upon the lacteals and lymphatic fyftem, and many other anatomical fubjects. In the year 1656 Thomas Wharton publifhed his « Adenogra- phia;" a work of eftablifhed reputation, in which, among other things, he has obServed Some which relate to the gravid uterus. This work is quoted in the firft edition of Nuck. On the claims to the firft difcovery of the lymphatics there Seem to have been early debates, and from the verfes prefixed to Ruyfch, who firft defcribed their valves, the difputes appear to be national. But if we confider the labors of Dr. William Hunter on this fubject, and above all the perSpicuous and conneaed arrangement he has made of the glandular and lymphatic fyftem, we muft be convined that the principal merit in this part of anatomy is due to him. Nathaniel Henfhaw publifhed his « Aero-Chalinos" in the year 1677. This contains the five following traas—« On Fermenta- tion—Chylification—Refpiration—Sanguification—The good ef- feas of changing Air." About the fame time lived Walter Charlton, who publifhed "Onomafticon Zoicum" in the year 1668, and in the following year his " Economia Animalis," of which Sir George Ent gave this charaaer—opus maturo confdio inchoatum, magna euro tlabora- tum ingenio denique et doSlrina fmgulari perfeclum. Charlton wrote XXIV PREFACE. Several other works, particularly "De caufis Catameniorum et Uteri Rheumatifmo." He alSo publifhed the works of Theodore Mayerne, to whom a vain monument was ereaed in the church of St. Martin in the Fields. In 1668 Dr. Mayow of Oxford publifhed his works, entitled, " Opera omnia Medico-Phyfica," in the German edition, which is the only one I have Seen. TheSe confift of the following efTays : 1. De Sal-Nitro et Spiritu Nitro-aereo.—2. De Refpiratione.—3. De Refpiratione fsetus in utero & ovo.—4. De Motu MuSculari & Spiritibus Animalibus. —5. De Rachitide. In theSe he treats of many other interesting and curious fubjeas, which have been lately brought into public notice, and much approved, though Mayow Seems to have been greatly negleaed ; but this may be accounted for by his dying at the age of thirty-five. Dr. Richard Lower, before mentioned in the account of Willis, in 1676 publiflied his "Traaatus de Corde, item de motu et colore Sanguinis, et chyli in eum tranfitu." This celebrated work has many obfervations on the lymphatfft, and the receptaculum chyli, which he confidered as their general centre, as early as Pecquet. He alSo made many curious anato- mical and phyfiological experimertts, and in this work afferts his claim to the invention of the art of transfufing blood, to which he feems to have been very partial. The Chirurgical Treatifes of Richard Wifeman were dated in 1676, and, allowing for the time when they were written, are acknowledged to have great merit. He may not unjuftly, per- haps, be efteemed the firft Englifh furgeon. " The Comes Chi- rurgorum," containing Dr. Read's Lectures, was printed in 1686. But the improvements in furgery did not keep pace with thofe in phyfic, for in the laft, and even in the beginning of this century, it was not unufual for foreign furgeons to come into this country to perform the nicer and more difficult operations, fuch as thofe for lithotomy, all difeafes of the eyes, and every thing which related to the teeth. But Chefelden acquired fo much fame by his dex- terity in cutting for the ftone, that the King of Sweden fent his fecretary of State into England, for the exprefs purpofe of having that operation performed by Chefelden, who fuccefsfuUy extraaed from him a ftone of an unufually large fize. Every operation appertaining to the eyes, is now performed with the moft con- fummate fkill and dexterity, and with correfponding fuccefs, by Wathen, Ware, and Phipps; and thofe for the teeth, by* the Spences, and many others. It is at. the prefent time univerfally PREFACE. XXV acknowledged, that the Englifh furgeons equal, in every refpea, if they do not exceed, thofe of any other nation. Dr. Nehetniab Grew publifhed Separately, though they were afterwards colleaed into one volume, his " Anatomy of Plants," in which there are many obfervations refpeaing the Solutions of Salts; his " Anatomy of Roots—Comparative Anatomy of Trunks," between the years 1670 and 1680—" Cofmolpgia Sacra," and feveral other works. At the fame time lived John Ray, the celebrated Botanift. Clopflon Havers publifhed his " Ofteologia Nova," in 1690. In this work he deScribed the mucous glands oS the joints, which he discovered, and the internal Struaure and diSeaSes of the bones, cartilages, &c. In the year 1695 Ridley publifhed his " Anatomy of the Brain," of which he is faid to have difcovered the lymphatic veffels ; and his " Obfervations," in which he treats on feveral abftrufe parts of anatomy.' Dr. Richard Morton publifhed his " Phthiftologian in 1689 ; his u Pyretologia feu de Morbis acutis univerfalibus" in 1691 ; and .his work "De Febribus inflammatoriis" in 1694. Sydenham's treatment of Fevers was almoft univerfally antiphlogiftic; Mor- ton's, on the contrary, was cordial and Sudorific; but we have between thefe two writers, moft of the arguments which have been advanced in favor of both methods of praaice. The firft edition of Cowper's " Myotomia Reformata" was publifhed m 1695 ; and Keil's Anatomy in 1698. By the writings of thefe very eminent men, and of many others whom I might have named, particularly of the celebrated Robert Boyle, it appears, that the phyficians of* this country were, from the beginning to the end of the laft century, indefatigable in the acquifition and improvement of Science ; that they were not only acquainted with the general knowledge of the Greeks, Romans^ Arabians, Italians, and French, but might fairly be put in com- petition with thofe of any other nation, if they did not excel them; and that all the changes we have feen, were produced in left than two hundred years, that is, from the^ime when the College o£ Phyficians was eftablifhed, in the year 1518, to the termination of the Seventeenth century. Early in the eighteenth century, the benefits of medicine to fociety were rendered confpicuous by the introduaion into England of the praaice of inoculating for the fmall-pox, for the knowledge of which we were indebted to the Sagacity and judgment of Lady M. W. Montague. The mortality attending that difeafe in a natural way, was eftimated as one in eight; but by inoculation it fcarce exceeds one in a hundred.—- Vol. I. D XXVI PREFACE. Many objeaions were made to inoculation, when firft intro* duoed; but the praaice, being conduaed with much caution and understanding, by able medical men, and proteaed by Queen Caroline, at length became general. It required, however, the experience of fifty or fixty years, to bring inoculation to its pre- fent flate of perfeaion, the merit of which is exclusively due to Englifh phyficians and furgeons. Inoculation for the cow-pox, as a preventive of the fmall-pox, has been lately recommended and carried to a confiderable length by Dr. Jenner, a phyfician of great worth and abilities, to whom only we are alfo indebted for the firft account of the cow-pox, as a part of natural hiftory, and for our knowledge of the treatment ©f the difeafe when inoculated. As far as can be judged at prefent, Dr. Jenner's propofal, when carried into execution, will be the means of Saving much anxiety, and many lives, and may perhaps lead to the ex- tinaion of the fmall-pox. I muft in this place beg leave to make a digreffion. In the year 1668 Herman Boerhaave was born near Leyden. He was originally defigned for the church, but was led by inclination, and the ill State of his own health, to apply himfelS, when very young, to the ftudy of medicine. He graduated in the year 1693, was chofen Leaurer on the Institutes of Medicine in 1701, and enjoyed all the honors, which the univerfity could beftow, or the city of Leyden confer upon him. He raifed the reputation of this School of medicine beyond that of any other in Europe. The induftry of Boerhaave, in the purfuit of knowledge of every kind, is almoft incredible ; that of any other man, com- pared with his, may be called amufement; the facility with which he communicated this knowledge to others, was beyond exprefiion happy; and his whole condua, in every religious, moral, and Scientific view, to the higheft degree laudable. He was honored in his life, and his memory is univerfally refpeaed. His hiftory, which was written by Dr. Samuel Johnfon, muft ever remain a very uSeful ftudy to medical men, and an example of fine compofition. Boerhaave died in the year 1738, in the 70th year of his age. +> Among the favorite ftudents of Boerhaave was Alexander Mon- ro, who in the year 1719 returned from Leyden to Edinburgh, a city at that time not diftinguifhed by any eminence in medicine. But in the following year Dr. Monro being chofen profeffor of Anatdmy and Surgery, and Dr. Alflon of Botany, they began to give Lectures, and by their abilities Soon acquired that high re- putation, which enabled them to eftablifh a School of medicine which they had the very great fetisfaaion of raifing to an equal PREFACE. xxvn degree of honor with that of any preceding or prefent time. Dr. Monro died in the year 1767, leaving behind him many valuable works, which were afterwards colleaed into one volume, and publifhed by his Son Dr. Alexander Monro, who fucceeded his father as profeffor. By this eftablifhment, the further advantage was gained to Britain of having at Edinburgh a fucceffion of very able and eminent men, who dedicated the chief part of their time to the acquifition and improvement of medical fciemje, and to the instruction of thofe who were intended for the profeffion. Here I fhall conclude thefe general obfervations, and confine myfelf to fuch only as relate to the praaice of midwifery, pre- mising a fhort remark on a fubjea, in which the interefts of fo- ciety, and the claims of individuals, are deeply concerned. The ceconomy of the medical profeffion has, in this country, undergone many alterations, according to thofe of fociety at large. Phyficians, who are called to take charge of all cafes of uncom- mon difficulty or danger, or of the lives of perfons of high rank and eminence, have generally fuch an education, as leads not only to the acquifition of medical knowledge, but to the cultivation -alfo, and higheft improvement, of all the powers of the mind. But the operative, and all the inferior parts of the profeffion, fall under the condua of thofe who were educated as furgeons, or apothecaries. By thefe are performed all the operations in fur- gery, many of which require an admirable combination of mental and perfonal qualities ; and to their fkill and care the lives of the greatest part of the lower clafs of people, and of thofe who Serve in the army and navy, are almoft conftantly Submitted. In or- der to their being duly qualified for thefe important duties, young men, having received a reafonable fhare of claffical education, are bound, for a certain term of years, to fome perfon, compe- tent to give them proper inftruaion and information. To fuch young men it can only be neceffary to obferve, that they will at fome future time be called upon, to take charge of the lives of men, for which they muft be refponfible, not only to the laws of God, but to the law of the land; which has the power of infix- ing fuch punifhment, as any particular inftance of ignorance or negligence may be proved to deferve ; and, which is beyond all other puniShment, their names become ignominious. I may therefore be permitted to recommend the profeffion of any part of medicine, as a very facred truft to thofe who engage in it; the neceffary and proper qualifications for which, demand all then- attention, and the fober, conftant, and moft indultnous ppr-h- cation of all their abilities. But it is very much to be doubted, whether fome of thofe who, both as parents and mailers, take the xxviii PREFACE. charge of fuch young men, are not fometimes fclfifh, and negli- gent in the performance of that fhare of the duty which they un- dertake ; and whether, having received the gratuity ufually paid, they give due attention either to the morals of the young men, or inftrua them properly in the knowledge of their profeffion. Through this negligence of the mafters, or the thoughtleffneft and inattention of the young men, at the end of their Servitude they muft frequently be ignorant of many things which they ought to know, to their own misfortune and difgrace, and to the great prejudice of fociety. By the nature of one part of my employment, that of giving Leaures, I have had too many opportunities of knowing the trutk of this remark; and, with the greateft unwillingneSs to give of- fence, I feel called upon to make the preceding animadversions, in confirmation of which I beg leave to add the following quota- tion, from unexceptionable authority: " Clerks and apprentices ought to be employed entirely in the profeffion or trade, which they are intended to learn. Instruc- tion is their hire ; and to deprive them of the opportunities of inftruaion, by taking up their time with occupations foreign to their bufinefs, is to defraud them of their wages."* The " Byrth of Mankind,or the Woman's Book," with Sketches not badly intended or engraved, was printed in the year 1540 : and as it went through many editions, and as I find no other book of equal value publifhed about that time, I confider it as having been the popular book Sor near one hundred years ; that is, till the year 1634, when all the works oS Ambrofe Pare were tranflated in one volume. Pare was a man of much experience, fome erudition, and not a little credulity, but he made many ufeful obfervations. relative to midwifery. In the year 1653 Harvey*s Exercitations were publifhed in Englifh, but whether tranflated or original I can- not decide. About the fame time alfo lived Dr. Chamberlen, a very celebrated phyfician, who applied himfelf to this branch of the profeffion.f He had three Sons, who, with their father, were fuppofed to have a better method of relieving women in cafes of difficult parturition than any other perfon, by means of an instru- ment Said to be the forceps, but which I believe to have been a veElis ; or perhaps they had more than one inftrwment. One of * Paley's Moral and Political Philofophy, Vol. I. f A very elegant monument was ereSled in Weflminfler Abbey to this Dr. Chamberlen by the Duke of Buckingham, of whom he has alfo in his Effays given a very amiable charafter. PREFACE. XX1X the fons went over to Paris, with a view of felling the fecret, or of making a fortune by praaice ; but being foiled in the firft cafe to which he was called, and fuffering more obloquy than he de- fended, he returned to England, and immediately published a trans- lation of Mauriceau's work, which remained for many years m very high efteem. This was in the year 1672. Having been favored by the late Dr. Kirkland with a manu- fcript written by Dr. Percival Willughby, who lived at Derby, and afterwards in London, I am able to give the reader fome idea of the praaice of that time, many of the cafes being dated from 1640 to 1670. This work is entirely practical, and was in- tended to be publiflied for the ufe of midwives, there being a title page, and two copies with variations. His preface is in this manner: " I haue read many bookes, with all the late writers in mid- wifery, and I do perceiue that they all follow one common roade, taking their feueral fcheemes and figures one from another. _ « In feueral of thefe fcheemes uarious things may be perceiued ^which will be trublefome to the labouring woman, which a ju- dicious praaicioner will not followe. Let midwiues mark what hath been written in my obferuations, let them confider diligent- ly the feueral reportes not faigned, or the furmifed thoughtes, nuaors, or man's fantafie, fitting and meditating in his Studye, but which really haue been performed in the trailing woman s " From mine and their direaions let midwiues choofe the beft and facileft waies of relieuing women in affliaion, and to decide all difputes, let reafon be the judge, let experience argue the dubious points of praaice, and, after a full debate, let unfpotted truth recorde to fucceedinge times what is moft ntt to be fol- lowed and uSed, &c." . , . This is a Specimen of his illuftration—" Let midwiues obferue the waies and proceedinges of nature for the produaion of her fruit on trees, or the ripening of walnutts and almondes, from theire firft knotting to the opening of the hufkes and falling of the nutt; the grecne hufkes Sticking fo clofe that it is not poffible to feparate the V *ora the acU» ?Mf -V8 ^"pe *' b* ? the fruite ripenefe the hufke choppeth and with a fiffure openeth, and by degrees feparateth the fruite without any enforcement. " An else reprefenteth the wombe : now the henne with keep. injr theegge warme doth breed the chicken, which when it come, to maturiSe doth chip the {hell, and i, by degrees hatched wrihj out iniurie. Thefe Signatures may teach midwiues patience, an4 pevfiudc them to let nature alone to performe her own worke, XXX PREFACE. and not to difquiet women by their ftrugglings, for fuch enforce- ments rather hinder the birthe than any waie promote it, and oft ruinate the mother and ufually the childe; and let midwiues knowe that they be nature's Seruants, &c." Willughby's praaice is not much different from that of the prefent time. He divides labors into two kinds only, natural and unnatural. The particular rules I cannot pretend to defcribe in this place ; but the following letter, which he has quoted from a fcarce work, correfponds So nearly with an observation it was my fortune to make fome years before I Saw this manufcript, that I may be excuSed relating it. " Referam hoc cafu, quid beatse meae conjugi acciderit. Ter- tio foetu gravidam, nono praegnationis menfe, labores parturien- tium arripiunt circa noaem.' Mox rupta aqua (ut hie mulieres loqui amant) extra genitale, infantuli manus propendit. Ubi obftetrix adveniffet, uxorem meam in fedili collocavit, eamque ad continuos conatus (me nolente nee inftigante natura) adegit. Cum vero res eo modo non fuccederet, meamque conjugem fu- pra fedem continuo detineret, ac diris cruciatibus illapfum ex uteri cervice manum brachiumque retrudere niteretur, quo fce- tum ad exitum commodius difponeret. Ego prae dolore charae meae conjugis impatiens, ac indefinenter obftetricem admonens, ne quidem elapfi membri reduaionem in uterum congitaret poffi- bile, multo minus moliretur, Secundam obftetricem accerfiri jufli, prJeSertim cum uxor mihi nunciaret, quod obftetrix earn dilace- raret per illam praeconceptam ac miSeram elapfi membri repulfio- nem. Cum infequenti die, obftetrix altera veniffet, ilia manus ad opus applicans remque diligenter explorans, uxorem meam in tectum depoSuit, mandavitqueut Se quietam deteneret,nulloSque conatus excitaret, nifi quando natura earn Sui admoneret officii. " Interim obftetrix ilia prudens et expertiflima praedixit mihi amicifque praefentibus, uxorem meam non ante parturam, quam foetus in utero ex indebito fitu, conatibus ftangularetur, quod eventus docuit. Multiplicati funt labores parturientis, et foetus inflexo ad dorfum capite, (falva matre) prodiit in lucem."* By a genealogical manuScript, written by the firft DucheSs of Chandos, in the poffeflionof Colonel,Kearney, it appears, that this Dr. Willughby was one oS the fix Sons oS Sir Percival Willughby, and grandSon oS Sir Francis, So famous in the time of Queen Eli- zabeth. It is probable, that the fortune and eminence acquired by the fuppofed advantages of the method of the Chamberlens, which * Novus exortus hominis et animalittm* ANTON. EvERARD. PREFACE. XXXI they referved as a Secret, might be the occafion, that many gen- tlemen, engaged in praaice, endeavoured to eftablifh themfelves upon the Same principles, that is, oS concealing the instruments they uSed; of which clafs was Dr. Bamber. Others might at- tempt to gain equal reputation and fortune by the very contrary means, that is by decrying the ufe of inftruments of every kind, on any occafion; for about the year 1723, Dr. John Maubray publifhed a volume upon this fubjea,called "The Female Phy- fician," or the " Whole Art of New improved Midwifery," in which he exclaims with great vehemence againft their uSe, and the book, though written in quaint language, has Some general merit. In the following year he alSo published an appendix, un- der the title of " Midwifery brought to Perfeaion," in which he demands great credit for the many improvements he had made. This appendix is in truth no more than a Syllaius of his Lec- tures, a courfe of which confifted of twenty, twelve anatomical and phyfiological, and eight praaiciil. I believe it would be un- juft, to deny to Maubray the credit of having been the firft pub- lic teacher oS MidwiSery in Britian. He gave his Leaures at his houSe in Bond-flreet. In the year 1719 Dionis' Midwifery was tranflated into the En- glifh language ; and in the year 1729 Deventer's work was tranf- lated and publifhed : and though it appears, that rather more credit has been given to this author than he deferved, yet as he en- ters upon a difcuffion oS the cauSes of many difficulties which oc- cur in praaice, and of the means of relieving them, and as he was generally averfe to the uSe of inftruments, Deventer's work might be efteemed a confiderable addition to the flock of obftetric knowledge in this country. Deventer was originally a watch-ma- ker. Dr. Simfon, profeffor at St. Andrew's, publifhed in 1729, his " Syftem of the Womb," a work of fufficient ingenuity, but not ' of much ufe in praaice, even if his theory had been true. About the year 1733 Edmund Chapman publifhed hi6 " Trea- tife on the Improvement of Midwifery," in which there are feve- ral ufefui obfervations ; and other writings of temporary confe- quence only. Chapman was the fecond public Teacher of Mid- wifery in London, and he was the firft alSo who deScribed the Forceps, in the third volume of the Edinburg Medical Effays. In the year 1734 Dr. Hody publifhed a "Colkaion of Cafes in Midwifery," written by Mr. William Gijfard. Thefe cafes, two hundred and twenty-five in number, feem to be written with great fidelity; and as they occurred in his own praajce, they were leffons of condua which was to be purfued in fimilar cafes, xxxft PREFACE. and may now be confidered as examples of the State of practice at that time. Qiffard alfo gave a plate representing the Forceps, and was, I believe, among the firft who afferted, that the placenta might be attached over the os uteri. " The Midwife rightly inftruaed" was publiflied in the year 1736 by Thomas Dawke : and the " Midwife's Companion" by Henry Bracken, in the following year, with feveral other things equally unimportant. About this time lived Richard JMnnningham, who quitted the profeffion of Pharmacy, and applied himfelf with great affiduity to the praaice oS Midwifery. In a controversial pamphlet, pub- lished in the year 1730, he is mentioned as having been knighted. In the year 1739 ^e eftablifhed a ward, or Small hoSpital, in the parochial Infirmary of St. James, Weflminjier, for the reception of parturient women, which was the firft thing of the kind in the Britifh dominions. At this ward, which was Supported by pub- lic Subscription, he gave leaures, and the Students had opportu- nities of being qualified for praaice. He publifhed a Compendium Artis obftetrica" a " Treatife on the Febricula," on the " Ufe and Abufe of Phyfick," Aphorifmata Medica," and many other effays, relating chiefly to the practice of Midwifery. Sir Richard Man- ningham was a man of much learning and information, eminent and fuccefsful in praaice, and very humane in the exercife of his art. He died about the year 1750. Before that time there had alfo been publifhed a tranflation of Heifler's Surgery, and this, containing not only a general outline of midwifery, but many ex- cellent praaical obfervations, muft have been a fource of great benefit in a country not then overstocked with information. Sir Fielding Oulde of Dublin, in the year 1741, publifhed a ilTreatife of Midwifery," the moft interesting parts of which are his obfervations on the continuance of the thicknefs of the uterus during pregnancy, and his defcription of the manner in which the head of a child paffes through the pelvis at the time of birth ; the truth of which obfervations has fince been fully proved and acknowledged. Having taken this Short and imperfea view of the progreft of Midwifery in this country, from 1540 to the year 1740, it will be prudent to conclude, or this preface would be carried to an inadmifliblc length. The Englifh might then be faid not only to have purfued, but to have been in full poffeffion of the Subject; all the books written in the neighbouring countries being tranf- lated, public leaures given, and an hofpital eftablifhed Sor the farther impjovement of the art, which was taught by men of ability and eminence in praaice. As all the books and paper* PREFACE. XXXUt printed Since that time may be readily procured, every gentle- man has an opportunity of forming his own opinion of their re- ipeaive merits without any laborious refearch. But the College of Phyficians having been pleafed, in the year 1783, to form a rank, in which thofe who dedicate themfelves to the praaice of Midwifery fhould be placed, I truft that Suture accounts will be more appofite and correa ; and that this meaSiire adopted by the College will promote the public benefit, by confining the induftry and abilities oS one clafs of men to this branch of the profeffion. It is my earnefl wifh, to fupport their views in this wife and be- nevolent arrangement, as the fruits of which, I do entreat Doaor Thomas Gifborne, Prefident of the College of Phyficians, not left dignified by his learning, and the integrity and liberality of his principles and condua, than by his rank in the profeffion, to ac- cept thefe two volumes, dedicated, with all refpea, by his moft obedient and obliged Servant, THO. DENMAN London, December 1, 1800. Vol. I. jt, V INTRODUCTION TO THE PRACTICE OF MIDWIFERY. CHAPTER I. SECTION I. ON THE PELVIS. 1 he anatomical and phyfiological knowledge of all the parts concerned in parturition, is indifpenfably neceffary for thofe who mean to excel in the praaice of midwifery; even that of the whole body may, on various occafions, be employed with ad- vantage. In the inveftigation of every fubjea there muft, how-. ever, be fome point of commencement, and, as there is much ufe and propriety in the method hitherto purfued by fyftematiG writers, I Shall follow their example, and give, in the firft place, a defcription oS the Situation, ftruaure, conneaion, uSe, and difeafes of thefe parts; beginning with the pelvis, which is of great importance, on account of the direa influence which it has upon labors, and becaufe it may be efteemed the foundation on which all the other parts are fuftained. But this is only intend* ed fo far as may be requifite# Sor the ftudy and praaice of mid- wifery. The term pelvis has been indifcriminately given to the inferior part of the cavity of the abdomen, and to the bones which form the cavity ; but it appears more eligible to confine the term to the bones, and to call the Space between them the cavity.of the pelvis. The pelvis in the adult State is compofed of four bones; the facrum, the os coccygis, and the ojfa innominata. The facrum is Situated at the pofterior and inferior part of the trunk of the body, and Serves as a bafis for the fupport of the INTRODUCTION TO ;.iip\VIFERY. fpine, of which it is an imperfea continuation. Its figure is that of an irregular triangle, with the fhorteft fide placed upT wards. The anterior Surface is fmooth and flat, and has a con- siderable degree of infleaion or curvature, called the hollow of rhe facrum, by which the cavity of the pelv\s is much enlarged. The pofterior furface is convex and uneven, to which fome of the mufcles of the fpine and thigh are attached. In the infantile State, the facrum is compoSed of five, and in fome fubjeas of fix bones, called falfe vertebra, cemented to- gether by intervening cartilages, which in the adult become bone; leaving little ridges or lines on the anterior SurSace, indicating the parts where they had been Separate. TheSe bones diminifh in their Size as they deScend, fo that the loweft, which makes the point oS the facrum, Scarcely maintains the charaaer of one of the vertebra. The articulation of the upper part of the facrum, with the laft of the lumbar vertebra, is Similar to that of the vertebra with each other; but, by the manner in which the facrum and vertebra are joined, the latter inclining over the former, an obtufe angle is made, called the great angle of the facrum. Through the facrum there is a canal for the refidence and Se- curity of the lower pp.rt of the medulla fpinalis ; but the pofterior part of the canal is incomplete below the third bone, a Strong ligamentous Subflance Supplying the place of bone. That part of the medulla which is contained in the facrum, is called the cauda equina. On the anterior part of the facrum there are four pair of holes or perforations, or more, according to the number of bones of which the facrum was originally compofed, through which large nerves pafs for the ufe of the parts contained in the pelvis and of the inferior extremities. On the pofterior part oS the facrum. there is an equal number of perforations difpofed in the fame longitudinal order; but they are leSs than thoSe on the anterior part, and covered by membranes, which allow Small nerves to paSs through them. ' The facrum is of a very cellular texture, and is Said to .be lighter than any other human bone of equal magnitude. The lateral parts of the facrum form a broad unequal furface, by which it is conneaed with intervening ligament and cartilage, to another uneven furface at the pofterior part of the offa innomi- nata. The inequalities of thefe Surfaces, receiving and being received by each other, contribute very much to the firmnefs of the union of thefe bones. An anchylofs is not unfrequently formed, between the facrum and offa innominata s and fometimesa ON THE PELVIS. 3 in confequence of their Separation, an imperfea joint, which very much weakens that part, and impairs the manner of walk- ing for the remainder of life. To the inferior extremity or point of the facrum is fubjoined the os coccygis, which has by fome writers been confidered as a diftina bone, and by others as an appendage to the facrum; and thefe form, by the manner of their union, an obtufe angle, called the little angle of the facrum. In infancy the os coccygis is carti- laginous, but in adult age it is compofed of three, or, more fre- quently, of four bones, conneaed by intermediate cartilages, the uppermoft oS which is Somewhat broader than the lower part of the facrum. In fome fubjeas thefe bones coalefce and form a Single bone ; and in others an anchylofis is formed between the fa- crum and os coccygis; in confequence of which the latter is fhort- ened and turned inwards, fo as to obftrua the head of the child in its paffage through the pelvis. But the impediment thereby occafioned at the time of labor, may be overcome by the force with which the head of the child is propelled, and the os coccygis again feparated from the facrum with a noife loud enough to be diftinaiy heard, of which I have known more than one inftance. In general, however, between the bones oS which the os coccygis is compoSed, Some regreffive motion is preferved; and that which is produced between the facrum and os coccygis, when the latter is preffed by the head oS a child puffing through the pelvis, occa- sions a considerable temporary enlargement of the inferior aper- ture of the pelvis* The infer tion of the coccygai mufcles, of a part of the levatores ani, and of portions or flips of the facroSciatic ligaments into the fides of the os coccygis, keeps it fteady, and prevents any lateral motion. The offa innominata are the broad large bones which form the fore part and fides of the pelvis, and the lower part of the fides of the abdomen. In children each of thefe bones is compofed of three; and, though they afterwards become one, the lines of original diftinaion may be obServed at the acetabulum, or Socket, which receives the head of the thigh bone. While the bones are diftina, they have peculiar names, the ilium, the ifchium, and pubis, which nam^s it is neceffary to retain in the adult State, that we may be able to deScribe with more accuracy each individual bone, or allude to it in the defgription of the adjoining parts, and on many other occaSions. * Os coccygis adeo extrorfum fape vertitur, ut integros deinde annos covqucrantur dc dolore, in partibus his reftduo. Ruyfch, Adverf. Dec. 2 4 INTRODUCTION TO MIDWIFERY. The ilium is the largeft and uppermoft of the bones which form the offa innominata. It is flat, broad, unequally convex and con- cave ; in fome parts round, and in others of an irregular Square figure. It is divided by anatomifts into the crijla, bafs, anterior and pofterior edge, and the two fides, external and internal. The upper part, which has a thick arched border, is called the crijla. The anterior and middle part oS it is convex outwardly, and the pofterior Somewhat convex inwardly. The crijla has originally on its verge an epiphyfis, of which there are often marks to an advanced age. The bafts or inferior part of the ilium is thick and narrow. It forms anteriorly a portion of the acetabulum, or Socket, which re- ceives the head of the thigh bone; and posteriorly a large Share of the circumference of the ifchiatic finus, which is completed by the ifchium and facrofciatic ligaments. The anterior edge of the ilium has two eminences, called fpines, distinguished as Superior and inferior, between which there is an excavation or notch, and another below the inferior fpine. The pofterior edge is fhorter and thicker than the anterior, and terminates with two protuberances or fpines, between which there is alfo an excavation. The external fide of the ilium is convex on the fore, and con- cave on the back, part. The internal fide is irregularly concave; and upon that furface which is conneaed with the facrum there are feveral irregularities. From the upper part of this furface there runs a prominent line, which forms a margin, defining the upper aperture of the pelvis. The ifchium forms the loweft portion of the offa innominata. Its parts are defcribed under the names of body, tuberofity, or ob- tuSe proceSs, and ramus. The body of the ifchium forms the loweft and largeft part of the acetabulum, and fends out a fmall apophyfts, which projeas back- wards and inwards, and is called the fpine or fpinous proceft of the ifchium. The tuberofity or obtufe proceft of the ifchium is very thick and uneven, and is turned downwards. As it is the part on which the body refts when we fit, it hath alfo been called os fedentarium. The convex portion was originally an epiphyfis ,• and, from the re- mains of the tendons and ligaments which were affixed to it, has, in the frefh fubjea, a cartilaginous appearance. The ramus is a flat thin proceSs or apophyfts, proceeding from the curvature of the tuberofity, afcending and joining to a fimilar but ftiorter proceft, which Springs from the anterior and inferior ON THE PELVIS. 5 part of the offa pubis. The ramus oS the ifchium, aided by this Short proceSs, form a large part of the outline of that opening called the foramen magnum ifchii. This opening, in the recent Subjea, is filled up by a Strong ligamentous membrane, which gives riSe to the external and internal mufcles called obturatores. The offa pubis contribute the Smalleft fhare towards the forma- tion of the offa innominata. Each of them has been defcribed in three parts, the body, the angle, and the ramus. The body is that part which is placed tranfverSely before the anterior part of the ilium, to which it is united, forming by this union the oblique eminence, which diftinguifhes on the inner part of the pelvis thefe two portions of the offa innominata. The body of the pubis contributes alfo to the formation cf the acetabulum. The upper edge has on its inner part an oblique ridge, which is called the crifla, and is continuous with that of the ilium before- mentioned, as defining the margin of the pelvis. The anterior part of the pubis is called the angle, and constitutes that Surface, which, being joined to the oppofite bone, forms the fymphyfs of the offa pubis. This part of the bone is flat and thin. The offa pubis conneaed together form on the external or inferior Side an unequal concavity ; but on the internal or Superior Sur- face they are pretty equally convex, and both the edges have a fmall degree of flexure outwards. The ramus is a flat, thin, fhort apophyfts, which, running ob- liquely downwards, unites with that of the ifchium. The two rami of the ifchia and of the offa pubis form on the interior and inferior part of the pelvis an arch, which is ufually called the arch of the pubis. This arch is much larger in women than in men ; which circumftance is favourable to the emergence of the head of the child at the time of birth, and constitutes the moft distinguishing mark between the male and female pelvis. SECTION II. The advantage to be derived from the knowledge of the bones of the pelvis, in a dried or feperate State, is not very evident. But we may confider the previous intelligence of this and Some other parts oS our Subjea, as effentiaily uSeSul and neceffary, becauSe it comprehends the rudiments of a more perfea knowledge than can be otherwife acquired; we fhall therefore proceed to examine the manner, in which thefe bones are conneaed. To the two lateral furfaces of the facrum are joined the pofte- rior furfaces of the offa innominate, and thefe are covered with a 6 INTRODUCTION TO MIDWIFERY. thin intevening cartilage, or ligamentous cartilage ; the inequali- ties, as was before obferved, contributing very much to the firm- nefs of the junaion. The offa innominata are alfo joined at the anterior part by a thin cartilage, which covers the Scabrous end of each bone, and the fpace between them is filled up with a ligamen- tous fubfiance. This conneaion is called the fymphyfs of the offa pubis.* Within the circuit of the pelvis the periojleum is thickened at the parts where the offa innominata are joined to the facrum, and at the fymphyfs ofthe offa p:-bus. Thefymphyfts has alfo been defcribed as conneaed by a thin tranfverfe ligament, or by ligaments which form what may be confidered as a capfular ligament, adhering to the part which it enclofeth, and to which it giveth the principal ftrength. Greater Stability could not be procured by any internal mode oS union, without a diminution of the cavity of the pelvis. But on the external parts of the pelvis, where the union of the bones could be more firmly eftablifhed by a ligament, there is no point where one is omitted ; even the tendons of the mufcles in- serted into the projeaing parts of the bones, though particularly defigned for other purpofes, eventually contribute to the ftrength of the pelvis. From the pofterior edges of thofe furfaces of the offa innominata which are joined to the facrum, Strong ligaments paSs, which bind theSe bones firmly together ; and all that unequal Space behind them is filled up with Small muScles, or the Small parts of large mufcles, in fuch a manner as to give in the frefh fubjea, when covered by their tendinous expanfion, a furface almoft Smooth. From the obtufe proceffes of the ofchia Strong ligaments ariSe, which, expanding, paSs to the pofterior edges and apophyfes of the facrum, detaching in their paffage Small portions to the' ofcoccygis. TheSe ligaments are called the broad or external SacroSciatic. From the Spinous proceffes of the ifchia ligaments arife, which, croft- ing and adhering to the ligaments before defcribed, paft to the in- ferior and inner edge of the facrum and the upper part of the os coccygis, fending flips or fmall portions to the edges of this bone through its extent. Thefe are called the internal facrofciatic ligaments. * See afhort but very precife account of the connexion of the bones of the pelvis^ ky Di- William Hunter. Medical Obfervations and Inquiries, Vol. IL ON THE PELVIS. 7 SECTION III. "By the knowledge of the parts where, and the manner in which, the bones of the pelvis are conneaed together, we are enabled to explain many uneafy-fenfations which women have, and many in- firmities to which they are liable at the time of pTegnancy and af- ter their delivery. It was for many centuries a received opinion, that thefe bones, though joined together in fuch a manner as Scarcely to afford any fuSpicionof a Separation, were always feparated at the time of par- turition ; or that there was a difpofition to Separate, and an actual feparation, if the neceffity of any particular cafe required that en- largement of the cavity of the pelvis, which was confequent to it. The degree of feparation was alfo fuppofed to be proportionate to fuch neceffity; and if it did not take place, or not in fuch a de- gree as was required, distending inftruments were contrived and » uSed to produce or increaSe it: and upon the Same principle the feaion of the fymphyfs of the offa pubis, of which we fhall hereafter fpeak, hath been lately recommended. This opinion ought probably to be affigned as one reaSon for the fuperficial notice taken by the early writers inmidwifery, of thofe difficulties which are fometimes ; found to occur at the time of parturition, from the fmallnefs or • deformity of the pelvis.* To this may alfo be referred much of the popular treatment of women in child-bed, and many popular expreffions in ufe at the prefent time. But this opinion hath been controverted by many writers, who affert, that there is neither a feparation, nor a difpofition to feparate ; but that when either of them does happen, they are not to be efteemed as common effeas attendant on the parturient State, but as diSeaSes of the conneaing parts.-f The difputants on each fide have appealed to prefumptive *■ Edotlus affero, offa pubisfape ab invicem in partu loxarifemollito eorum cartilaginofo connexu, totomque hypogaflrii regionem, ad miracu- lum ufque, ampliari ; non qtj^em ab aquofa fubflantia profuficne, fed fuafponte, utfrutlus maturi excludendis fuis feminibus fjent hi/cere. Harv. Exercitat. lviii. In partu difficili et laboriofo offa ifchii ajiquantulum a fe invicem dehifcunt. Ruyfch. Adv. Dec. 2. f Les tins et les autres difent, qui ces os que fe feparent ainft a theure de Paccouchement, y ont ete dijpofez peu a peu auparavant, par des humiditez glaireufes qui f'ccoulent des environs de la matrice, lef quelles amolliffent pour lors le cartilage qui les joint firmement, en - dered as morbid. Several cafes of this kind, which have occurred in my own praaice, and a great number for which I have been confulted, have laid me under the neceffity of considering this Sub- jea with the moft Serious attention, and I prefume that it may be ON THE PELVIS. 9 produced by two cauSes ; firft, a Spontaneous difpofition of the eonneaing parts; Secondly, the violence with which the head of the child may be protruded through the pelvis* Of a feparation from each of thefe caufes it will not be improper to give an exam- ple, to prove the faa, and to fhow its confequences. \ CASE I. A young lady of a healthy conftitution, and lively difpofition, who was married in the twenty-firft year of her age, was, in the beginning of 1774, delivered of her third child, which was unu- Sually large, after a very Severe and tedious labour. For Several days beSore her delivery fhe was rendered unable to walk without affiftance, by pain and weakneSs in her loins Her recovery was favourable and uninterrupted, except that for feveral fucceeding weeks fhe was incapable of {landing upright or putting one foot before the other ; the attempt to do either being attended with pain, and a SenSe of loofenefs or jarring, both at the parts where the offa innominata.zxe joined to the facrum and at the fpmphyfts of the offa pubis. By the uSe oS Such medicines and means as con- tributed to Strengthen her conftitution fhe Soon became able to walk, and, in a few months, was perfeaiy well. Having before feen a cafe of the fame kind, I fufpeaed, that thefe complaints were occafioned by the weakneSs of the connex- ion, of the bones of the pelvis; and, imputing this weaknefs to»too frequent parturition, fhe was advifed to Suckle her child a longer time. She accordingly continued a nurfe fifteen months. After weaning her child fhe Soon conceived again ; and when the time of her confinement drew near, the complaints which fhe had in her former pregnancy were increafed to fuch a degree, that fhe could neither walk nor Stand ; and, Sor three weeks before her delivery, there was reafon to SuSpea, that the bones of the pelvis were Separating. July 7, 1777, She was delivered of her fourth child. At the time of her labour fhe had frequent faintings, great marks of dis- turbance and irritability, and was wholly unable to move her in- ferior extremities. A few days after her delivery fhe had a fever, which terminated * In the 484th number of 'the PhilofophicalTranfuclions there is an account of the feparation of the fymphyfs pubis to the diftance of four inches, occafioned by the fudden farting of thehorfe when a gentleman was riding. JO INTRODUCTION" TO MIDWIFERY. in an abfceft in one of her breafts. By this, which was very painful and diftreffing, fhe was confined to her bed for near feven weeks. At the end of nirie weeks She could walk with crutches, when She was Sent into the country, from which fhe received much benefit; as fhe believed fhe likewife did by drinking half a pint of Strong infufion of malt twice every day. In about five months fhe was able to walk without affiftance, though fhe was fometimes fenfible of the motion of the bones, which fcem never to have been per- feaiy united. About ChriftmaS fhe was again pregnant ; and in July, 1778, being indifpofed to move, as fhe imagined by the fudden and un- common heat of the weather, the pain and weaknefs in her back returned, and fhe could not walk any more without affiftance to the time of her labour, which came on Oaober 1 ith. On the 13th fhe was delivered of a very fine child Her labour, which was unufually fevere and alarming, was made infinitely more fa- tiguing by her inability to move, all power of fupporting herfelf being wholly loft, and every neceffary change of pofition, though fhe was in bed, being made by her affiftants. On the Sourth day aSter her delivery She was Seized with a fe- ver, which was foon removed, but her Situation remained really deplorable. The pain at the junaion of the bones continued ; fhe had no command of her inferior extremities ; and when fhe. was moved, the pain, which fhe defcribed as the cramp, became excruciating, as if fhe was tearing afunder. Her Stomach was at all times much disturbed, but, when (he had the pain in an increas- ed degree, a vomiting, oroppreffivenauSea, or hiccough wasbrought on. The pain alSo produced Strange Sympathies in various parts, as a very teafing cough, a conftant Sneezing, a SenSe of weight in her eye-lids, which fhe could not keep open, though fhe was not fleepy, noife in the bowels, and many other nervous affeaions. When, therefore, the pain was violent, fhe had recourfe to opiates, which fhe took diScretionaily, and the pain being quieted the Sym- pathies Soon ceaSed* At the requeft of my patient I explained upon a fkeleton the opinion entertained of her complaints; and, when I pointed out the manner in which the parts were fuppofed to be affeaed, (he was fully perfuaded of the truth of the opinion. In this Situation She had remained for feveral months, when it was thought expedient, that fhe fhould be raifed from her bed, and make an effort to Stand or walk, left her conftitution Should be injured, and her complaints rendered worSe by the habit of refting So long in an inaaive State. Every pofition was tried, and>. every contrivance made, which had a chance of being ufeSul ;^v^ t v ON THE PELVIS. »I the power of Supporting her Self was totally gone; the motion of the bones was plainly perceived •, and the confequences of every trial were fo painful and uncomfortable, that it was not judged proper to repeat them, but to wait till, by time, the connexion of the "bones was more confirmed. About fix months after her delivery fhe menftruated, which flie continued to do at irregular periods ; yet, though much bene- fit was expeaed from this circumftance, no alteration Was pro- duced by it with refpea to her complaints. In the year 1779 fhe was removed, upon a couch in a boat, to Margate, for the benefit of the air and bathing in the fea, from which fhe was always fenfible of receiving advantage. There {he continued to refide ; when eight years were elapSed from the time of her delivery, fhe became able to walk without crutches ; and though now perfeaiy recovered, her amendment was ex- tremely gradual.* CASE II. Many years ago I attended a young woman of a healthy but delicate conftitution, who was in labour of her firft child. The or uteri was fully dilated, the membranef broken, and the waters difcharged, before I arrived at her houfe. She was immediately put to bed, and the pains being very ftrong, the head of the child was foon preffed upon the perinaum, the laceration of which I endeavoured to prevent by fupporting it in the ufual manner; but the head of the child was rapidly forced through the external parts in oppofition to the refiftance which I was able to make. At that inftant when the head of the child was expelled I per- ceived fomething to jar under my hand, and was even fenfible of a noife, which led me to fufpea, that the perinceum was lacerated by the fudden expulfion of the head, but on enquiry this was found to be perfeaiy fafe. After a fhort time the placenta, being feparated and protruded into the vagina, was extraaed without hurry or violence. The uneafineft oS which fhe then complained, being fuppofed to b« what are called after pains, did not make me Solicitous, but a few drops of tinBura opii were given to appeafe it. * I have lately been informed of two other cafes of the f me kind, in one of which the procefs, by which the lamenefs was at length turea^ alfo required eight years for its completion. 12 INTRODUCTION TO MIDWIFERY. On the following days fhe complained of more than ufual pain in the lower part of the abdomen, which fhe did not accurately defcribe; but as there was no fymptom of fever, and the milk was duly Secreted, no particular inquiry was made, and I pre-. Sumed that fhe would Soon be well. On the fourth day after her delivery fhe was taken out of bed, but could not ftand or fit in her chair on account of the pain and weakneSs in the part of which fhe originally complained, and which I found to be immediately upon the fymphyfs of the offa i>ubis. For near three weeks fhe remained in the fame ftate, perfeaiy well in her health, ?nd eafy in her bed, unlefs when fhe attempt- ed to turn on either Side ; but when five was removed from her bed fhe could neither ftand nor make any effort to walk without affiftance, though fhe could fit for a few minutes, refting her elbows upon the arms of the chair. The continuance of a complaint fo very uncommon, rendered it neceffary to have a conSultation, and a gentleman oS great ex- perience and ability was called in. ASter a very careSul exami- nation, we found the internal parts in the natural fituation and tree from difeafe; the perinaum was not lacerated, nor was there the lead appearance of injury about the external parts. But it. was judged by the feat of the pain, by her inability to ftand or walk, except in particular attitudes and pofitions, that the fym- phyfs oS the offa pubis had given way, and was wholly Separated ; and there was Scarce a doubt, but that the Separation had taken place when the bulk of the head of the child was paffing between the Spinous proceffes of the ifchina, when I was fenfible. of the jarring noife. The opinion of. the feparation was chiefly founded on the par- ticular attitudes and pofitions in which the patient fought relief, it therefore feems neceffary to deScribe them more fully, as they were very remarkable. When She endeavoured to ftand upright, which fhe could do better on one, foot than both, and better with her feet clofe than at a diftance, together with the pain at the fymphafs, fhe had a fenSe of extreme weakneSs, accompanied with a faintnefs. When fhe firft fat down in her chair, refting her elbows upon the arms of the chair, the complaints became tolerable. When fhe had remained a little time in this pofition, they were again imports nate, and fhe Supported herfclf with her hands upon her knees, and prefently bent forwards, fo as to lean her elbows upon her knees; this pofition becoming irkSome, She was obliged to return to her bed,, where fhe was immediately eaSy. When five firii ON THE PELVIS. *3 attempted to walk, fhe was compelled to bend forwards in fuch a manner as to reft her hands upon her krcxs, making a ftraight line from her fhoulders to her feet. The explanation of her cafe, and the comfort fhe received from the affurance that was given oS her recovery, encouraged her to bear her confinement and the preSent inconveniencies She Suffered with compoSure : yet the knowledge we had acquired, preSuming our opinion to be true, was ufeful, rather by teaching us how to avoid doing mifchief, than by enabling us to render any aaual fervice. At the end of fourteen weeks, whilft fhe was in a coach, into which fhe had often been lifted for the benefit of air and exer- cife, flic had a difcharge, which fhe fuppofed to be menftruous ; and, though it had ceafed before her return, fhe was fenfible of immediate relief. From that time fhe mended daily, and in fix weeks was able to walk, her complaints having gradually left 1 er. She had afterwards three children, with all which I attended her. Her labors were eafy ; and neither before nor after her de- livery had fhe any tendency to the complaints .1 have been def- cribing. The difcharge which preceded her recovery was thought to be menftruous ; but as it had ceafed before her return, and gave re- lief to a part not diredtly aft'eaedby menftruation, it is more rea- sonable to conclude, that it was from the fpmphyfs ; and of what- ever kind it was, that it had aaed as an extraneous body, preventing the re-union of the bones. Inftances have occurred, though they are rare, of women who, after labors, have Suffered much pain in the region of the facrum, and have loft all power of moving their inferior extremities ; and the inability has been imputed to fome paralytic affeaion. They are faid to be bedridden, which defcribes the effea, though it does not explain the caufe, of their difeafe. As thefe patients have, after a confinement of feveral months, or even years, been gene- rally reftored to the ufe of their limbs, it is not unreasonable to think, that th.:ir infirmity was occafioned by a feparation of the bones, which, at different periods after the accident, according to the degree of feparation, had recovered their former connec- tion and Strength. SECTION IV. An inquiry into the manner in which the bones of the pelvis mav re-unite v. hen they have been Separated, Seems neceffary, as rbc'tivatmmt to be enjoined, and the protpect of fuccefs, will be J4 INTRODUCTION TO MIDWIFERY. regulated by the idea we entertain of the State of the parts when feparated. % When the connexion of the bones of the pelvis has either been impaired or destroyed, it is probable, that a confirmation or re- union takes place by a reftoration of the original mode ; by a eallus, as in the cafe' of a fraaured bone ; or by anchytofts. It is alfo poffible for them to remain in a feparated ftate ; and that an articulation fhould be formed by the ends of each bone, at the fymphyfs of the offa pubis, and at the junaion of the offa in- nominata with the facrum; of which, by the favour of Mr. Cline, I have feen an inflance in the dead body, and have had reafon to fufpea the fame accident in the living. In all the lower degrees of imperfeaion in the union of thefe parts, it is reafonable to conclude, that thejformer mode is reftor- cd foon after delivery; for the complaints which women make of pain and weakneft in thefe parts are almoft always relieved, be- fore their month of confinement is concluded. But fhould they continue a longer time, it appears, that the greateft benefit will be derived from reft and an horizontal pofition, which will leffen the preSent inconveniences, and Savour that aaion of the parts, by which their infirmity muft be repaired. But, if the complaint be in an increafed degree, and the healtk of the patient, likewife affeaed, a longer time will be required for the recovery of the part; which may be forwarded by fuch means as invigorate the conftitution, Such applications as quicken the aaion of the parts, or by mechanical fupport. Should the injury be too great to allow of the restoration of the original mode of union, of which we are to judge by the confe- . quent impotence to move, a much longer time will be required for the formation of a callus, if that be ever done but as a previ- ous Step to an anfiylofts, which has been obServed by anatomifts to take place 2t the junaion of the offa innominata with the facrum not unfrequently, but never or very Seldom at the fymphyfs of the offa pubis. Under fuch circumftances, unleSs by an amendment of the general health, little good is to be expeaed from medicine, the proceft which the parts muft undergo being an operation of the conftitution, which it will not be in our power to control. In the firft cafe related, a variety of applications were tried, from the moft emollient to thofe which are aaive and Stimulating; but from cold bathing only did fhe receive any real advantage. The patient was alfo very much affifted by the uSe of a fwath, or broad belt, made of foft leather, quilted, and buckled with fuch firmnefs over the lower part of thi body as to leffen, if not pre- vent, the motion of the bones ; and this was restrained in its fitua- ON THE PELVIS. 15 tion by a bandage pafled between the legs, from tha hind to the fore part of the belt. If this belt be made with a fpring, it may be fixed over the ilia, worn tighter, and with left inconvenience. In that unfortunate fituation, in which a joint is formed be- tween the feparated furfaces of the bones, all hopes of recovery of the patient to her former abilities maybe given up ; and what remains to be done for her relief will be by the ufe of a belt, or a fimilar contrivance, to fubftitute as much artificial firmneSs as we can, Sor the natural which is loft. In the caSe in which I SuSpeaed this event to have happened, the life of the patient was truly miferable ; but I prefume that fuch very rarely occur, hav- ing been lately informed of another perfon, who,- after a confine- ment of more than eight years to her bed, in confequence of the feparation of the bones at the time of labour, was reftored to the full and perfea ufe of her inferior extremities. SECTION V. There is a wonderful variety in the pofition of the pelvis of animals, as it relates to that of the body in general; and their powers and properties very much depend upon this circumftance* But, with a view to this fubjea, they may be divided into three kinds; the ftrong, the fwift, and the mixed. In thofe animals, which poffeft the greateft fhare of ftrength, the pofition of the pelvis is nearly perpendicular, and the two apertures of the cavity nearly horizontal, as may be feen in the elephant. In thofe which are dlftinguifhed by their fpeed or agility, the pofition of the pelvis is nearly horizontal, and the two apertures nearly perpendicular, as may be feen in the flag. In mixed animals, or thofe in which ftrength and fpeed are united, the pofition of the pelvis is neither horizontal nor perpen- dicular, but inclined ; fo as to partake, by different degrees of in- clination, of a certain fhare of the advantages of either pofition, as may be feen in the horfe and aft. But this defcription is taken from the dried flceleton. In the human fpecies, when the pofition of the body is erea, the pelvis, which, bearing the weight of the whole body, is ftron- ger in proportion to their fize than in any quadruped, is fo placed, that a line paffing from the third of the lumbar vertebra will fall nearly upon the fuperior edge of the fymphyfs of the offa pubic ; the cavity of the pelvis being projeaed fo far backwards, that the a/fa pubis beconte the part on which the enjarged uterus chiefly refts Vol. I. G i6 INTRODUCTION TO MIDWIFERY. in the advanced State of pregnancy.* If then we recolka the. fmallneft of the offa pubis, the manner in which they are connea- ed, and advert at the fame time to the increafihg effea, which may be produced by the internal preffure of the weight fupported by them, in addition to that of the body, we Shall not be furprif- ed at the frequency of the complaints of pain and weaknefs at the fymphyfs •, efpecially when the child is large, or the patient un- der the neceffity of ftanding for a long time. And fhould there be any degree of weaknefs, relaxation, or difunion, at the parts where the offa innominata are joined to the facrum, fimilar effeas will be produced ; and one of thefe parts can Scarcely be afteaed without an equivalent alteration in the other. The confequences of the feparation of the bones of the pelvis, or of their difpofition to Separate, will be more clearly compre- hended, if we confider thepelvis as an arch fupporting the weight of the fuperincumbent body. In this view the facrum may be called the key-Stone ; the offa innominata, as far as the acetabula, the pendentives ; and the inferior extremities the piers of the arch. If a greater weight be laid upon an arch than it is able to fuf- tain, one of thefe confequences will follow ; the key-ftone will fly, the pendentives will give way, or the piers will yield to the preflure. To prevent the two firft accidents, it is uSual to lay heavy bodies upon the different parts oS the arch, the weight oS which muft bear a relative proportion to each other, or, the contrary effea will be produced •, for if too great weight be laid upon the key- ftone, the pendentives will fail ; and, if there be too much pref- fure upon the fides, the key-ftone will be forced. When the greatcft poffible ftrength is required in an arch, it is uSual to make what is called a counter-arch, which is a continua- tion of the arch till it becomes circular, or of any intended form. This contrivance changes the direaion of the weight, before fupported at the chord ; and part of it will be conduaed to the centre of the counter-arch, and borne in what is called the fine of the arch. If the refemblance of the pelvis to an arch can be allowed,- we may confider all the fore or lower part of it, between the acetabula, as a counter-arch, which will explain to us the reafon of fo much ftrefs being made upon the fymphyfs of the offa pubis, * This part has been confidered as the centre of gravity in the hu- man body ; but Defaguliers thought that it was in the middle fpace be- tween the facrum and offa pubis. , ON THE PELVIS. I 7 when there is any increafe of the fuperincumbent weight; or when that part is in a weakened or feparated flate, as in the Se- cond cafe before deScribed, and particularly by the bending of that part in the mollities ojfmm. When the patient before mentioned lay in an horizontal pofi- tion, fhe was perSeaiy eaSy, there being then no weight upon the pelvis. When She was erea, the weight borne by the fymphyfs being greater than it could Support, She could walk before fhe could ftand ; or, if fhe flood, She was obliged to move her Seet alter- nately as iS She was walking ; or She could ftand upon one leg better than upon both. By theSe various movements fhe took the Superincumbent weight Srom the weakened fymphyfs, and con- duaed it by one leg, in a Straight line, to the ground. The fatigue of walking, or of the alternate motion of the feet, being more than fhe was able to bear, fhe was obliged to fit. When fhe firft fat in her chair fhe was upright, refting her elbows upon the arms of the chair : by which means part of her weight was conduaed to the chair, not defcending to the pelvis. But there being then more weight upon the fymphyfs than it was able to bear for any long time, and her arms being weary, by putting her hands upon her knees, fhe took off more of the fuperincum- bent weight, conduaing it by her arms immediately to her knees, When fhe retted her elbows upon her knees the Same effea was produced in an increaSed degree ; but, this pofition becoming painSul and tireSome, She had no other reSource, and was obliged to return to her bed. It cannot eScape observation, that this patient inftinaively or experimentally difcovered the advantages of the particular atti- tudes into which fhe put herfelf, and by which fhe obtained eafc, as exaaiy as if fhe had underftood her complaint, and the man- ner in which I have endeavoured to explain it. In the wearinefs which follows common exercife, when we of- ten change our pofition, apparently without defign, the manner in which eafe is procured to any particular part may be readilv underftood by a more extenfive application of the fame kind of reafoning, and it feems as if the flighteft change was not made without fome good effea. SECTION VI. The violence which the conneaing parts of the bones un- dergo, when the head of the chiid is protruded through the pelvi. -,18 INTRODUCTION TO MIDWIFERY. with extreme rapidity or difficulty, fometimes occafiorts an affec- tion of the fymphyfs of the offa pubis of more importance than a feparation; becaufe, together with all the inconveniencies arifing from the feparation, the life of the patient is endangered by it. This is the formation of matter on the loofened furfaces of the bones, preceded by great pain, and other Symptoms of inflam- mation ; though, in the beginning of the complaint, it is difficult toafcertain whether the conneaing parts of the bones, or fomc- cohtiguous part, be the feat of the difeafe. When fuppuration has taken place in confequence of the in- jury fuftained at the junaion of the offa innominata with the facrum, the abSceSs has in Some caSes been formed near the part affeaed, and been cured by common treatment. But in others, when matter has been formed and confined at. the fymphyfs of the offa pubis, the Symptoms of a heaic fever have been produced, and the caufe has not been discovered until after the death of the patient. In others the matter has burft through the capfular ligament of the fymphyfs at the inferior edge, or perhaps made its way into the bladder; and in others it has infinuated under the periofteum, continuing its courfe along the offa pubis until it arrived at the acetabulum. The mifchief being thus extended, all the Symptoms were aggravated; and, the matter making its way towards the Surface, a large abfcefs has been formed on the inner or fore part of the thigh, or near the hip, and the patients, being exhaufted by the fever and profufe difcharge, have at length yielded to their fate. On the examination of the bodies after death, the track of the matter has been followed from the aper- ture of the abfcefs to the fymphyfs, the cartilages of which were found to be eroded, the bones carious, and die adjacent parts very much injured or destroyed. It may, perhaps, be poflible to difcover» by fome particular fymptom, when there is in this^part a difpofition to fuppurate ; or it may be difcovered when fuppuration has taken place. In all cafes of unufual pain, attended with equivocal fymptoms, it will therefore be neceffary to examine thefe parts with great care and attention. For, when there is a difpofition to fuppurate, by proper means that might be removed; and when matter is form- ed, if there be a tumefaaionat the fymphyfs, more efpecially if a fluauation Could be perceived, we might deliberate upon the propriety of making an incifion to evacuate the matter; and by fuch proceeding farther bad confequences might be prevented.* # See Medical Obfervations and Inquiries. Vol. II. ©N THE PELVIS. t$ SECTION VII. The form of the fuperior aperture of the peh's has been des- cribed by fome as triangular, 3r.d by ^hers as oval, with the wideft part from one fide to ti.. r.ther. £ut the inferior aper- ture, independent of the ligaments and Soft parts, cannot be faid to refemble any known or general f,erm, en account of its irre- gularity, though the wideft part;:-. from the inferior edge of the fymphyfs to the point of the os cxc\gi:, allowing for the regreffive motion of that bone. The dimenfions of the fuperior aperture of the pelvis, from the upper part of the facrum to the upper edge of the fymphyfs, are generally Stated to be rather more than four inches ; and between the two fides they Somewhat exceed five* Of the dimenfions of the inferior aperture it is difficult to form a judgment; but, if the ligaments are preferved, it may be faid that the proportions are reverted, the narrowest part being on each fide. But in-the Sorm and dimenfions oS the pelvis, in dif- ferent women, there is an endlefs variety, not depending upon any alteration which may be produced by diSeaSe. The depth of the pelvis, from the upper part of the facrum to the point of the os coccygis, is about five inches ; but this will be increafed when the latter bone is prefled backwards. From the margin of the pelvis to the inferior part of the obtufe procefles of the ifchia, the -depth is about three inches, and at the fymphyfc about one and a half. It appears that the depth of the pelvis, at the pofterior part, is rather more than three times the depth at the anterior; and that there is a gradual change between the two extremes, if we admit the ligaments to make a part of the outline of the inferior aperture. The knowledge of thefe circumftances will enable us to judge in the living fubjea, how far the head of the child has" proceeded through the pelvis, and prevent any de- ception to which we might be liable, if we were to form our opinion by the readinefs with which we can feel the head at the anterior part. The cavity of the pelvis is of an irregular, cylindrical form; but, towards the inferior aperture, there is fome degree of con- vergence, made by the points of the fpinous and obtufe proceffes of the ifchia and the termination of the os coccygis. This conver- gence is of great importance in regulating the paffage of the head * ghta menfura, pollice fere integro, ftmiles menfuras capitis foetus fupcrant. Haller. Phyfiol* lib. xxviii. 20 INTRODUCTION TO MIDWIFERY. of the child, as it defcends towards the inferior aperture ; and, being perfected by the foft parts, it gives to the vertex, or pre- fenting part of the head, the difpofition to emerge under the arch of the pubis. On the concavity or hollow of the facrum, the eafe or difficulty with which the Ik ud of the child pafleth through the pelvis, will very much depend. A fimilar curvature is continued by means of the ifchiatic finus, and by the difpofition of the facrofciatic ligaments, to the obtufe proceffes of the ifchia, where the fides of the pelvis are perpendicular. The upper edge of the offa pubis has a flight reflection outwards, which prevents any obftruaion to the entrance oS the head of the child into the pelvis; and at the lower edge there is fome degree of divergence, by which the departure of the head out of the pelvis is very much facilitated. SECTION VIII. J3efore we proceed to the examination of the manner in which the head of the child paffeth through the pelvis at the time of birth, it is neccf'nry to examine its dimenfions and Struaure. The largeft part of the head of a child, not altered by com- preffion, L from the hind to the forehead. The diameter from one ear to another is left by nearly the fame proportion, as the fpace bet'veen the facrum and pubis, at the fuperior aperture, is left than that between the fides of the pelvis. The head of a child, which appears to be larger, according to the fize of the body, than that of other animal^, is at the time of birth incompletely ofhfied at every part where the bones of which the cranium is compofed, afterwards unite; but chiefly at the greater fontanel';-, or the centre of that part where the parietal and frontal bones meet in the adult. By this incomplete offifica- tion, and by the preffure to which the head of the child is fome- times fubjea in its paffage through the pelvis, the form of the head may be very much altered, and the dimenfions leffened ; Sor the edges of the bones will not only accede to each other, but will lap' over in a very extraordinary manner, without anv detriment to the child. The degree of offification varies in different fub- jeas; but the head of a new-born infant is univerfally (exceot in fome very rare deviations) found to be incompletely oflified, and the advantage refulting from it is not only perceived in thofe difficulties which may be occafioned by the natural large fize of the head of the child, but in thofe alfo which are produced by sll the left confidcrabk degrees of deformity of the pelvis. It Is ON THE PELVX.S. 2! evident beyond all doubt, if this provifion had not been made, that many children muft nave been deftroyed at the time oS birth, or their parents muft have died undelivered. Daily experience very obvioufly and Sufficiently proves that there is a relative proportion between the head of the child and the pel- vis of the mother ; and, from the excellent order obferved in all the operations of Nature, it would be reafonable to conclude, that the largeft part of the head is conformable to the wideft part of the pelvis. 'By the examination of a great number of women, who have died in various ftages of the aa of parturition, it has appeared, contrary to the general doarine of the ancient and of many mo- dern writers, when the pofition of the head was perfeaiy natural, that the ears were placed towards the facrum and pubis, or a little obliquely ; and that the vertex, ox that part where the hair diverges, is exaaiy or nearly oppofed to the centre of the fuperior aperture of the pelvis* In the courfe of the defcent of the head, there being fome difference in the form of the pelvis at each particular part of the cavity, the pofition of the head is accommodated to each part, not by accident but ccmpulfion, and at the lower part of the pelvis, in confequence of that convergence before mention- ed. With refpea to the pelvis, the lower the head of the child has defcended, the more diagonal is the pofition of the ears ; but they are not always placed exaaiy towards the fides of the pelvis, even when a portion of the head has emerged under the arch of the offa pubis. But this defcription of the changing pofition of the head of the child in its paffage through the pelvis is Sounded on the preSumption that it preSents naturally, and is guided by the form of the internal Surface. If the head fhould preSent differ- ently, there will be correfponding, but not the fame, changes ; or, if it fhould be very Small, it will net be influenced by the pel- vis, but may paSs in any direaicn. It does not appear, that any ill confequences would follow an erroneous opinion oS the manner in which the head of the child is protruded through the cavity of the pelvis in a natural labour ; for, no affiftance being wanted, no principle was required for the re- gulation of our condua. But in ail cafes in which there was a neceffity of giving affiftance, and where a change of what was deemed the wrong pofition of the head was improperly comprifed as a very material part of that affiftance, as in the ufe of the for- eeps, great mifchief muft often have been unavoidably done both to the parent and child. * This obfervation was firft made by Sir Fielding Oulde about the xeor i -> -1 -. See *" Trwtife on Midwifery. aa INTRODUCTION TO MIDWIFERY. SECTION IX. * From the examination of the form and dimenfions of the cavity of the pelvis, and of the head of a child, attempts have been made to explain all the circumftances of a labour upon mechanical prin- ciples, and to eftablifh the praaice of midwifery upon the founda- tion of thofe principles. It may be fuppofed, for a moment, that the paffage of the head of a child, through the cavity of the pelvis, fhould be confidere.1 #mply as a body paffing through a Space ; and we may try whe- ther it is poffible to apply mechanical principles with advantage for the explanation. The firft circumftance to be confidered in the attempt is, to af- certain with precifion the capacity of the fpace. Now it is true that we have had many menfurations of the pelvis in all its parts, and that we have acquired a competent knowledge of the general dimenfions; but we know, at the fame time, that there is in the pelvis of every individual woman fome variety, and that the exaa know- ledge of thefe varieties, on which the explanation of a mechanical proceft muft depend, cannot be gained in any living Subjea. It is equally neceffary, that we fhould have an accurate know- ledge of the fize of the body intended to be paffed through this % Space. But, though we have a good general idea of the figure and bulk of the heads of children at the time of birth, we are not ignorant, that thofe of any two children were never found to be exaaiy alike, and that the peculiar difference cannot be difcovered before a child is born. The head of a child is of a limited fize before it enters the cavity of the pelvis ; but, by compreffion in its paffage, this is altered in a manner and to a degree of which it is impoffible to form any previous judgment. In the confideration of a body paffing through a fpace, there is alfo a neceffity of knowing whether it be intended to pafs by its own gravity or force, or whether it h paffive, and is to be propell- ed by any adventitious power. If by the latter, as is the cafe of a child at the time of birth, the knowledge of the degree of that power i; neceffary to enable us to form an eftimate of the poffibili- ty or likelihood of its fuccefs; but of the degree of this power ■we can form a very uncertain conjeaure in any particular cafe. If then we have neither precife ideas of the dimenfions of the fpace, nor of the magnitude of the body, nor of the alterations in Size or form which the body may undergo, nor of the power excit- ed to propel the body, it does not appear poffible to explain, upon mechanical principles, the progreSs of a labor. ON THE PELVIS. «3 So much is however to be granted to the introduaion of me- chanical principles into the praaice of midwifery, that they afford the greateft advantage in all thofe cafes of extreme difficulty, ill which the affiftance of art is ultimately required, becaufe fuch affiftance muft be given upon thofe principles ; and though they will not explain, they will eluftrate the operations of the animal body, and, when applicable, are the fureft guides of human aaions. But, on the whole, a fondneft for, an imperfea knowledge, and fome affeaation of mechanical principles, feem to have been ve- ry detrimental ; as to thefe the frequent and unneceffary ufe of inftruments, and fometimes their improper ufe, in the praaice of midwifery, may in a great meafure be originally attributed. ' SECTION X. The obfervations which were made on the form and dimen- fions of the cavity of the pelvis relate to its natural Slate ; but thefe are alSo to be confidered when the pelvis is distorted. OS the distortion of the pelvis there are two general caufes. The firft is that diSeaSe incident to children in the very early part of their lives, known by the term rachitis, which preventing the bones from acquiring their due ftrength, or fufficient firmnefs to fupport the weight of the fuperincumbent body, they bend in different direaions and degrees, according to their weaknefs and the weight impofed upon them, and the diftortion thereby occa- fioned is often fixed for the remainder of life. The fecond is a difeafe which may occur at any period of life, and from its effea is called ofteofarcofis, or mollifies offtum.* If is far left frequent than the rachitis, but more dreadful in its confequences; which no medicine hitherto tried has had fufficient efficacy to prevent or to cure. In this difeafe the offifie matter is not thought to be diflblved or altered, but to be re-abforbed from the bones into the conftitution, and carried out of the body by the common emunaories ; or depofited upon fome other part where it is ufe- lefs or prejudicial. The bones thus lofing the principle of their ftability become foft, according to the degree and continuance of the difeafe; are unable to fuftain the weight of the body, and change their natural forms, in proportion to their weaknefs ; fo * Malacofteon* Offmm mollities. Vogel. Etxxiij. Vol. I. H i*\ INTRODUCTION TO MIDWIFERY. • that in Some inftances the moft distorted and Srightful appear- ance of the whole body hath been exhibited.* m The effect of either of thefe difeafes is not confined to the pel- vis -, yet it is Scarcely poffible, that either of them fhould exift for any length of time withput producing its influence upon it.— Hitherto much advantage has not been obtained by the know- ledge of ofleofarcofs, nor have the fymptoms which precede or ac- company it been accurately obferved, beSore the effea was pro- duced. Yet it is poffible, by attending to the Secretions, and discovering an exceSs or deSea oS phoSphoric acid or the like principles, the deficiencies and exceedings might be Supplied or leffened. The pelvis is more commonly distorted at the Superior aperture than at any other part. This is particularly occafioned by the natural projeaion oS the upper part oS the facrum, and the loweft oS the lumbar vertebra ; though, in very bad caSes, a confiderable deviation Srom their natural pofition is given to Several of the ad- joining vertebra. Should a difeafe exift in the conftitution which is capable of weakening the bones, it will not appear extraordi- nary that the facrum fhould be diftorted, if we recollea, that its texture is originally fpongy ; that it Supports, both in the erea and Sedentary pofition, a great part oS the weight of the body ; and that, by the manner of its junaion with the laft oS the ver- tebra, a confiderable angle is made, which, if but little increafed, will cauSe a very important change in the Sorm and dimenfions of the fuperior aperture of the pelvis. In fome cafes an irregular convexity, and in others a concavity, are produced by the bend- ing of the offa pubis in different ways and degrees ; by which, to- gether with the projeaion of the facrum and lumbar vertebra, the dimenfions of the fuperior aperture of the pelvis, which in the narrowest part Should exceed four inches, have been, in fome in- stances, reduced to leSs than one, and altered in every poffible di- reaion. It is probable that, from a mere view of a diftorted pelvis, independently of the weight of the bone or other circum- stances, we might be able to diftin^uifh, by the part chiefly dif- torted, between a distortion occafioned by the rachitis in infancy, and the mollifies offium happening to an adult. The Sorm and dimenfions of the cavity of the pelvis may be changed in any part of its fpace; but the moft Srequent alterati- ons proceed Srom the facrum, which befides the projeaions be- * See Medical Obfervations and Inquiries, Vol. V. cafe 23. Me- moirs of the Academy of Sciences, and various Authors. We jhall afterwards refer to thisfubjeft. ON THE PELVI*. 2? fore mentioned, may become too Straight, when the advantages which fhould be derived Srom its concavity will be loft. Or it may have too quick a curvature, by which the concavity will be rendered So Small as not to admit the head of the child ; or an ex- oftofis may be Sormed on its internal SurSace, which will be the cauSe oS inconveniencies equivalent to thoSe occafioned by the want of a prpper degree of curvature. The os coccygis may be preffed inwards in fuch a manner, that the point of it may approach the centre of the cavity ; or the mo- tions between the different portions of the bone may be loft ; or an anchylofs may be formed between that bone and the facrum ; by all which changes, according to their degree, the head of the child may be impeded in its paffage through the pelvis. The ifchia may be diftorted by the unnatural bent of the fpi- nous proceffes ; and the effea of their preffure may be obferved, for Some time aSter birth, on the temporal or parietal bones of the head of a child propelled between them with much difficulty. The dimenfions oS the inferior aperture alSo may be leffened hv the tuberofities of the efchia bending inwards or forwards, by which the arch of the pubis will be leffened, and rendered unfit to allow of the emergence of the head of the child under the fym- phyfs of the offa pubis. When the ftability of>the bones of the pelvis is impaired, it is not poffible to enumerate every kind oS distortion which they may Suffer; but it is principally in the degree that we are to Seek Sor thoSe great, and Sometimes, though rarely, inSurmountable difficulties, which occur in the praaice of midwifery, and prove dangerous to either, or both the parent and child. In fome cafes the diftortion of one part of the pelvis produces an enlargement of the reft. Thus when the Superior aperture is contraaed the inSerior may be expanded ; and hence it is often obferved in praaice, when the head of the child hath paffed the point of obftruaion with the moft tedious difficulty, that a labour will be unexpeaedly and Speedily completed. When women have the appearance oS being much deformed, it is reafonable to think that the pelvis muft be affiled. But there have been many inftances of extreme diftortion of the fpine, yet the pelvis has preferved its proper form and dimenfions; and Some women, who were in other refpeas Straight and well pro- portioned, have had a diftorted pelvis. If the inferior extremities are crooked, or if any part of th * body was diftorted at a very early period of life, and remained in that ftate, it is Said that we may be afltred the pelvis partakes of the difeaSe, and is involved in its conSequences. But when the 26J . INTRODUCTION TO MIBWIFERTf. Spine becomes distorted at a more advanced period, as at twelrt or fourteen years of age,it is not to be efteemed a prefumptive fign. of a diftortion of the pelvis, being generally occafioned by a local difeafe of the fpine. Thefe obfervations are, I believe, commonly well founded; but, as there are many exceptions, we fhould not be juftified in giving an qpinion of a cafe of this kind, unlefs we* were permitted to make ah examination/^ vaginam. Nor fhould we be able, by this examination, to determine with precifion the existence of every fmall diftortion, but fuch only as was confider- able in its degree. If we fhould not be able to feel any projeaU on of the facrum, or vertebra, we fhould have a right to conclude, that there was no confiderabje deformity of the pelvis; but, if we could feel the facrum, or vertebra, we muft judge by the readineft with which they can be felt, of the degree of diftortion, and of the impediments which may be thereby occafioned. But, in a matter which may be of fo much concern, it behoveth us to be ex- tremely circumfpea before we give an opinion, left by our error, flie peace of families and, the comfort of individuals fhould be destroyed. CHAPTER II. SECTION I. ON THE EXTERNAL PARTS OF GENERATION. 1 he preceding account of the pelvis appearing fufficient to ferve all the ufeful purpofes of the praaice of midwifery, we Shall, in the next place, confider the parts of generation, which have been properly divided into external and internal. The external parts are the mons Veneris, the labia, the perineeum, the clitoris, and the nympha. To thefe may be added the meatus urinarius, or. orifice of the urethra. The hymen may be efteemed the barrier between the external and internal parts. That Soft Satty prominence which is Situated upon the offa pubis, extending towards the groins and abdomen, is called mons Veneris. Its uSe feems to be chiefly that of preventing inconvenience or injury in the aa of coition. If a line be drawn acrofs the anterior angle of the pudendum, all that part above it, which is covered with hair, may be called mans Veneris ,• below it the labia commence, which, being of a fimilar, though loofer, texture, »p- ON THE EXTERNAL PART* OF GENERATION. k"J pc*r like continuations of the mons Veneris, paffing on each fide of* the pudendum,-which they chiefly compofe. Proceeding downwards and backwards the labia again unite, and the pmnozum is formed, All that fpace between the pofterior angle of the pudendum and the anus is called the periuaum, the external covering of which is flrin, as the vagina is the internal; including between them cellu- lar and adipofe membrane, and the lower part of the fphintler tmi. The extent of the perinmum is generally about an inch and a half, though in fome Subjeas it is not more than orre, and in others is equal to three inches. The thin anterior edge is tailed thefranum labiorum. Below the anterior angle of the pudendum the clitoris is placed, which rifes by two crura, or branches, from the upper part of tht rami of the ifchia. The external part, or extremity, of the clitoris is called the glans, which has a prepuce or thin covering, to which the nympha are joined. The clitoris is fuppofed to be the prirtci* pal feat of pleafure, and to be capable of fome degree of ereaion in the aa of coition. The nympha are two fmall Spongy bodies, or doublings of the" flcin, rifing from the extremities of the prepuce of the clitoris, left in fize, but reSembling in their form the labia. They pafs on each fide of the pudendum, within the labia, to about half its length, when they are gradually diminifhed till they difappear. Immediately below the inferior edge of the fymphyfs of the offa pubis,between the nympha, is the meatus urinarius, or termination of the urethra, which is about one inch and a half in length, and runs to the bladder in a Straight direaion, along the internal Surface of the fymphyfs, to which, and to the vagina, it is conneaed by cellu- lar membrane. On each fide of the meatus are fmall orifices, which difcharge a mucus, for the purpofe of preferving the exter- nal parts from any injury, to which they might be liable from the acrimony of the urine. There is a very great difference in the appearance of all thefe parts in different women, efpecially in thofe who have had many children, and at various periods of life. In young women th.y are firm and vegete, but, in the old, thefe, together with the in-, ternal parts, become flaccid and withered.* SECTION II. 'The external parts of generation are fubjea to many difeafes in common with the other parts of the body. They are alfo ex- * Partes genitales, cum earum nulltts eft ufus, marcefcu?it,detrahurt-, tur, ac veluti obliterantur. Harv. 23 INTRODUCTION TO MIDWIFERY. pofcd to fome peculiar complaints, and to accidents at the time of parturition, of which we ought to be well informed, that we may, by our care, prevent them, or give fuch relief as may be required when they have unavoidably happened. The labia and nympha, as might be expcaed from their fatty and cellular texture, are liable to elongation, to excrefcences, and to the produaion oS fchirrhous tumpurs ; which in Some inftan-j ces have grown to an enormous fize, efpecially in hot .climates.* For preServing all thefe parts in a healthy ftate, nothing is more beneficial than the daily uSe oS cold water. It is not unuSual Sor one oS the labia or of the nympha to be Jar-r ger and more pendulous than the pther ; but the enlargement, or elongation, are net regarded as difeafes till Some inconvenience is produced by them. The Same observation may be made of ex- crefcences or fchirrhous tumours, which are therefore generally found to have acquired a confiderable fize before they are divulged by the patient. In all the fubordinate degrees of thefe complaints, when there is reafon to think that they ariSe from fome conftitutional caufe, relief may be given by fuch medicines or treatment, as will alter and amend the general health. Or if they are owing to any Speci- fic cauSe, as the venereal diSeaSe, oS which excreScences in parti- cular are a very Srequent conSequence, preparations oS quickftlvej are to be uSed or given, till we are certain that the conftitution is freed from the infeaion. Applications fuitable to the ftate they are in are at the fame time neceffary ; and of thefe there will be occafion to ufe a variety, from the moft emollient, and Soothing, which may be proper when the parts are in a very irritable and inflamed ftate, to thofe which have different degrees of efcharotic qualities ; when we prefume there is a chance of removing the excrefcences by fuch means. But when complaints of this kind have been of long continuance, or when the parts have increafed t$> fuch a fize a,s to hinder the common offices of life, there is but little reafon to hope for their removal by any application or mediT cines, and the difeafed part mull be extirpated with the knife ; which operation may be performed with fafety, and the faireft profpea of fuccefs. As the blood-veffels are few, and naturally fmall in proportion to the Size of the parts, there is not much dan- ger of an hemorrhage, though, in fome cafes, this is faid to have been alarming and extremely difficult to manage.f But 1 have * Nympha aliquando enormes funt'; quare Copte et Manri eas circumcidqit. Haller. Phyfiolog. f §ee Mauriceau, Vol. ii. Obf. clxxiv. K. ON THE EXTERNAL PARTS OF GENERATION. fy more than once feen the enlarged nympha, and feveral excrefcen- ces of confiderable fize, removed by the khife at the fame time, yet the furgeon has not been under the neceffity of tying a Single blood veffel. SECTION III. EdematoSe Swellings of the external parts may occur, either in a general anafarcous ftate of the Whole body, or when any caufe. produces a temporary preffure upon thofe veffels, which are in- tended to condua the returning fluids from the inferior extremi- ties : particularly the enlarged uterus, in the advanced ftate of preg- nancy. Whatever may be the caufe of thefe Swellings, if they fhould increafe fo as to become troublefome, the method of giving relief is obvious and eafy, as it confifts only in making a few very flight Scarifications in different parts of the labia, by which the ftagnating fluids will be difcharged, and the labia reduced to their natural fize. It is not unuSual for thefe Swellings to return two or three times towards the conclufion of pregnancy; in which cafe, or even in the time of labour, the Scarifications, if neceffary, may be repeated. A flannel wrung out of fome emollient fomentation, and applied to the parts when they have been Scarified, will con- tribute to the eaSy and perSea discharge of the fluids. SECTION IV, The cohefion of the labia to each other has been mentioned as a complaint occurring to adult women, efpecially in hot cli- mates, if inflammation, preventing the due fecretion of the mu- cus, with which thefe parts are naturally clothed on their internal furface, fhould take place ;- or if they fhould be excoriated by any accidental caufe, and negleaed in that ftate. The labia will al- fo very frequently cohere in children, in fuch a manner as to leave no veftige of a paffage into the vagina, except at the interior part, for the difcharge of the urine; and lead us, by the general ap* pearance, to apprehend a defect in the organization of the parts. In fuch cafes we have been direaed to feparate them with a kniSe; and how Sar Such an operation may be neceffary in the adult, if the parts fhould cohere either in confequence of fome new affeaion, or if a cohefion originating in infancy fhould con- tinue to adult age, muft depend upon the judgment of the fur- geon. But, in infants, fuch an operation is neither requifite nor proper; becaufe afparation may always b.2 made, by a firm and 3© INTRODUCTION TO MIDWIFERY. fomewhat diftraaing preffure upon each labium at the fame time, which fcarcely makes the child complain; though the fmall vef- fels, which had inofculated from one labium to the other, may be perceived to be dragged out during the continuance of the pref- fure-. It is extraordinary that fo little notice fhould have been taken of a complaint which is very frequent in children; but it is pro- bable that the conftant and free ufe of their limbs, when they be- gin to walk, caufes a feparation without any other affiftance, otherwise the cohefion muft frequently have occurred in adults, in whom the cafe is very rare. But on this expeaed probable fe* paration we fhould be afraid to rely. When a feparation of the cohering labia has been made in the manner before mentioned, a folded piece of linen, moiftened in a very weak Solution of the zincum vitriolatum, or Some lightly aftringent liquor, fhould be applied every night when the child is put to reft, to prevent the re-union, to which there is a great diSpofition; and which wiil certainly take place, if the labia are fuffered to remain in contaa Immediately after the Separation. SECTION V. In confequence of violent inflammation from accidental or other caufes, the labia may become tumefied, and a large abfcefs has been fdmetimes formed. This is attended with extreme pain, the defire of relieving which has induced furgeons to open the abfcefs, and give vent to the matter as foon as it could be perceiv- ed to fluauate. But though the pain may, for the prefent, be abated by the early difcharge of the matter, the part continues indurated, is indifpoSed to heal, and not unfrequently becomes fiftulous. But, if the abfceSs be Suffered to break of its own ac- cord, the part will have the kindeft tendency to heal, and, with common care, the cure be foon perfeaed. Should the pain be extreme during the fuppuration, which is often the eafe, befides the ufe of fomentations and cataplafms, recourfe muft be had to Opiates for its abatement. There is never any reafon to fufpea this complaint to be a token of any venereal infeaion. SECTION VI. Though the perinaum is not often affeaed with any particular difeafe, it is fubjea to a laceration from the diftention which it undergoes, when the head of the child is paffing through the ex- ON THE EXTERNAL PARTS OF GENERATION. 3! ternal parts. This laceration, which is moft likely to happen with firft children, though with rude treatment, hurry, or neglea, Cither on the part of the patifent or praaitloner, it may occur with fubfequent ones, efpecially in thofe women who have the perinoeum. naturally Short, differs in direaion and extent, and may be, in every degree, from the franum, or edge of the perinoeum, to the ex- tremity of the fphinbler ani, or even higher up into the retlum. That fome degree of laceration fhould Sometimes occur, will not be Surprising, if we confider the great change and violence which all thefe parts fuftain, at the time when the head of the child is paffing through them; or that when a laceration begins, it fhould extend through a part rendered at that time extremely thin, and Suffering an equal degree of force. When the perinoeum is indifpoSed to diftend; or if, when diftended, it cannot per- mit the head of the child to pafs with facility, the anterior part of the reSlum is dragged out, and gives to the perinoeum a tempo- rary elongation. The true perinoeum, and the temporary, as it may be called, thus forming an equal, uninterrupted fpace, if a laceration fhould commence at any part, it might extend through the whole. Of the method by which the laceration may be pre- vented, and of the treatment which may be proper when it has occurred, We Shall Speak in other places. At preSent we Shall inquire into the caufes of an accident^ the prevention of which is the principal objea of our attention in natural labours. Though no means are ufed to prevent the laceration of the perinoeum in quadrupeds at the time of parturition, it is remarka- ble that they are very rarely or never liable to it, except in thofe cafes in which the neceffity oS their Situation is SuppoSedto require affiftance ; and this being given with ignorance and violence, may not improperly be efteemed the cauSe of the accident. It is, therefore, reaSonable to preSume, that the frequent occurrence of this laceration in the human Species, allowing that it is in Some caSes unavoidable, ought to be imputed to Some accidental cauSe, or to error in condua, rather than to any peculiarity in the con- Struaion of the part, or in the circumftances of their parturition. For, I believe, no obfervation is more generally true, than that oS the exiftencc of a power in the ftruaure and conftitution of every animal, by which evils are prevented or remedied, and by which the greater part of the difficulties occurring at the time of their parturition, are overcome; which power is commonly ex- erted with a degree of energy and effea proportionate to the dif- ficulty. Vol. I." I 22 INTRODUCTION TO MIDWIFERY. The caufes difpofing to, and capable of, producing a laceration of the perinoeum, feem to be thefe : Firft—The increafed tendernefs and delicacy of the fkin, oc- cafioned by peculiar habits or modes of living. That this and every other part of the body may, by alteration from its natural ftate, become more fufceptible of pain, and left able to bear vio- lence of any kind, is clearly proved by the different degrees of thofe properties in parts of the body which are ufually clothed or uncovered. Secondly—The pofition of women at the time of delivery. Women in this country, at the prefent time, are placed in bed upon their left fide, with their knees drawn up towards the ab- domen : which pofition, though convenient to the attendant, feems to occafion a projeaion of the part of the child which pre- fents, in a line unfavorable to the perinaum. But, if they were to be placed upon their hands and knees, which is a pofition at that time perhaps the moft natural, as it is often inftinaively Sought Sor, and, in Some countries, choSen in caSes of difficulty and diftrefs; then the head or part prefenting would, by its line of gravitation, leffen the preffure upon the perinoeum, and, of courfe, the hazard of its laceration. Thirdly—The disturbance oS the order oS a labour. Every change which is made in the parts, both external and internal, at the time of labour, is fucceffive, and every pain Seems to produce two effeas; it dilates one part, and gives to Some other part a diSpofition to be dilated. If, therefore, by hurry, or imprudent management^ the head of the child, in its paffage through the pelvis, be brought into contaa with parts which have not yet acquired their difpofition to dilate ; or if, by artificial dilatation, we attempt to fupply the want of the natural, the parts will Sooner be lacerated than diftended. Fourthly—When animals bring forth their young, the effort to expel is inftinaive, no part of the force exerted appearing to be voluntary. Women on the contrary, either from erroneous opinions, or from falfe inftruaions, exert a confiderable degree of voluntary force, often indeed their whole ftrength, with the hope and intention of finifhing their labours Speedily. Now if we fuppofe that the perinoeum is able to bear all the force inftinc- tively exerted, without injury, but no greater ; then the whole voluntary force will, in proportion to its degree, induce the dan- ger of a laceration, unlefs its effea be counteraaed by fome ad- ventitious help. On this principle it is ufual to Support the peri- naum, not with the view oS altering the direaion oS the head of the child, but of retarding its paffage through the external part-. ON THE EXTERNAL PARTS OF GENERATION. 33 For the perinaum is not torn becaufe the head of the child is large, or paffes in any particular direaion, but becaufe it paffes too fpeedily, or preffes too violently, upon the parts, before they have acquired their dilatability; it therefore rarely happens, that the perinaum is lacerated in very flow or difficult labours, SECTION VII. That kind of laceration of the perinoeum, which commences at the anterior edge, and runs obliquely or direaiy backwards, i$ alluded to in every differtation upon this fubjea. But there have been inftances of another kind, which may be called a burfting or perforation of the perinoeum, at that part which is conneaed with the circumference of the anus, when the anterior part is pre- ferved ; and through fuch perforations it is faid children have Sometimes been expelled.* In a cafe which occurred in my own praaice, I was fenfible of this kind of laceration before the ex- pulfion of the head, which I guided through the natural paffage, Supplying the want oS the perinoeum with the palm of my hand. The external parts were, in this patient, extremely rigid and contraaed; and, as I applied myfelS with great affiduity to pre- ferve them, at the anterior part of the perinaum, I imputed the accident to this circumftance, rather than to the neceffity of the cafe—The patient did not make any unufual complaint immedi- ately after delivery ; but, on the following day, there was a vio- lent inflammation of the parts, with a fuppreffion of urine, and the lochia were discharged through the ruptured part, but no faces ever came through it, or by the vagina. By the uSe oS fo- mentations and cataplaSms, of .cooling laxative medicines, and occafionally of opiates, the inflammation was foon abated. The fuppuration being profufe, the bark was given ; and, at the end of ten weeks, the lacerated parts were healed. No particular examination was ever made during the cure, and none but fuper- ficial dreffings applied. When I attended this patient with her Second child, I obServed a large round cicatrice at the rugous * There is in fome French writer, whofe name I cannot recollect, an account of a cafe of this kind, in which the head and body of /.!.■ child were excluded through an opening in the perinceum thus cafually made, in which the Sraenum of the perinceum was preferved attire. The common laceration of the perinceum does not alwuys commence ct the framum, but further back, and then bears down before it all the anterior part. 34- INTRODUCTION TO MIDWIFERY, part of the anus, but She Scarcely Suffered any inconvenience from it; and recovered as well as if no fuch accident had for* merly happened. SECTION VIII. The clitoris is littje concerned in the praaice of midwifery, on account of its fize and fituation. But it is faid to have been Some- times elongated and enlarged in Such a manner as to equal the Size of the penis, when it makes one of thofe many pecularities which have been fuppofed to conftitute an hermaphrodite, * or an animal partaking of the Sexual properties of the male and fe- male ; but if there are any examples of true hermaphrodites, the term is, in this cafe, improperly ufed.f Should the clitoris increafe to fuch a fize as to occafion much inconvenience, it may be extirpated either with the knife or ligature;% but if the caufe of the enlargement, which is com-: monly aftigned, be true, it is not probable that any motive of deli- cacy or inconvenience will be a fufficient inducement to fuffer the pain of extirpation,^ SECTION IX, The bladder and urethra in women are naturally liable to few- er difeaSes than the Same parts in men, becauSe their connexion is Sar more Simple, and their uSe is wholly confined to the recep- tion and conveyance of the urine. Women have, nevertheless, a ftone Sometimes formed in the bladder ; and it has been thought an improvement in praaice to evade the operation, of lithotor- my, by distending, with bougies gradually enlarged, the urethra, till it is of fufficient dimenfions to allow a ftone to paSs through it. It is proved by experience, that the urethra will diftend, or may be artificially diftended, Sufficiently to allow a ftone of a con- * Hermaphroditi veri non dantur—Ruyfch. TheS, viii. f Clitoris major infostu exiftit.—RuySch. TheS. vi. 1. i. Cercofs* Clitoris pralonga. Vogel. cccccxxxv. \ See Bruce's Travels; and Travels in Africa, Egypt, and Syria, by G. W. Browne, in which we are told that it is always extirpated as a religious ceremony; yet of this there remains fome doubt. See alt fo Sonnini, Chap. 23. § ghia extra venerem, iu cafta femina, parva fuerat, fuo etiam inodo arrigit et intumefcit, tit prepoftera veneri fervire pofftt, multoqin vfu ejus turpitudiniSf denique moles ejus atigetur.—Hallcr. Phyfiolog. ON THE EXTERNAL PARTS OF GENERATION. $f fiderable fize to paSs, as I have known in many inftances ; but if the diftention be carried beyond a certain degree, it is Said the tone oS the part will be destroyed, and the patient ever remain Subjea to an involuntary diScharge of urine, which is a greater evil than any of the common confequences of lithotomy. In the courfe of the urethra, and about the meatus urinarius, excrefcences fometimes grow, which produce fymptoms equally troubleSome, and fimilar to thoSe which are cauSed by the ftone or other diSeaSes in the bladder, for which they are often mistaken. Thefe may be extirpated by the knife, by ligature, by cauftic ap- plications, or by wearing bougies, according to their Size, or the part where they grow, which may render one method more con> venient or preSerable to the reft. But theSe excreScences, when they ariSe in the urethra or bladder, are Sometimes not to be re^ moved without much difficulty and trouble, SECTION Xt The pruritus, itching, or ftinging of the external parts, is a complaint to which women are liable at any period of life ; but it is moft frequently attendant on the ftate of pregnancy, of which it is one of the moft troubleSome conSequences. IS it affea the internal parts, or be exceffive in its degree, it is Said to terminate in the furor uterinus. It is Sometimes occafioned by a difeaSe or affeaion of the bladder, and is then equivalent to the itching of the glans penis in men; but it more commonly proceeds from fome affection oS the uterus, having been moft frequently ob- ferved to occur in pregnancy, efpecially when the child was dead, or about the time of the final ceffation of the menfes, when there was a difpofition to difeafe in the uterus. I do not, however, re- collea any inftance of this pruritus either preceding or accompa- nying any truly cancerous difpofition of the uterus or its appen- dages. The means ufed for the relief of the patient, muft depend up- on the feat, the caufe, and the degree of the complaint. When it happens during pregnancy, and at all other times, if attended with inflammation, it is neceffary to bleed ; to give gentle laxa- tive medicines ; and to ufe fedative applications, of which per-! haps the beft is a weak Solution of ceruffa acetata as a lotion; or a decoaion of poppy heads, with a fmall quantity of ceruffa acetata diffolvcd in it, as a fomentation. But of all the applications I have feen ufed, none has more generally afforded relief than cold water frequently applied with a fponge, and occasionally made colder a* INTRODUCTION TO MIDWIFERY. with the addition of ice, or a little vinegar and Spirits. More aaive applications are often prefcribed; but I have SuSpeaed that thefe, in many caSes, rather aggravate than leffen the com- plaint, though much benefit is Sometimes derived Srom wafhing the parts with water moderately acidulated with the nitric acid, or the application of one part of the unguentum hydrargyri muriatic, and three parts of the unguentum ceruffa acetata. If the patient be pregnant, the attempt to cure it will often be vain, and we muft be Satisfied with moderating it till fhe is delivered, when it will generally ceaSe Spontaneoufly. When this complaint is in- dependent oS pregnancy, originates Srom an affeaion of the uterus, and is of long continuance, the applications muft be varied, and fuch medicines given as promife relief by changing the ftate of that part. Sulphur, taken internally, has Sometimes been of much Service ; or applied to the part as a powder, liniment, or lotion. The burnt Sponge with nitre, and the extratlum cicuta, have alSo been given with advantage; together with a lotion com- poSed of equal parts of the aqua zinci vitriolati cum camphora and rofe water; or the application oS the unguent, hydtargyr. fort. I have alSo frequently given five grains of Plummer's pill every night at bed-time for a month, and a pint of the decoaion of farfapa- rilla daily; though there was no fufpicion of any venereal in- feaion, of which the itching is, I believe, a very unufual fymp- tom. But when this complaint has been occafioned by an affec- tion of the bladder, the conftant or daily ufe of a bougie in the urethra has, in fome cafes, effeauajly cured the patient. SECTION XI. The hymen is a thin membrane of a Semilunar, or circular form, placed at the entrance of the vagina, which it partly clofes. It has a very different appearance in different women, but it is ge- nerally, if not always,* found in virgins, and is very properly efteemed the teft of virginity, being ruptured in the firft aa of coition ; and the remnants of the hymen are called the caruncula myrtiformes.f The hymen is alfo peculiar to the human Species; from which circumftance a moral writer might draw inferences favourable to the eftimation of chaftity in women. * Membrana hymen, qua utrum deter, necne,fubjudice lis olim fuit, hoc autem tempore in anatomia magis verfatis nihil'not ius effe pot ell.— Ruyfch. TheS. iii. No. xv. f Hymenis diffoluti rellguia, et corrupta adeo pudicitia. indicia.—: IJaller. Phyfiolog. ON THE LXTERNAL PARTS OF GENERATION. ,37 There are two circumftances relating to the hymen which re- quire medical affiftance. It is Sometimes oS Such a Strong liga- mentous texture, that it cannot be ruptured, and prevents the connexion between the Sexes. It is alSo Sometimes imperforated, wholly clofing the entrance into the vagina, and preventing any discharge from the uterus ± but both thefe cafes are extremely rare. If the hymen be of an unnaturally firm texture, but perforated, though perhaps with a very fmall opening, the inconveniences thence arifing will not be difcovered before the time of marriage, when they may be removed by a crucial incifion made through it, taking care not to injure the adjoining parts. But the imperforation of the hymen, will produce its inconve- niences, when the perfon begins to menftruate.* For, the men- Struous blood being Secreted Srom the uterus at each period, and not evacuated, the patient Suffers much pain from the diftention of the parts; many ftrange fymptoms and appearances are occafi- oned, and fufpicions injurious to her reputation are often enter- tained. In a cafe of this kind, for which I was confulted, the young woman, who was twenty-two years of age, having many uterine complaints, with the abdomen enlarged, wa# fufpeaed to be pregnant, though fhe perSevered in afferting the contrary, and had never menftruated. When fhe was prevailed upon to Sub- mit to an examination, the circumScribed tumour of the uterus was found to reach as high as the navel, and the external parts were Stretched by a round foft fubftance at the entrance of the vagina, in fuch a manner as to refemble that appearance which they have when the head of a, child is paffing through them; but there was no entrance int© the vagina. On the following morn- ing an incifion was carefully made through the hymen, which had a flefhy appearance, and was thickened in proportion to its diftention. Not left than four pounds of blood, of the colour and confiftence of tar, were difcharged; and the tumefaaion of rhe abdomen was immediately removed. Several ftellated incifi- ons were aSterwards made through the divided edges, which is a very neceffary part of the operation ; and care was taken to pre- vent the re-union of the hymen till the next period of menftruati- on, after which fhe fuffered no inconvenience. The blood dif- charged was not putrid or coagulated, and Seemed to have un- dergone no other change, after its Secretion, but what was occafi- oned by the abforption of its more fluid parts. Some caution is required when the hymen is clofed in thofe who are in advanced * Menfes a membrana vulvam claudente fupprefft, perqtte hujus in- cift::iem evacuati.—RuySch. Obf. xxxii.—and all the older writers. 38 INTRODUCTION TO MIDWIFERY-! age, unlefs the membrane be diftended by the confined menfes, as I once Saw an inftance of inflammation of the peritonaum being immediately produced after the operation, of which the patient died as in the true puerperal fever, and no other reafon could be affigned for the difeafe. The caruncula myrtiformes, by their elongation and enlarge* ment, Sometimes become very painSul and troubleSome. Under fuch circumftances they may be managed, or extirpated, if re-* quifite, in the fame manner as the diSeaSed fiympha. CHAPTER III. SECTION L ON THE INTERNAL PARTS OF GENERATION* 1 he internal parts of generation are the vagina, the uterus, the fallopian tubes, and the ovaria. The ligaments may be efteemed appendages to the uterus. That canal which leads from the pudendum, or external orifice, to the uterus, is called the vagina. It is Somewhat of a conical form, with the narrowest part downwards, and is defcribed as being five or fix inches in length, and about two in diameter.— But it would be more proper to fay, that it is capable of being extended to thofe dimenfions; for in its common ftate, the os ute- ri is Seldom found to be more than three inches from the exter- nal orifice, and the vagina is contraaed as well as fhortened. The vagina is compofed of two coats, the firft or innermoft of which is villous, interSperfed with many excretory duas, and contraaed into plica, or Small tranSverSe folds, particularly at the fore and back part ; but, by child-bearing, thefe are leffened or obliterated. The fecond coat is compofed of a firm membrane, in which mufcular fibres are not diftinaiy obfervable, but which is endowed to a certain degree with contraaile powers like a mufcle. This is furrounded by a cellular membrane, which con- neas it to the neighbouring parts. A portion of the upper and pofterior part of the vagina is alfo covered by the peritonaum. The entrance of the vagina is conftriaed by mufcular fibres, originating from the rami of the pubis, which run on each fide'of the pudendum, furrounding the pofterior part, and executing an ON THE INTERNAL PARTS OF GENERATION. 39 equivalent office, though they cannot be faid to form, a true fphincler. The upper part of the vagina is conneaed to the circumference of xheos uteri, but not in a Straight line, fo as to render, the cavi- ty of the uterus a continuation of that of the vagina. For the lat- ter Stretches beyond the former, and, being joined to the cervix, is refleaed over the os uteri; which, by this mode of union, is fufpended with protuberant lips in the vagina, and* permitted to change its pofition in various ways and direaions. When there- fore thefe parts are diftended and unfolded at the time of labour, they are continued into each other, and there is no part which can properly be confidered as the precife beginning of the uterus, or termination of the vagina. The form of the uterus refembles that of an oblong pear, flat- tened, with the depreffed fides placed towards the offa pubis and facrum ; but, in the impregnated ftate, it becomes, more oval, ac- cording to the degree of its diftention.* For the convenience of defcription, and for fome praaical pur- pofes, the uterus is diftinguifhed into three parts; the fundus, the body, and the cervix. The upper part is called the fundus, the lower the cervix, and the fpace between them, the extent of which is undefined, the body. The uterus is about three inches in length, about two in breadth at the fundus, and one at the cervix. Its thicknefs is different at the fundus and cervix, being at the Sormer uSually rather leSs than half an inch, and at the latter Somewhat more, and this thicknefs is preferved throughout pregnancy, chief- ly by the enlargement of the veins and lymphatics, there being a. fmaller change in the fize oS the arteries, f But there is So great a variety in the fize and dimenfions of the uterus in different wo- men, independant of the States of virginity, marriage or pregnan- cy, as to prevent any very accurate menfuration. The cavity of the uterus correfponds with the external form. That of the cervix leads from the os uteri, where it is very fmall, in a Straight direaion, to the fundus, where it is expanded into a triangular form, with two of the angles oppofed to the entrance into the fallopian tubes; and at the place of junaion between the cervix and the body of the uterus the cavity is fmaller than it is in any other part. There is a Swell, or fullneft, oS all the parts, to- 1 * Fades uteri anterior planior efl, convexior pofterius ; latera pene in aciem extenuata.—R.oedercr. f Pars magna craffttiei uteri ad venas pertinet.—All the older Writers. Vol. L £ 40 INTRODUCTION TO MIDWIFERY. wards the cavity, which is Sometimes diftinguifhed by a promi- nent line running longitudinally through its middle. The villous coat of the vagina is refleaed over the os uteri, and is continued into the membrane which line the cavity of the uterus*. The internal furface of the uterus is corrugated in a beautiful manner, but the ruga, which are longitudinal, leffen as they advance into the uterus, the fundus of which is fmooth. In the intervals between the ruga are fmall orifices, like thofe in the vagina, which difcharge a mucus, ferving, befides other purpoSes, that of clofing the os uteri very curioufly and perfeaiy during pregnancyf. The % fubftance of the uterus, which is very firm, is compofed of arteries, veins, lymphatics, nerves, and mufcular fibres, curi- oufly interwoven and conneaed together by cellular membrane. The mufcular fibres are of a pale colour, and appear alfo in their texture Somewhat different Srom muScular fibres in other parts of the body. The arteries of the uterus are the Spermatic and hypogastric. The Spermatic arteries ariSe Srom the anterior part oS the aorta, a little below the emulgents, and Sometimes from the emulgents. They pafs over the pfoa mufcles, behind the peritonaum, enter between the two lamina, or duplicatures of the peritonaum, which form the broad ligaments of the uterus, proceed to the ute- rus, near the fundus of which they infinuate themfeives, giving bran ches in their paffage to the ovaria -and. fallopian tubes. The hypogastric arteries are on each fide a confiderable branch of the internal iliacs. They pafs to the fides oS the body of the uterus, fending off a number of fmaller branches, which dip into its fubftance. Some branches alfo are refleaed upwards to the fundus uteri, which anaftomofe with the Spermatic arteries, and others are refleaed downwards Supplying the vagina. The veins which recondua the blood from the uterus are very numerous, and their fize in the unimpregnated ftate is proporti- oned to that of the arteries; but their enlargement during preg- nancy is fuch, that the orifices of fome of them, when divided, will admit even of the end of a fmall finger. The veins anafto- moSe in the manner of the arteries, which they accompany out * Pulpufum magis quam vagina vleamentum aliquoties reperi.—. Haller. Phyfiolog. f Adeo abundans et totam cervicem repleat, et ofculum quafi abturet. Haller. Phyfiolog. and many of the older Writers. X In gravida femina in laminas pofftt dividi, et in morbis in I aci- ni as, fquamaf que. Noortwyck. Utcr. Gravid, i. 1. c. ON THE INTERNAL PARTS OF GENERATION. 41 of the uterus ; and then, having the fame name with the arteries, Spermatic and hypogastric, the former proceeds to the vena cava on the right fide, and on the left to the emulgent vein; and the latter to the internal iliacs. From the fubftance and furfaces of the uterus an infinite num- ber of lymphatics arife, which follow the courfe of the hypogas- tric and fpermatic blood-veffels. The firft pafs into the glands of the internal iliac plexus; and the other into the glands which are Situated near the origin of the fpermatic arteries. Of thefe Nuck firlt gave a delineation. The uterus is fupplied with nerves from the lower mefocolic plexus, and from two fmall flat circular ganglions, which are fitu- ated behind the reblum. Thefe ganglions are joined by a number . of fmall branches from the third and fourth facral nerves. The ovaria derive their nerves from the renal plexus. By the great number of rierves thefe parts ar rendered extremely irritable; but it is by thofe branches which the uterus receives from the inter- coflal, that the intimate confent between it and various other parts is chiefly preferved. The mufcular fibres of the uterus have been defcribed in a ve- ry different manner by anatomifts, fome of whom have aflerted that its fubftance was chiefly mufcular, with fibres running in tranfverfe, orbicular, or reticulated order; whilft others have contended, that there were no muScular fibres whatever in the uterus. In the unimpregnated uterus, when boiled tor the pur- pose oS a more perSea examination, the Sormer Seems to be a true representation ; and when the uterus was diftended towards the latter part of pregnancy, thefe fibres are very thinly Scattered; but they may be difcovered in a circular direaion at the junaion between the body and the cervix of the uterus, and furrounding the entrance ofeach fallopian tube in a fimilar order. Yet it does not feem reafonable to attribute the extraordinary aaion of the uterus at the time of labour to its mufcular fibres only, if we arc to judge of the power of a mufcle by the number ef fibres of which it is compofed, unlefs it is preSumed, t*nat thofe of the ute- rus are Stronger than in common mutclcs. With reSpea to the glands of the uterus none are difcoverable diSperSed through its fubftance. Upon the inner furface of the cervix, between the ruga, there are lacuna which fecrete mucus, and' there are fmall follicles at the edge of the os uteri. Thefe lift are only obfervable in a ftate of pregnancy, when they are much enlarged. From the angles at the fundus of the uterus two proceffes, of an irregularly round form, originate, called, from the name of the 42 INTRODUCTION TO MIDWIFERY. firft defcriber, the fallopian tubes. They are about three inches • in length, and, becoming fmaller in their progreft from the uterus,^ have an uneven, fringed termination, called the fimbria. The canal which paffes through thefe tubes is extremely fmall at their origin, but it is gradually enlarged, and terminates with a patu- lous orifice, the diameter of which is about one third of an inch, furrounded by the fimbria. It is alfo lined by a very fine vafcu- lar membrane formed into ferpentine plica. Through this canal the communication between the uterus and ovaria is preferved.— The faliopian tubes are wrapped in duplicatures ofthe peritonaum, which are called the broad ligaments of the uterus; but a portion of their extremities thus folded hangs loofe on each fide of the pelvis. The ovaria are two flat oval bodies, about one inch in length, and rather more than half in breadth and thicknefs, fuSpeftded in the broad ligaments at about the diftance of one inch from th« uterus, behind, and a little below, the fallopian tubes.* To the ovaria, according to the idea of their ftruaure enter- tained by different anatomifts, various uSes have been affigned, c% the purpoSe they anSwer has been differently explained. Some have SuppoSed, that their texture was glandular, and that they Secreted a fluid equivalent to and Similar to the male femen,• but others, who have examined them with more care, affert that they are ovaria in the literal acceptation oS the term, and include a number of veficles, or ova, to the amount of twenty-two of dif- ferent Sizes, joined to the internal furface of the ovaria by cellular threads or pedicles; and that they contain a fluid, which has the appearance of thin lymph. Thefe veficles are in faa to be Seen in the healthy ovaria of every young woman. They differ very much in their number in different ovaria, but are very Seldom So numerous as has juft been flated. All have agreed, that the ovaria prepare whatever the female Supplies towards the formation of the foetus} and this is proved by the operation of fpaying, which confifts in the extirpation of the ovaria, after which the animal not only lofes the power of conceiving, but defire is for ever extinguished. The outer coat of the ovaria, together with that of the uterus, is given by the peritonaeum; and whenever an ovum has paffed into the fallopian tube, a fiffure may be obferved at the part through which it is fuppoSed to have been transferred. TheSe fiffures healing, leave fmall longitudinal cicatrices on the furSace, ^ Ovaria in vetulis admpdum exilia, ut plurimum vifuntur.----- JtuySch. ObS. Anatom. xlv. ON THE INTERNAL PARTS OF GENERATION. 43 which are faid to enable us to determine, whenever the ovarium is examined, the number of times a woman has conceived. The corpora lutea are oblong glandular bodies, of a yellowifh colour, found in the ovaria of all animals when pregnant, and, according to fome, when they «re falacious. They are faid to be calyces from which the impregnated ovum has dropped; and their number is always in proportion to the number of concep- tions found in the uterus. They are largeft and moft conSpicu- ous In the early ftate of pregnancy, and remain for fome time after delivery, when they gradually fade and wither till they dis- appear. The corpora lutea are extremely vafcular, except at their centre, which is whitifh; and in the middle of the white part is a fmall cavity, from which the impregnated ovum is thought to have immediately proceeded. From each lateral angle of the uterus, a little before and below the fallopian tubes, the round ligaments arife, which are com- pofed of arteries, veins, lymphatics, nerves, and a fibrous Struc- ture Thefe are conneaed together by cellular membrane, and the whole is much enlarged during pregnancy. They receive rfieir outward covering from the peritonaeum, and pafs out of the pelvis through the ring of the external oblique mufcle to the groin, where the veffels fubdivide into Small branches, and terminate at the mons veneris and contiguous parts. From the inSertion of theSe ligaments into the groin, the reaSon appears why that part generally Suffers in all the diSeaSes and affections of the uterus: and why the inguinal glands are in women fo often found in a morbid or enlarged ftate, The duplicatures of the peritonaeum, In which the fallopian tubes and ovaria are involved, are called the broad ligaments of the uterus. TheSe prevent the entanglement of the parts, and are conduaors of the veffels and nerves, as the mefentery is of thofe of the interlines. Both the round and broad ligaments alter their pofition during pregnancy ;* appearing to rife lower and more forward than in the unimpregnated ftate. Their ufe is fuppofed to be that of preventing the defcent of the uterus, and to regulate its direaion when it afcends into the cavity of the abdomen,- but whether they anfwer theSe purpoSes, may be much doubted. * Ovariorum eorumque ducluum jtttts mutatur, tempore geflatioms et puerperii.—RuySch. TheS. ix. No. xv. 44 INTRODUCTION TO MIDWIFERY. SECTION II. The difeafes of the internal parts of generation will be beft underftood if they are defcribed in the order obferved in the dc- Scription of the parts. The difeafes of the vagina are, firft, fuch an abbreviation and contraaion as render it unfit for the ufes Sor which it was de- figned ; Secondly, a cohefion oS the fides in conSequence oS pre- ceding ulceration; thirdly, cicatrices, after an ulceration of the parts ; fourthly, excrefcences ; fifthly, fluor albus. This abbreviation and contraaion of the vagina, which ufually accompany each other, are produced by original defeaive forma- tion ; and they are feldom discovered beSore the time of marriage, the confumation of which they Sometimes prevent. The cura- tive intentions are to relax the parts by the uSe of emollient ap- plications, and to dilate them to their proper fize by fponge or other tents, or which are more effeaual, by bougies gradually en- larged. But the circumftances which attend this diforder are fomctimcs fuch as might lead us to form an erroneous opinion of the difeafe. A cafe of this kind which was under my care, from the ftrangury, from the heat of the parts, and the prof ufe and in- flammatory difcharge, was fufpeaed to proceed from venereal infedtion; and with that opinion the patient, had been put upon a courfe of medicines compofed of quickfilver for Several weeks without relief. When (lie applied to me, I prevailed upon her to fubmit to an examination, and found the vagina rigid, fo much contraaed as not to exceed half an inch in diameter, and not more than one inch and a half in length. The repeated, though fruitleft, attempts, which had been made to complete the aa of coition, had occafioned a confiderable inflammation upon the parts, and all the SuSpicious appearances beSore mentioned. To remove the inflammation, fhe was bled, took Some gentle purgative medi- cines, uSed an emollient Somentation, and afterwards fome unc- tuous applications; fhe was alfo advifed to live Separate from her hulband for Some time. The inflammation being gone, tents of various Sizes were introduced into the vagina, by which it was diSU tended, though not very amply. She then returned to her huS- band, and in a fev/ months became pregnant. Her labour, though flow, was not attended with any extraodinary difficulty; fhe was delivered of a full fized child, and afterwards fuffered no incon- venience. Another kind of conftriaion of the external parts Sometimes occurs, and which Seems to be a mere SpaSm. This ia to be re- ON THE INTERNAL PARTS OF GENERATION. 4$ moved in Some caSes by Such applications as Sooth and allay irri- tation, and in others by Such means as diftend them by refitting the fpafm, which is Sometimes So Sorcible as to require the uSe of bougies of a proper fize fpr a long time, even in women who are married or have borne children. SECTION III. By the violence or long continuance of a labour, by the morbid State oS the conftitution, or by the negligent and improper uSe ot inftruments, an inflammation of the external parts, or vagina, is Sometimes produced in Such a degree as to endanger a mortifica- tion. By careSul ^management this conSequence is uSually pre- vented ; but, in Some cafes, when the conftitution of the patient was prone to difeafe, the external parts have floughed away, and in others equal injury has been done to'the vagina. But the ef- fea of the inflammation is ufually confined to the internal or vil- lous coat, which is fometimes caft o"ff wholly or partially. An ulcerated furface being thus left, when the difpofition to heal has taken place, cicatrices, have been formed of different kinds, accord- ing to the depth and extent of the ulceration; and there being no counteraaion to the contraaile ftate of the parts, the dimen- fions of the vagina become much reduced: or, if the ulceration fhould not be healed, and the contraaibility of the parts continue to operate, die ulcerated furfaces being brought together may co- here, and the canal of the vagina be perfeaiy clofed. The in- conveniencies and ill confequences of this complaint may in ge- neral be prevented, or very much leffened, by proper attention at the time of healing; but in many of the cafes I have feen, the firft inflammation being negleaed, and the Houghing Srom the vagina overlooked, the cohefion had taken place loug before it was fufpeaed. SECTION IV. Cicatrices in the vagina very Seldom become an impediment to the connexion between the Sexes ; when they do, the fame kind of affiftance is required as was recommended in the natural contraaion or abbreviation of the part, and I believe they always. give way to tlie pre flu re of the head of the child in the time of labour, though in many cafes with great difficulty. Sometimes t]ic appearances may miflead the judgment: for 1 was lately cal- led to a woman in labour, who was thought to have become preg- 4<* INTRODUCTION TO MIDWIFERY. nant, the hymen remaining unbroken. But on making very par- ticular inquiry, I difcovered that this was her fecond labour, and that the part which, from its form and Situation, we SuppoSed to be the hymen, with a Small aperture, was a cicatrice, or unnatural contraaion of the entrance into the vagina, consequent to an ul- ceration of the part after her former labour. When the fides of the vagina cohere together, it may be requi- site to Separate them with a knife ; and, when they are in a heal- ing ftate, their reunion may be prevented by tents or bougies, or by a leaden canula of a proper fize, introduced into and worn in the vagina. But, if the cohefion has taken place far up in the vagina, the knife muft be ufed with the utmoft circumfpeaion, or irreparable injury may be done to the bladder, reel urn, or the adjoining part, as they all are drawn cloSely together. A patient under thefe circumftances, who applied to me for relief, and in whom the menftruous blood was Secreted, though it could not be difcharged, was advifedto defer any operation; as I prefumed the menftruous blood, at Some Suture time, would be colleaed in fuch a quantity as either to Separate or protrude the cohering parts in Such a manner as to render the operation more Secure, effec- tual, and eafy. Accordingly when they were ftretched and pro- trudedby the retained menfes, thepoint moft eligible for perforation was indicated, and the operation was performed eafily and fafely. But in fome cafes of cohefion it has not been thought justifiable to attempt to Separate the united parts by incifion, and the pa- tient has been obliged to fubmit to the injury for the remainder of her life. SECTION V. Fungous excrefcences arifing from any part of the vagina or uterus have been distinguished, though not very properly, by the general term, polypus. TheSe are of different forms and fizes, and may fprout from any part of the cavity of the uterus, and perpend in the vagina ; or from the os uteri; or from the vagina. The texture of the excrefcences is alfo very different, being in fome cafes flefhy and firm, and in others truly funguous and almoft as foft as coagulated blood. Some of them hang by a fmall pedicle, and others have a broad bafis, efpecially at their commencement. But thefe fubftances not having been accurately deScribcd by an- atomists, nor the accompanying Symptoms marked by noSologifts, thofe who are not very guarded in their praaice are oSten led int • error, ifltfheir prognostic and treatment of theSe cafes. ON THE INTERNAL PARTS OF GENERATION. 47 The caufe of polypi may be Some accidental Injury done to the part at the time of labour or otherwife; but more generally it is a fpqntaneous diSeaSe, proceeding Srom a certain diSpofition oS the constitution or oS the part itSelf, as thofe who have a polypus of the uterus for inftance, are apt to have excrefcences from other parts, and they frequently exift in thofe who have never been pregnant, and even in virgins. Thofe which are of a fmall fize are not impediments either to conception or parturition; at leaft if theyfpring from the vagina Or os uteri. In the firft ftage, a polypus may be accompanied with all thofe fymptoms which proceed from uterine irritation ; and in it% pro- greSs and advanced ftate with a mucous, Sanious, or Sanguineous difcharge, increafing in quantity, Srequently changing its appear- ance, and irregular in the times of its continuance,- according to the growth of the difeaSe and the ftate oS the conftitution. By thefe difcharges, and often by the continual pain, the patient may at length be reduced to extreme weaknefs; and if relief be not given by the extirpation of the polypus, fhe may perifh from mere loft of ftrength, or the production of other difeafes. But thefe fymptoms being common to fome other affeaions of the uterus, the caufe of them is frequently overlooked. When therefore no advantage is obtained in fuch cafes, by the ufe of fukable and ef- ficacious medicines, it fhould be made a general rule fo inquire whether there may not be a polypus, or what is the nature of the local difeaSe. The polypus may be removed by excifion, or by ligature, but the latter is by Sar the preSerable method, and the ligature is to be uSed in the Same manner, and on the Same principle as in the extirpation of nafal polipi. The kind of ligature I have generally ufed has been either one of the laces made of filk, ufed in the dreft of women, or a piece of fine whipcord. The difficulty of the operation lies in the proper application of the ligature, and this depends upon the diftance of the part to be tyed from the external orifice, upon the fize, and thicknefs of thebafis or Stem of the polypus. If the circumftances of the cafe will admit of a delay, the operation will be rendered more eafy by deferring it, as the tumour will defcend lower, and the item or pedicle become thinner and longer. This is the manner oS tying the polypus; draw the ligature, doubled, through the canuia or ligator commonly uSed Sor this purpoSe, and then condua the bow of the ligature with the fin- gers, all round and over the bulk of the polypus, taking care that it does not hitch on one fide when it is paffed over the other, Vol. I. L 48 INTRODUCTION TO MIDWIFERY. which it is apt to do if the polypus be large. The ligature being paffed over the polypus and upon its ftem, the canula is to be car- ried to the ftem, and both the ends of the ligature carefully drawn through till it is tightened. We are then to examine with the finger, whether the ligature be fixed upon the moft eli- gible part, which is ufually as high up as we can reach, but there is not occafion to fix it upon any precife part of the root of the ftem, becaufe the part beyond the ligature decays and comes away with the reft, leaving the uterus clear. I have found it better to. draw the ligature flowly to what may be called its bearing, than to tighten it haftily, left the ftem Should be cut through prematurely, if the fubftance were tender, and then there would be an awkward difcharge for fome time afterwards. I therefore gradually tighten the ligature every day till it comes away, which cannot happen till the ftem is Separa- ted, which is uSually on the fourth or fifth day according to the thicknefs or texture of the ftem. The firft fign of a fuccefsful operation is the Scent of fomething putrefying. The ligature being loofened and taken away, there is feldom any difficulty in extraaing the polypus, unlefs it were very large j but of this we Shall afterwards fpeak. During the operation of the ligature we muft carefully watch any tendency there may be to pain or inflammation in the abdomen, and if either of thefe fhould come on in any material degree, we muft proceed more circumfpeaiy. It has been mentioned as a general rule, that we ought not to pafs the ligature round a polypus, unlefs we can feel the ftem ; but in cafes of extreme danger this rule muft be difregarded. We muft alfo diftinguifh a polypus from an inverted uterus ; and there is in fome refpeas a refemblance between the two complaints, and fometimes they exift together even when the polypus is not large. Should a polypus arife ffom the fubftance of the part, with a bafis as large or larger than the excrefcence, the ligature cannot be fixed, for it will either Aide off, or take a partial hold. In fuch cafes attempts to pafs the ligature produce no advantage, for in general fuch tumours have a cancerous difpofition. When the polypus has a fmall pedicle, the cafe is commonly more favourable than were the pedicle is of a confiderable thicknefs. Before the ligature is paffed, we fhould be informed of the ftate of the uterus, for if this be difeafed the patient will not profit by the extirpation of the polypus,-and We may acquire no credit, though aaing with the greateft (kill, in the operation. ON THE INTERNAL PARTS OF GENERATION. 49 . The polypus has fometimes terminated favourably without af- fiftance, or with affiftance of a different kind. After a long continuance of the difeaSe, which may not have been fufpeaed, or perhaps miftaken Sor Some other, the tumour has preffed through the vagina and external orifice, and the ftem being too weak to fuftain its weight, or to afford nouriffiment, it has decayed and dropped away ; or when the polypus has pufhed through the exter- nal orifice, a ligature has been fixed round the ftem, and the po- lypus been eafily and perfeaiy extirpated. But in fuch cafes the uterus is more frequently inverted by delaying to remove the poly- pus at a proper time, and the patient is unnecefTarily expofed to a continuance of fuffering and an increafe of danger. As little has been faid on this fubjea by any writer in this counr try, I prefume it may be of ufe to give a detail of fome cafes not common, efpecially as it will give me an opportunity of mention.- ing fome circumftances unnoticed in the foregoing defcription of the operation. CASE I. A Single lady, twenty-two years of age, had for a confiderable time been fubjea to frequent and profufe returns of uterine he- morrhage, which refitted all the means that could be devifed Sor her relief, and at length reduced her to a ftate of great weaknefs. Dr. Turton (whofe worth and continued friendfhip to me I am happy on every occafion to acknowledge) was the phyfician who attended, and he fufpeaing fome local diSeaSe, dcfired I might be permitted to make enquiry. I difcovered a polypus, not oS a large fize, lying low in the vagina. When J came to paSs the ligature, there was much embarraffment from the ftate of the parts, any injury to which I was Solicitous to avoid. On the fifth day from the time of my paffing the ligature it came away, but the polypus could not be extraaed without much caution and trouble. There was no return of the hemorrhage, fhe foon recov, pred her ftrength, and in a few months was married. She has had feyen fine children with fafe and eafy labours. This polypus weighed about four ounces. CASE II. Another young lady had long Suffered from frequent uterine hemorrhages, together with moft violent pains, recurmg in the manner of thofe of labour. High up in the vagitu, juft cleared 5* INTRODUCTION TO MIDWIFERY. through the os uteri, I difcovered a fmall polypus, round which i ligature was with difficulty paffed. The late Mr. Hunter was with me at the time. When I began to tighten the ligature She complained of very Severe pain, and preSently vomited. The li- gature was immediately flackened, but on every Suture attempt to draw it tighter, the fame fymptoms were inftantly produced. After many trials I was obliged to defift altogether, leaving the ligature loofe round the polypus, merely to keep up in the mind of the patient fome faint hope of benefit. The health of this pati- ent was very bad when I firft Saw her, and in about fix weeks from the time of the operation, She died. Leave being given to open the body, the uterus was found in- verted, and the ligature to have paffed over the inverted part, which occafioned all the fymptoms before mentioned. This polypus could not have weighed mora than one ounce, and had a very Short, iS it could be Said to have any Stem ; So that the uterus could not in this caSe have been inverted mechanically, but by its own vehement aaion excited to expel the polypus, which, like any other extraneous and offending body, was a perpetual cauSe off irritation. CASE III. Many years ago I vifited a lady, who had for a long time fuf- e_ fered greatly from various uterine complaints, and was fuppofed *^ to have a cancer in the uterus, of which her general afpea gave very ftrong indications. But on examination I found a large po- lypus in the vagina. The late Dr. Ford, than whom no one was more intelligent or expert in praaice, was in confultation with me. I paffed the ligature and drew it tight, confidently expea- ing a happy termination of the cafe. The ftem of the polypus was very thick, and it required eight or nine days aaion of the ligature to divide if. When I had removed the polypus, I was ve- ry much mortified to find a new fubftance, nearly of the fize of that which had been taken away, in the vagina. Her health be- ing being very infirm, it was thought advifable for her to go to a Short diftance in the country, Sor the chance of re-eftablifhing her health, before another operation. But a colliquative diarr- hoea with aphthae came on, She gradually declined, and about the end of the month died. Of this repullulation, if it was fuch, I have never feen any other inftance, and it might be attributed, i, to the thickneSs of the ftem ; or, 2, to the flow decay oS the ftem ; or, 3, to a can- cerous diSpofition of the uterus. If a cafe Similar to this were to. ON THE INTERNAL PARTS OF GENERATION. 5"* occur to me, I fhould certainly aa more fpeedily with the liga- ture, and however reduced the patient might be, fhould feel justi- fied in paffing the ligature on the Second excrefcence, as affording the only chance of faving the patient. CASE rv\ A Lady about fixty years of age, who had had feveral children, had, with violent pain, frequent hemorrhages from the uterus, fo profufe as to bring her at each time of their return into the great? eft danger. When fhe permitted me to take an examination, there was no polypus in the vagina, but the uterus was much diftend- ed, and the os uteri being opened nearly to one third of its cir- cumference, I could difcoyer within and preffing upon it, a tu- mour of apparently a very large Size. In the courSe of a few weeks an immenfely large polypus dropped into the vagina. Her health was much reduced, and the extirpation of the polypus ap- pearing die only chance of faving her, I made many and Strenu- ous attempts to pafs the ligature, but without fuccefs. I then pro- cured a longer and different inftrument, like that ufed in tying the tonfils, but with this I was alfo Soiled. In my endeavours to paSs this inftrument round the polypus, the Surface was abraded, a blood-veffel of a confiderable fize was wounded, and there wjs a loft of blood, which rendered the patient ftill more weak. Af- ter a few days, without any inftrument, I gradually introduced my hand into the vagina, got the ligature over the polypus, and then tightened it. Dr. Orme and Mr. Croft were with me at the time. But many complaints came on, and fhe died in a few days before the/>c/v/w*could be extirpated. The blood veffels which convey nourishment to a polypus, pro- bably bear a relation to its fize, and muft, of courfe, be Sometimes very large ; fo that in paffing the ligature, it behoves us to be very careful that we do not wound the polypus : and, perhaps, in every cafe when the polypus is large, it would be better, if poffi- ble, to introduce the hand, for the conveyance of the ligature, than to ufe any inftrument. Much will alfo depend on the tex- ture of the polypus, which is Sometimes fo flight as to refemble an injeaed and corroded liver or kidney. I remember a cafe in which, though I only took a common examination, and with the. ufual caution, fo violent an hemorrhage was occafioned, that I thought the patient would have died inftantly. The three preceding cafes are the only ones among a very great number,'in which I have not been fucceftful; and I have 5- INTR0DUCTI0N TO MIDWIFERY. judged it right to ftate them thus circumftantially, to fet other* upon their guard, and to prepare them for the poffibility of disap- pointment. In the mufeum of the late Dr. Hunter, there is a large polypus, and by the regifter it appears that, after many attempts to paft the ligature, without, fuccefs, this patient died. Perhaps by a know- ledge of the caufes of the mifcarriage of others (as in cafe 4 juft recited), Subsequent trials, even in polypi which aire oS the largeft fize, may be more Sortunate. I have very great pleaSure in relating the following cafe, which was lately under my care. CASE V. A foreign lady who was born, and had lived the greatest part of her time, in a hot climate, applied to me. , She had every day? for more than three years, a very confiderable difcharge of blood from the uterus, together with others of a different kind and complexion, by which her ftrength was much reduced. She had been attended by different gentlemen, who had not given any decidr ed opinion of the nature of her difeafe. When I firft examined her, I was indeed very much furprifed, for not only the whole vagina was filled up with a flefhy fubftance, but the os uteri was as completely dilated as when the head of a child is paffing through it, and the cavity of the uterus was filled with the Same fubftance. I at firft hefitated whether I Should make an attempt to paSs the ligature, as I could not reach the ftem oS the Subftance, but after deliberating upon the ftate of the patient, who muft foon perifh, unlefs relief could be given, and knowing that if the ligature could be paffed I fhould have the power either of proceeding, or of flopping on the appearance of any untoward fymptom, I de- termined to make a trial. The firft and fecond attempts to paft the ligature were fruitleft, but I at length conveyed the ligar ture beyond the bulk of the tumour and far beyond my reach, by means of a piece of thin cane, notched at the end. The ligature being daily drawn gradually tighter, was at liberty on the fixth day. The external parts were unufually contraaed, and as, any endeavours to bring away the'polypus at that time muft have fail- ed, it was left in the vagina to foften and decay. On the ninth day ffie had pains as regular as thofe of labour, and when the os externum became Somewhat dilated, I laid hold of a portion of the tumour, firft with my fingers, and then with a fmall fharp point- ed hook, favouring the expulfion of it as well as I could, during the pain6 by which it was propelled with confiderable force. At* ON THE INTERNAL PARTS OF GENERATION. 5$ ter a labour of four hours continuance the polypus was excluded. From that time to the end of five weeks there was no difcharge of any kind, then fhe menftruated regularly, and returned home in perfea health. • This polypus, which was the largeft I ever Saw, was put into the hands oSDr. Baillie, who Saw the patient during the operation. It weighed two pouhds and three ounces, So that allowing Sor its decay, perhaps it could not originally have weighed leSs than three pounds. When polypi are too large to be extraaed without much diffi- culty after their feparation, no harm can arife from their remain- ing fome days in the vagina, as I have found in feveral inftances. In the mufeum of the late Dr. W. Hunter, there is preferved a polypus, which from its fize appears to have inverted the uterus, and the ligature when paffed over it, being out of reach, was found to have been fixed over the inverted part of the uterus, fo that when drawn tight it had produced the fame fymptoms as thofe defcribed in caSe 2. It is remarkable that this woman lived till the inverted portion of the uterus was more than half cut through by the ligature, and I am of opinion with very flow proceeding She might have Sur- vived the operation. For in a caSe in which I was concerned with Mr. Heavifide and other gentlemen, the ligature being paf- fed round aJbuliflower excrefcence, as it is called, of the os uteri, a portion ofnhe os uteri, itfelf was included and came away with the excrefcence, and the patient lived feveral months after the operation. But the fame caufes and degrees of irritation differ fo widely in their effeas in different constitutions, the event of fuch cafes muft be both hazardous and doubtful. The late Dr. Hamilton of Glafgow obliged me with a drawing of a polypus which weighed one pound and four ounces, and had dropped through the os externum, inverting and dragging along with it the fundus of the uterus. The patient died. Had the nature of this complaint been underftood in due time, it would in all likelihood have been poffible to have tied and extirpated it, before it had occafioned fo much mifchief. It is an example, among many others, of the impropriety of waiting till the polypus is excluded through the os exterrium before we attempt to tie it, an opinion which fome have entertained. A very great part of thofe on whom I have performed this operation have been foreigners, or perfons who have lived in hot climates ; but it remains to be proved whether women in Such climates are more Subjdft to the polypus than thoSe who live in cold ones, or whether this has been an accidental circumftance. ?4 INTRODUCTION TO MIDWIFERY. I have Seen Several caSes oS excrefcences, not above the thick- nefs of a large earth-worm, fpringing from the cavity of the uterus or os uteri, and growing to a great length. Thefe were cafily tied and removed. In one cafe the cervix of the uterus was fo much elongated as to drop through the external parts, affuming the appearance of a thickened membrane, but with this it was not thought prudent to interfere. I am Sorry to have known reaSons Sor concluding this account with the following obfervation. When a polypus is difcovered to jexifl, it does not feem right to proceed to the operation immedi- ately, but to requeft a confutation ; to prove the nature of the difeafe and the neceffity of the operation, that the honour of the profeffion, and of the perfon employed, may be preferved inviolate. SECTION VI. A mucous, ichorous, or fanious difcharge from the vagina or uterus, is called the fiuor albus*. Thefe difcharges are various in their degrees as in their kinds, from a fimple increafe of the natural mucus of the part, to that which is purulent or of the moft acrimonious quality; but the firft is not efteemed a difeaSe, unleSs it be exceffive in its degree. It is the moft frequent complaint to which, women are liable,, and is by them fufpeaed to be the caufe of every difeafe which they may atfgke fame time fuffer; but it is generally a fymptom of fome local d'iWKe, or a con- quence of great debility of the conftitution, though, when prof ufe, it becomes a caufe of yet greater weaknefs. In many cafes the fiuor albus is an indication of a difpofition to difeafg in the uterus, or parts conneaed with it, efpecially when it is copious in quantity, offenfive in Smell, or acrimonious in quality, about the time oS the final ceffation of the menfes ; and before the ufe of fuch means as are merely calculated forthe^movalof the difcharge, we muft firft endeavour to reftore the ifterus to a healthy ftate. The fymptoms attending the fiuor albus, whether it be an original difeafe, or a fymptom of other difeafes, are very Similar. The complexion is of a pale, yellowifh colour, the appetite is depraved, there is invariably a pain and fenfe of weaknefs in the back and loins, the patient has'ufually a feverifh difpofition, with the wafting of the flefh and reduction of the ftrength, and ultimately becomes heaic or leucophlegmatic. .* Leucorrhcca. Nimia mud aut ichoris ex vulva profufio.— Vogel. cxix. • Cachexia uterina, five fiuor albus.—Hoffman. ON THE INTERNAL PARTS OF GENERATION. $$ The method of relieving or curing the fiuor albus muft depend upon its caufe, whether the difcharge proceeds from the uterus or vagina. When it is occafioned by general weaknefs of the conftitution, all thofe medicines which are claffed under the general term of corroborants or tonics, efpecially bark and pre- parations of iron, may be given, under a variety of forms, with great advantage. But their effea is not immediate ; and, previ- oufly to their ufe, it will be proper and neceffary that the patient Should take Some mild purgatives, and in all cafes where there is any feverifh difpofition, that is to be removed before the ufe of any kind of tonic medicine. Balfamic and agglutinating medi- cines of every kind, as the extraa of bark with gum olibanum mafic or elemi, and all the clafs of terebinthinate balfams, of which theoeft for internal ufe is that called the balfam of Gilead, are alfo frequently prefcribed, and often with much benefit. In fome obftinate cafes, preparations of quickfilver, efpecially calomel in very Small dofes, have been given with advantage, when there was no fufpicion of any venereal infeaion. Gentle emetics have alfo been recommended in fome cafes of long continuance, and they are fuppofed to be of fingular ufe, not only by cleanfing the prima via, or by making a revulfion of the humours from the inferior parts, but by exciting all the powers of the conftitu- tion to more vigorous aaion. Cold bathing, partial or general, particularly UK the fea, has often been of eminent Service. In this and all fimilar complaints, good air, moderate exercife, nourifh- ing and plain diet, and a regular manner of living, will of courfe be advifed. When there is reafon to think that the complaint is local, and arifes from the relaxation of thofe orifices by which a neceffary mucus is discharged on particular occafions; or if the difcharge fhould continue after an amendment of the conftitution, injeai- ons of various kinds may be ufed daily. But the fafeft ^nd beft are thofe which are compofed from aftringent vegetables, as a Strong infufion of green tea, or the leaves of the red rofe ; pro- ceeding cautioufly to weak folutions of ceraffa acetata, zincum vitriolatum, or alum, as is the praaice in long continued deflux- ions upon the eyes. Though thefe applications cannot well be expeaed to produce an abfolute cure, they feldom fail to afford temporary benefit, which is a great comfort to the patient, and if cautioufly and judicioufly direaed, they may be continued or repeated without hazard. Vol. I. M 5* INTRODUCTION TO MIDWIfERf^ SECTION VII. The uterus is liable to many difeafes, and, being a part with which the whole body is readily drawn into confent, there is fcarce a difeafe under Which women have at any time laboured, but what has been attributed to its influence: yet it is not prov- ed, that there is any effential difference in thofe difeafes of wo- men to which men are equally fubjea, though there is fome vari- ety in the fymptoms. We fhall confine our attention to the moft obvious difeafes of the uterus, and begin with the prolapfus or pro- eidentia, which very frequently occurs. By the prolapfus is meant a fubfidence or defcent of the uterus into the vagina, lower than its natural Situation, and it is termed a procidentia when the uterus is puffied through the external orifice ofthe pudenda*. This fometimes happens to fuch a degree as to put on the appearance of an oval tumor growing from the exter- nal parts, depending very low betwen the thighs, caufing great pain and uneafinefs, and rendering the patient unable to perform the common offices of life. A moderate fhare of circumfpeaion, efpecially with regard to the ftate of the os uteri, will enable us to diftinguifh the procidentia of the uterus from its inverfion, and from all refembling difeafes. There are many caufes of the prolapfus or procidentia of the uterus; as long flanding during the time'of pregnancy, carrying heavy burdens, an extreme degree of coftiveneSs, and all Sudden and violent exertions oS the body; whence they moft frequently happen to women in the lower ranks of life. They may be occa- fioned by the circumftances of a labour, as the defcent of the os uteri into the pelvis, before it is dilated; by the prepofterous ef- forts of the woman in an erea pofition; by the rude and hafty extraction of the placenta, and by rifing too early after delivery. They may alfo be produced by mere relaxation of the parts, after a long continued fiuor albus, as unmaried women are fometimes fubjea to them, though left frequently than thofe who have had children. By a knowledge of the caufes of thefe complaints, we are led to their prevention and cure; and it is worthy of ob- servation, that, when a prolapfus or procidentia has been occafioned by the circumftances of one labour, they may generally be reliev- ed, or fometimes perfeaiy cured, by care and long confinement of the patient in an horizontal pofition after the next. When women who have a prolapfus are pregnant, the inconveniences are increafed in the early part of pregnancy, becaufe the uterus, * Hyfleroptofis* Uteri vel vagina procidentia.—Sauvag. xlix. ON THE INTERNAL PARTS OF GENERATION. 57 being then more weighty and enlarged, finks lower than ufual into the vagina ; but in the latter part, they are leffened, as it is then fupported above the brim of the pelvis. Yet, when the pel- vis is very capacious, and the parts much relaxed, the lower part of the uterus, including the head of the child, has in fome cafes been puffied through the external orifice, before the os uteri wal dilated, even in the time of labour. The procidentia is not, properly fpeaking, a difeafe of the ute- rus, but a change of its pofition, cauSed by the relaxation or weak- neSs of thofe parts to which it is conneaed, and by which it fhould be fupported. It accordingly moft commonly happens, that the firft tendency to it is discovered by the protrufion or fulnefs of the anterior part of the vagina, and fometimes alfo the pofterior part of the vagina firft becomes tumid, forming a kind of pouch by the partial diftention of the reclum ; and this happens in fome cafes where there is no defcent of the'juterus. But, in the principal degrees of the procidentia, the pofition of the uterus and vagina is not only very much altered, but that it would be contradicted by daily experience. But the matter 119 longer refts upon the foundation of opinion or conjecture : %, from the firft cafe in which I thought I had reafon to fuSpea it, J have fo conftantly obferved it, either by the referye of wqrnen of fuperior rank in life, or by the restraint of thofe in inferior Situations, neglecting or being prevente4 from attending to the calls of nature, that there 4oes not remain a 4oubt concerning it. * By repeated and flrwg inflations of the bladder, an4 then prejftng out the air in the dead' fubjeel, I could give a very good idea of the retroverfion of the Uterus ; and probably, if / could have had an ?)portunity of making the experiment in a ftate of pregnancy, I might ave fucceeded in produting an atlual retroverfion. 74 INTRODUCTION TO MIDWIFERY. The Saa hath alSobeen proved in a variety of cafes by praaitionr ers of the firft eminence, who have fupplied me with the moft unqueftionable teftimonies of its truth; and, in this cafe, it is a matter of great importance to difcover the caufe of the difeafe, as the method of preventing it and relieving the patient is thereby immediately pointed out. But the preceding fuppreffion of urine may be overlooked, as there is not occafion for it to be of long continuance in order to produce this effea ; efpecially in a woman who hath a capacious pelvis, in whom the retroverfion of the uterus is moft likely to happen. It muft alfo be obferved, that, though the fuppreffion of urine gives to the uterus its firft inclination to retrovert, yet the pofition of the os uteri is fuch, in the aa of retrovef ting, and the tumour formed by the fundus is fometimes fo large, when aaually retroverted, as to become, in their turn, cauSes of the continuance of the fuppreffion of urine. Should any doubt remain of the caufe of the retroverfion, it cannot, however, be difputed but that all attempts to reftore the uterus to its natural pofition, beSore the diftention of the bladder is removed, muft be fruitlefs, as the uterus will be irrefiftibly borne down by the preffure oS the Superincumbent bladder. The firft Step then to be taken Sor the relieS of the patient is, to draw off the urine : yet there is always in thefe cafes great difficulty in the introduction of the common catheter, becaufe the urethra is elongated, altered in its direaion, and preffed againft the offa pubis by the tumour formed by the retroverted uterus ; and many women, when the uterus was retroverted, have loft their lives from the want of expertnefs in introducing the catheter. But the attending' inconveniencies may be avoided or furmounted by the ufe of a flexible male or female catheter, flowly conduaed through the urethra. I fay flowly, becaufe, whatever catheter is ufed, the fuccefs of the operation, and the eafe and faSety of the patient, very much depend upon this circumftance. For it we affea to perform it with hafle and dexterity, or Strive to over- come the difficulty by Sorcc, we Shall be Soiled in the attempt, or it will be Scarcely poffible to avoid doing very great injury to the parts. The catheter ffiould not be carried farther into the bladder, when the urine, often colleaed in an immenfe quantity and miftaken Sor Some other difeaSe, begins to flow, unleSs it ceaSes beSore the diftention be removed ; which in fome cafes, happens in fuch a manner, as to give us the idea of a bladder divided into two cavities. External preffure upon the abdomen, when the catheter is introduced, will alfo favour the difcharge of the urine, after which the patient is fenfible of fuch relief, as to ON THE INTERNAL PARTS OF GENERATION. *J$ conclude tljat fhe is wholly freed from her difeafe. A clyfter fhould then be injeaed, or fome opening medicine given,/ and repeated if neceffary, to remove the faces, which may have been detained in the retlum before, or during the continuance of the retroverfion. But though the diftention of the bladder is removed by the difcharge of the urine, and all the fymptoms occafioned by it re- lieved, the uterus will continue retroverted. It has been Said, that the ftate oS retroverfion was injurious to the uterus itSelS, and would Soon produce Some dangerous diSeaSe in the part : it has alSo been afierted, that iS the uterus was permitted to remain in that ftate, it would be locked in the pelvis by the gradual enlarge- ment of the ovum, in fuch a manner as to render its reposition impraaicable, and the death of the patient an inevitable confe- quence. On the ground of thefe opinions we have been taught that it is neceffary to make attempts to reftore the uterus to its natural fituation, with all expedition, when the urine is difcharged, and that we are to perfevere in thefe attempts till we fucceed. In cafe of failure by plain and common methods, the means we have been advifed to purfue, many of which are Severe, and Some extremely cruel, as well as uSeleSs, would beft deScribe the dread of thofe confequences which have been apprehended from the retroverfion. For both thoSe conSequences there cannot Surely be reaSon to fear. If the uterus he injured, there will be no farther growth of the ovum ; and if the ovum ffiould continue to grow, it is the moft infallible proof that the uterus has. not received any material in- jury. But it is remarkable that, in the moft deplorable cafes of the retroverfion of the uterus, thofe which have terminated fatally, the death of the patient has been difcovered to be owing to the injury done to the bladder only. It is yet more remarkable, in the multiplicity of cafes bf this kind which have occurred, many of which have been under the care of praaitioners, who had no fufpicion that the uterus could be retroverted, and who would of courfe make no attempts to replace it, that there Should be So few inftances oS an injury whatever. Yet every patient under theSe circumftances muft have died, if their fafety had depended upon the reftoration of the uterus to its proper fituation by art; atten- tion having only been paid to the moft obvious and urgent fymp- tom, the fuppreffion of urine, and to the.prevention of the mif- chief which might thence arife. Opinions are often vain and deceitful, but with refpea to the matter now under confideration, they have alfo been very prejudi- cial. For it has been proved in a variety of caSe., many of which 7uod fietum amiciat et obvolvat.-^Harv. f A vetiarum copia five choro nomen obtinuit.—Idem. X Mihi liceat nominare membranam placenta, villofam.—-Ruyfch. Thef. Ahatom. vi. 41. 122 INTRODUCTION Tp MIDWIFERY. firmer texture than the others, and lines the whole ovum, making like the middle membrane, a covering for the placenta 2nd funis. With the two laft the ovum is clothed when it pafles from the ovarium into the uterus, where the firft is provided Sor its recep- tion. TheSe membranes, in the advanced ftate oS pregnancy, cohere Slightly to each other*, though ha Some ova there is a con- fiderable quantity of fluid colleaed between them, which, being difcharged when one of the outer membranes is broken, fornix one of the circumftances which have been distinguished by the name of by, or falfe waters. Between the middle and inner membrane, upon or near the funis, there is a Small, flat and oblong body, which, in the early .part oS pregnancy, Seems to be a veficle containing milky lymph, which aSterwards becomes oS a firm and apparently Satty tex- ture. This is called the vefcula umbilkalis, but its ufe is not known. SECTION X. All that fluid, which is contained in the ovum, is called by the general name oS the waters, or the waters oS the amnion or ovum. The quantity, in proportion to the fize oS the different parts of the ovum, is greateft by far in early pregnancy. At the time of parturition, in fome cafes, it amounts to, or exceeds, four pints, and in others it is Scarcely equal to as many ounces. It is ufually in the largeft quantity when the child has been Some time dead, or is born in a weakly ftate. This fluid is generally tranfparent, pSten milky, and Sometimes of a yellow or light brown colour, and very different in confift- ence £ and theSe alterations Seem to depend upon the ftate of the conftitution oS the parent. It doe6 not coagulate with heat like the Scrum oS the blood; and, chemically examined, it is Sound to be compofed of phlegm, earthly matter, and fea fait, in dif- ferent proportions in different fubjeas, by which the varieties in its appearance and confiftence are produced. It has been fup- pofed to be excrementitious, but it is generally thought to be Se- creted from the internal furface of the ovum, and circulatory as in other cavities. It was formerly imagined that the fetus was nourifhed by this fluid, of which it was faid to Swallow Some part Srequently ; and it was then affertedi that the qualities of the fluid were adapted for its nouriffiment. But there have been many examples of * Amnios et chorion flbi invicem leviter coharent.—Ruyfch. ON CONCEPTION. J*3 children born without any paffage to the ftomach ; and a Sew, of children in which the head was wanting, and which have neT verthelefs arrived at the full Size. TheSe caSes Sully prove, that this opinion is not juft, and that there muft be Some other medium by which the child is nourished befides the waters. The incon- trovertible uSes of this fluid are to Serve the purpofe of affording a foft bed for the -residence of the fetus, to which it allows free motion, and prevents any external injury during pregnancy ; and encljfed in the membranes, it procures the moft gentle, yet effi- cacious dilatation of the os uteri and foft parts at the time of parr turition. Inftances have been recorded, in which the waters of the ovum are faid to have been voided fo early as in the fixth month of preg- nancy, without prejudice either to the child or parent. The truth of thefe reports feems to be doubtful, becaufe when the membranes are intentionally broken, the aaion of the uterus never fails to come on, when all the water is evacuated. A few cafes have occurred to me in praaice, which might have been conftrued to be of this kind; for there was a daily difcharge of fome colourleft fluid from the vagina for feveral months before delivery ; but there being no diminution of the fize of the abdo- men, and the waters being regularly difcharged at the time of labour, it was judged that fome lymphatic veffel near the os uteri had been ruptured, aad did not clofe again till the patient was delivered. I have alSo met with one caSe, in which, aSter the expulfion oS the placenta, there was no Sanguineous diScharge, but a proSufion of lymph, to the quantity of feveral pints, in a few hours after delivery; but the patient fuffered no incor^eni^ ence, except from the furprife. The diSeaSes of the different parts of the ovum will be confi-. dered when we Speak of the caufes of abortion, SECTION XI. It hath been obferved, that the ftate of the uterus is, in many refpeas, altered in confequence of impregnation. Befides the derivation of a greater quantity of blood to it and the neigh- bouring parts, on which the fize chiefly depends in the early part of pregnancy, and the formation of the conneaing membrane of the ovum, it becomes endued with the properties of diftention and afcent into the cavity of the abdomen. The fundus of the uterus is the part firft diftended, and after- wards the inferior parts in regular order; at length the cervix is 124 INTRODUCTION TO MIDWIFERY. obliterated, except the mere circle of the ps uteri, and the uterus, which was originally pyriform, becomes nearly oval. The disten- tion is alSo more confiderable on the pofterior than the anterior part, which is one cauSe oS the change oS pofition and courSe of the fallopian tubes and ligaments. Thefe, in the unimpregnated ftate, depart from the concerns of the fundus of the uterus nearly at right angles; but, towards the conclufion of pregnancy, they go off from the fore part near the cervix, as was before obferv* cd. This diftention is evidently not mechanical from the enlarg- ment of the ovum, but from the acceffion of a new principle ; for the uterus is never fully upon the ftretch, like a bladder inflat-s td. with air, but relaxed in Such a manner as to be apparently capable of bearing the farther increafe of the ovum without in- convenience. The uterus is placed between the bladder and retlum, the os uteri be ing generally projeaed a little backward, fo that the axis of the cavity of the uterus correfponds with that of the pelvis* After conception, the weight of the uterus being increafed, it fubfides lower into the vagina, the fhortneft of which is there? fore reckoned one of the equivocal figns of pregnancy. But, after a certain time, the uterus, though more increafed in weight, begins to afcend, which it continues to do till it emerges out of the pelvis, acquiring fupport from the fuperior and anterior part of the aperture ; in which difpofition and ftate it remains, till the changes previous to labour comes on. In the latter part of pregnancy the vagina muft therefore be elongated, and the effeas of the temporary abbreviation and elongation are readily difcor vered in thofe pregnant women who have a procidentia of the uterus, or a tendency to it, in whom the complaint is aggra- vated in the early, and leffened in the latter part of pregnancy. In the firft pregnancy the uterus rifes almoft directly upwards, becauSe the integuments oS the abdomen Support it Sorwards; and the diftention may be readily perceived on each fide, but com7 monly on one fide more than the other, Srom the pofition of the child. In Subsequent pregnancies the uterus projeas forwards, the integuments generally yielding with greater or left readinefs^ according to the number of" children which a woman hath before had; but it always lies before the vifcera of the abdomen, which are raifed higher, and protruded backwards, in proportion to its afcent and diftention. Through the integuments of the abdomen the uterus may be felt fpringing out of the pelvis, about the fourth month of preg- nancy ; in the fifth about the midway between the pubis and navtl; in the fixth as high as the navel; in the Seventh half- ON CONCEPTION. I 2C way between the navel and fcrobkulus cordis; and in the eighth as high as the fcrobkulus cordis ; in the ninth month it ufually begins to fubfide, fo that, at the time of parturition, the fundus of the uterus is not higher in the abdomen than in the Seventh, if the uterus be in a proper difpofition to aa ; but when that is not the cafe, the fundus will be as high as the fcrobkulus cordis-, even when the woman is in labour. At the time of labour a new principle fuperfedes thoSe of dif- tention and afcent*. This gives a diSpofition to the uterus to ex- clude whatever is contained in its cavity, and the effea produced is in proportion to the energy oS the principle and the power of the uterus. A perSea intelligence of this principle, and of the mode of its operation, would probably be of infinite ufe in prac- tice, as we might be enabled to fupprefs the aaion thereby occa- fioned when premature, moderate it when too violent, ftrengthen it when too feeble, and regulate it in a variety of ways conducive to the welfare of our patients. On the knowledge wc at prefent have of the manner in which this principle operates, and the circumftances by which it is influenced, the affiftance which Science and dexterity can give in caSes oS difficult parturition, very much depends. But this expulSatory power, which takes place at the time of parturition, does not feem to be peculiar to the uterus, but to proceed Srom a general principle diffuSed through the whole bo- dy, which aas in a like manner whenever an offended part makes an extraodinary effort to free itfelf from any offending body ; and the mode of its operation is according to the general laws of the animal economy, as is ufually the degree according to the difficulty. It is in common obfervation, that no violent aaion can be of long duration ; and it might therefore be expeaed; that the efforts made by the uterus, for the purpofe of expelling the child at the time of birth, would be periodical ; and attended with pain, from the diftention and preffure which the refitting parts undergo, as we fhall have occafion to obferve when we Speak oS naturalJabours. It was Said, t^at this expulSatory aaion was not peculiar to the uterus, but a property common to all parts of the body, when the longer continuance of any thing extraneuous was likely to become hurtful. Their efforts on fuch occafions, like thofe of the uterus at the time of labour, are obferved to be periodical, and accom- panied with pain proportionate to the aaion and the fenfibily of * Expultrix uteri facultas infurgit et excitatur. F^ttts ab utero compreffus,propulfatus atque expreffus.—Fabr, ab Aquapendente. 126 INTRODUCTION TO MIDWIFERY. the part. Thus, in the cafe of a ftone in the bladder, what jp called a fit of the" ftone feems 'o be a confequence of an effort made by the bladder to expel the ftone when injured by it ; or When a fmall ftone is paffing through the ureters from the kid- :iic> to the bladder. In the coacervation of the faces in the retlum alfo, when the common aaion of the inteflines is not fufficient for their expulfion, an extraordinary aaion is exched periodically^ v/hich is attended with pain, returning, like the aaion, at inter- vals, and proportioned to it. Perhaps a more appofite illuftration of a labour may be taken from Hones paffing from the gall-blad- der to the inteftine. TheSe may continue inoffenf.ve in the bladder Sor a confiderable time after their formatir. ; but when an effort is made to exclude them, it is always accompanied with pain, periodical in its returns, and excruciating in its degree, from the fenfibility of the parts immediately affeaed or drawn into content. Of the primary caufes of this general property we may juftly be faid to be ignorant, as we are likewife of that of the aaion of the uteri's in particular, except from its effeas. But the im- mediate caufes appear to be different. Firft, there is the genu- ine or original caufe, which produces the aaion of fhe uterus at a proper time, and in a proper manner; Secondly, adventitious caufes operating upon the uterus, and producing that aaion to which it is difpofed, at an improper time, and in an irregular manner; thirdly, fympathetic cauSes, when a disturbance origi- nates in Some part conneaed with or conSenting with the uterus, and is transferred or fpreads to the uterus from the part firft af- feaed. We may Search for the original or genuine caufe of the aaion of the uterus in its ftruaure, form, or qualities, or fome pecu- liar, though inexplicable impreflion made upon it by the child, at the full period of utero-geftation. The manner in which the effeas are produced is much influenced alfo by the circumftan- ces of the conftitution, as its ftrength and difpofition to aa; and it appears, that the blood is of much importance in this ref- pea ; for, in hemorrhages, though there be a difpofition in the uterus to aa, there is no power of aaion; and in other cafes, when there is apparently no want of ftrength, the diSpofition to aa is wanting. The aaion of the uterus is totally independent of the will, and therefore often comes on during fleep, having produced its effea before the patient is awake. But, if the whole frame be disturbed by any violent emotion of ;the mind, the aaion of the uterus may be induced, obftruaed, or Suppreffed. The pro- ON CONCEPTION. 127 jgreft of a labour is therefore often retarded by fuch paffions as depfeft the Spirits; as, on the contrary, it is accelerated by cheer- SulneSs, by feSolution, and a certain preparation of the mind for enduring pain and fatigue. Opinions were formerly much divided with refpea to the ftate of the uterus during pregnancy; but it was generally imagined to become thinner in proportion to its diftention. - Later obser- vations however have proved, that iS healthy, it retains its thick- nefs through the whole period, to whatever degree it may be dif- tended. By this thicknefs, which is the medium of its ftrength, the human uterus is capable of exerting infinitely greater power for the expulfion of its contents, than that of any animal. Had there been a neceffity for an equal degree of force, animals would have failed to perform the office of parturition, becaufe there is not the fame medium, by which that force could have been exerted. As greater proportionate force is therefore requir- ed and exerted in human parturition, than in that of animals, there muft of neceffity be a greater degree of pain, even if we allow them to have an equal degree of fcnfibility. The adventitious caufes of the aaion of the uterus, which are numerous, may arife from the general ftate of the body, as a fever ; or the particular ftate of the uterus, as a difeaSe of the part itfelf; or Some extraneous irritation of the os uteri, between which and the uterus there feems to be a content fimilar to that between the cardia and the ftomach. This was known to the ancients, who occafionally introduced irritating Subftances into the vagina, for the purpofe of facilitating or accelerating the birth of the child. But, with regard to adventitious caufes of every kind, it appears that their effea continues only fo long as they are applied, and the aaion of the uterus produced by them is left perfea, than when it arifes from the genuine caufe. Thus, if the premature aaion of the uterus be brought on by irritation of the os uteri, it proceeds only during the continuance of the irritation, unlefs it be urged till the original caufe of the aaion of the uterus fhould Supervene* Hence the observation was made, that if the os uteri has been untimely dilated by any im- proper management, or any other caufe, it will clofe again, and the woman often go on to her full time, if fhe be kept in a quiet ftate*. The Sympathetic cauSes of the aaion of the uterus may arife from the difturbance of any part, with which the uterus is con- * See Chapman's Treaties on Midwifery, chap. v. cafe i. Vol. I. X 128 INTRODUCTION TO MIDWIFERY. neaed or difpofed to content, as is the cafe with all the contents of the abdomen, efpecially with the lower part of the inteftinal canal and the bladder, as in a tenefmus or ftrangury. On the removal oS theSe, the aaion of the uterus caufed by them will prefently ceaSe ; but iS the difturbance be violent, and oS long continuance, the uterus, though the original cauSe be wanting, may affume that aaion, to which, by its ftruaure, it is diSpoSed, at any period oS pregnancy, and the exclufion oS its contents will of courfe follow. From adventitious and Sympathetic cauSes the aaion of the uterus is often produced prematurely, at the latter part of preg- nancy, and from the want of a juft diftinaion they may be en- couraged, to the great detriment of the patient. In fuch cafes the action of the uterus may continue during the continuance of the caufe, or it may become regular, proceeding after the caufe is removed, or it may ceafe entirely on the removal of the caufe. Of all thefe there are fjequent inftances in practice ; and, feeing there is fuch variety in the caufes of the aaion of the uterus, it is not furprifing, that there fhould be fuch differ- ence in the effea produced, and fo many deviations from the ordinary courfe of labours. All the difficulties attending parturition may be reduced to two kinds ; firit, thofe which arife from the imperfea aaion of the uterus ; Secondly, thofe which are occafioned by the refift- ance made to that aaion when duly exerted. The regulation of, or beft methods of affifting that aaion or power, and the- removal of the impediments to its effeas conftitu|e the chief objeas in the praaice of midwifery. ON CONCEPTION AND PREGNANCY. 120 CHAPTER VII. SECTION I. ON THE SIGNS OF CONCEPTION, AND THE DISEASES OF PREGNANCY. Conception is Succeeded by may important changes in the constitution, and uSually by affeaions of various parts, which, in (he beginning of pregnancy, are efteemed figns that a woman hath conceived. In the more advanced ftate, the Same or fimilar changes and affeaions increafed in degree, together with Some Supervenient ones, have been termed and confidered as the dif- eafes of pregnancy. Yet, in either State, theSe evidently do not depend upon pregnancy as a Specific caufe, being often occafioned by irritation or disturbance of the uterus from other caufes, efpe- cially during the aa of menftruation. Nor do they commence with conception, and continue to the time oS parturition; but are in general moft frequent, and moft troubleSome alSo, Soon after conception, or in fhe early part of pregnancy, gradually abating, and often wholly disappearing, as the patient advances in her pregnancy. The figns oS conception muft therefore be very ambiguous and uncertain; though, from the common oc- currence of the cafe, and the particular attention which is paid, a faculty of discriminating them is acquired? which generally prevents error. It is a popular observation, confirmed by experience, that thoSe women are leSs Subjea to abortion, and ultimately fare better, who have Such Symptoms as generally attend pregnancy, than thofe who are exempt Srom them. The ftate of pregnan- cy is then an altered, but cannot with propriety be called a mor- bid ftate. But if the term difeafe be ufed on this occafion, with the intention of giving a more Intelligible explanation of the tem- porary complaints to which women are then liable, or to denote their irregularity, or an exceffive degree of them, it may be re- tained. With this view the difeafes of pregnancy may be divi- ded into two claffes , in the firft of which will be included all thofe which occur in the early, and in the fecond, thofe in the utter part of pregnancy. The time of quickening may confti* 130 INTRODUCTION TO MIDWIFERY. tute the line of diftinaion between them, and we fhall thus be led to the moft ufeful method of proceeding, that of obferving . the complaints in the order in which they arife. It appears, that every part of a living body has two principles^ or performs two offices ; one of which regards its own diftina preservation and eafe ; the other, by which each part contributes to and partakes of the harmony or diforder of the whole frame. The degree of difpofition and ability to perform thefe offices, and the manner in which they are performed, vary in different parts, and for peculiar purpofes ; but it may be prefumed, that they both potentially exift in every part, though not at all times aau- ally exerted, as in the caSe of convulfions from an injury of fome minute part. When thefe offices are executed in a manner and degree neceffary for, and confiftent with, the common purpoSes of being, they are called natural ; but when they are irregular or exceffive, or are excited on extraordinary occafions, though the cxiftence of the occafion may render them needful or unavoidable, they are not improperly termed violent or morbid. The difpofi- tion to aa is called irritability, and the aaion, when produced, irritation. Irritation is defcribed to be of two kinds. It may be confined to the part in whiqh the caufe exifts, or it may be transferred and extended to fome diftina cr diftant part. The firft is called Simple irritation, and the latter Sympathy or irrita- tion by conSent. Sympathy*, or irritation by.content, has again been diftinguiffied into two kinds, primary or direa, as between the uterus and Stomach; and Secondary cr intermediate, as be- tween the uterus and the brain by the intervention of the ftomach. The modes oS this conSent between diftina and diftant parts have been varioufly explained, and affigned to many different cauSes -f; but with the propriety of the explanations, or the ingenuity of theories, we are riot, on the prefent occafion, concerned. * Diftinguitur irritabilitas 'm primariamfeu diretlum, et fecunda- riamfeu per confenfum.—Gliffon, Traaat, de Ventric. et Inteftin. f JHfuinque adminicula, qui bus, una pars alterius aflfetlumfua natu- rali perceptione eoufque cogncfcat, ut eidem eompatiatur, propoftero. Primum eft immediata continuitas, prafertim fibrarum et tunicarun partium ; fecundum nervorum a communi fiipite derivatio ; tertium, infiuxusper arterias mutatus ; quartum, reduilioper vencs prapedita aut diminuta ; quintum, contatlus vel alia idonea vicinitas, qua una pars in aliam agat—Idem. Gliffon, who was a phyfician to queen Elizabeth, has a right to be efteemed the father of the dotlrine of irritability. He often feems ts ufe the word perceptions/or irritability, and the word irritability fir fympathy, or difpofttion to confent. ON CONCEPTION AND PREGNANCY. I3I The truth of no obfervation in medicine has been more gene- f*lty acknowledged than that of the extreme irritability of the uterus and of the propenfity which the whole body has to be affeaed or difturbed by its influence *. Some parts are neverthelefs more difpofed to this influence than others, fome by direa content, and fome by the interpofition of other parts. Thofe affeaions which occur moft frequently during, or in confequence of pregnancy, it is neceffary that we fhould underftand, that we may be able to form a competent judgment of the fubjea ; and for this purpefe the following account will be fufficient either in the way of illuf- tration or example. Between the uterus and the breafts the content Is fo intimate and conftant, that it is Scarcely poffible Sor them to be affeaed Separately. The enlargement of, and fhooting pains in, the breafts, are therefore not improperly enumerated among the fymptoms of pregnancy ; though they are alfo obferved to occur at the time of the final ceffation oS the menfes, when theSe are caSually obftruaed, and in Some women in a flight degree at each period oS menftruation. The areola, or brown circle round the nipples, has been repre- sented as an indubitable mark of pregnancy. This is not how- ever fufpeaed to be a primary conSequence oS a particular affeaion of the uterus, but of the preceding enlargement and alteration of the breafts : and though, it generally occurs in pregnancy, it may be produced by any caufe capable of giving to the breafts a ftate reSembling that which they are in at the time of pregnancy, of which it can only be efteemed a doubtful fign. The areola, is therefore found in many of the complaints which refemble preg- nancy, and though generally, not univerfally, I think, in pregnant women. Equally or more uncertain, for the fame reafon, is uneafineSs in the region of the uterus, and about the navel, though frequently attendant upon pregnancy ; yet the latter, as far as I know is a fymptom peculiar to' affeaions of the uterus. The navel alfo, according to the progrefs of pregnancy, is conftantly emerging till it comes to an even Surface. There are few difeafes of much importance in any part of the body in which the ftomach is not affeaed; but the content between this and the uterus is peculiarly frequent, and often violent. It is not therefore furprifing, that the ftomach during pregnancy ffiould fo generally be difturbed with naufea, vomiting, heartburn, loft of appetite, and indigeflion ; or that fuch com- * Eft enim uterus pars principalis, qua totum corpus facile in cr-~ fenfum trahit.—Harv. Exercitat. de partu. 132 INTRODUCTION TO MIDWIFERY. plaints fhould, under certain circumftances, have been confidered a? the fymptoms of pregnancy. In confequence of thefe affeaions of the ftomach, and perhaps by direa content with the uterus, any part of the inteftinal canal may be difturbed during pregnancy ; but the particular part may be cafual, and the manner will depend upon fome peculiarity in the conftitution of different women,as the fame caufe may produce very different or contrary effeas. Some women, who are at all other times conftipated, have a diarrhoea at each period of men- ftruation ; and thofe who are at other times fubject to a diarrhteS then become unufually coftive ; and fimilar changes often take place when women are pregnant. The whole habit of the body may be difturbed by a certain ftate of the uterus, and yet no individual part be peculiarly effeaed. Hence, at the time of pregnancy, there frequently occurs a feverifh difpofition, with debility, emaciation, and many fymptoms common to heaic fevers ; by which the countenance becomes altered, the eyes appear larger, the mouth wider, and 2 fharpnefs is given to every feature. In confequence alfo of this general and perpetual irritation, the temper of pregnant women ■ is fometimes rendered left gentle and patient than is confiftent with their ufual charaaer, and this claims compaffion inftead of refentment. The content between the uterus and ftomach feems to be of that kind which has been called primary or direa ; but affec- tions of the brain, heart, and lungs, appear to be Secondary, or by the intervention of the ftomach. Pain and giddineSs of the head, dimnefs of the fight, fleepineft, convulfions, palfy, palpitation of the heart, and peripneumonic complaints, though they fometimes occur during pregnancy, are lets frequent than fuch as are produced by the direa confentof any part with the uterus* There are alfo many inftances of affeaions of the uterus from its content with other parts. A Strangury, or tenefmus, may occafion a fimilar affeaion of the os uteri; and if it were to continue, a premature expulfion of the fcetus. Pain in the- ftomach or bowels, or of any part contiguous to the uterus, or with which it is prone to content, may difturb it ; and, if extremely violent, pr of long continuance, may produce the fame effea. From ihefe it appears, that when an abortion is apprehended, there U not only occafion to attend to and moderate thoSe circum- ftances, which may ariSe Srom original affeaions of the uterus, but thofe alfo, which may be produced in fome other part, and extended to the uterus. From thefe obfervations it will not be inferred, that every com- ON CONCEPTION AND PREGNANCY. *3S plaint, which happens to pregnant women, is to be attributed to uterine irritation. For fome appear to be caufed mechanically by the preffure of the enlarged uterus, and all of them to be ag- gravated by the erea pofition oS the body. The diftinaion which was made will nevertheless be equally proper; Sor, beSore the time of quickening, the complaints are generally owing to an inpreafed irritability of the conftitution, or to the admiffion oS a new cauSe of irritation into the habit, and afterwards to the en- largement of the uterus But, without a very Stria adherence to any general diftinaion, we will recolka, that a Small degree of enlargement oS the uterus, with its conSequent irritability, may become the cauSe of difeaSe in early pregnancy; and that Such a degree of irritability may arife or continue towards the conclufion, as may create fymptoms like thofe, which might be expeaed at the commencement. SECTION II. By the term quickening is underftood the firft SenSation, which the mother has oS the motion of the child, which ffie has con- ceived. This happens at different periods of pregnancy, from the tenth to the twenty-fifth week, but moft commonly about the Sixteenth after conception; yet the motion of the child is in fome women fo obfeure, or fuch little attention is paid to it, that it is not perceived or regarded, and in others fo indiftina as to be confounded with various other fenSations. In caSes thereSore of SuppoSed, but miftaken pregnancy, women oSten fancy that they feel the motion of the child ; or, if the child died in utero, when there is, afterbirth, the fulleft proof that it muft have ceaSed to move for a long time. It is not unufual for women to have a few drops of blood difcharged from the vagina at the time of quickening without any inconvenience; but the fymptoms which attend are gene- rally fuch as are occafioned by furprife or agitation from any other caufe, as fainting, or fome hyfteric affeaion. Thefe being of ffiort duration require no other means of relief than expo- fition to the open air, a glafs of cold water, or Some light cor- dial, and a Short confinement to an horizontal pofition. ^ The changes which follow quickening have been attributed to various caufes. By fome it has been conjeaured, that the child then acquired a new mode of exiftence; or that it was arrived to fuch a fize as to be able to difpenfe with the menftruous blood, before retained in the conftitution of the parent, which it dif- turbed by its quantity or malignity. But it is not now fufpea- *34 INTRODUCTION TO MIDWIFERY ed, that there is any difference between the aboriginal life of the child, and that which it poffeffes at any period of pregnancy* though there may be an alteration in the proofs of its existence^ by the enlargement of its fize, and the acquifition of greater ftrength. It was before obferved, that the notion of fome per- nicious influence from the retained menfes Seem to have been admitted without Soundation. Others have believed, that the changes ought to be affigned merely to the enlargement of the uterus, increafed by the growth of the ovum to fuch a fize, that it was fupported above the brim of the pelvis; by which means all the inconveniencies, which arofe from the dragging or Subsi- dence of the uterus in the vagina, were removed : and this feems to be the true reafon. Becaufe, in morbid enlargements of the uterus, not of a Scirrhous or cancerous nature, there is an abate- ment of the fymptoms, when they become ©f a certain fize; which circumftance has often rendered patients an eafy prey to empirics, who have availed themfelves of the impreffions made by the caSual and temporary relief as the critical moment for impofition. But though this explanation may not be fatisfaaory, the changes are very Important and certain ; for whatever com- plaints women before fuffered, in general, after the time of quickening they decline or are wholly removed. SECTION III A suppression of the menfes is one of the neverfaifing cort* fequences of conception, at leaft I have not met with a Single inftance of any woman continuing to menftruate when ffie was pregnant; though I know, that popular opinion is againft the affertion, and that exceptions to it are frequently mentioned by men of Science. What gratification the human mind is capable of receiving by the aflcaation of Singularities of conftitution, which do not depend upon our will or power, and from which neither reputation nor advantage can be derived, philofophers may determine. But it is well known, that in praaice there is great occafion to be circumSpea ; for, either from the misre- presentation oS patients, cr the credulity or vanity of writers, many medical works are filled with the moft ufelefs and impro- bable hiftories, defeaive in the effential article of all records, truth; and this charge hath been made in the moft pointed terms againft many writers on the fubjea of midwifery*. Some * Plena erroribus fabulifque. RuSch. ON CONCEPTION AND PREGNANCY. 13$ -who have faid' that women might menftruate during pregnancy, have SuppoSed the difcharge to be made from the veffels of the vagina or neighbouring parts ; or they have , confidered every eruption of blood frorh the uterus as menftruous. But if men- ftruation, according to the definition already given, had continued in pregnancy, it is Scarcely poffible, but that abortion muft often have followed, as a part of the ovum would neceflarily have been detached from the uterus at every period; unlets we conclude that, by fome fubfequent procefs, their connexion had been occa- fionally re-eftablifhed. As therefore, in cafes in which preg- nancy can be SuSpeaed, we have, in the Suppreffion oS the menfes, the beft proof of its exiftence, and in their continuance, of the con- trary ; it will be wifer to leave the bufinefs to be determined by time, or to place our confidence in, and to form our judgment by this circumftance, as leaft liable to error ; rather than to involve ourfelves in doubt, by Searching after equivocal appearances, which deferring this circumftance, cannot lead to any fatisSac- tory contlufion. But though it may be laid down as a general principle, that, when women continue to menftruate they are not pregnant, it will not Sollow, that in every caSe of the fuppref- fion of the menfes women are certainly pregnant, though preg- nancy is always to be SuSpeaed ; as I have known many inftances of young married women who have ceafed to menftruate for feve** ral months, independently oS any diSeaSe, when they were not with child. SECTION IV. All the complaints attending pregnancy, and perhaps the ftate ttf pregnancy, h accompanied with a febrile- difpofition or increafe bf heat, which, when duly regulated, is probably intended to anfwer fome important purpofe to the child. This Seems to be proved by the blood of pregnant Women, which independently Of difeafe; is always found to have what is called a fizy appear- ance, though Of a peculiar kind, and evidently very different from that which is obferved in cafes of inflammation, and which rnav be confidered as a confequence of fome new and Specific action. But it any inflammatory diSeaSe Should occur in preg- nancy, then the blood loSes its pregnant appearance, as it may be termed, and affumes that of the difeafe. An extreme degree of thofe fymptoms which appertain to pregnancy may alfo pro- duce the inflammatory appearance of the blood. From this ftate of the biood, and from the relief which bleeding almoft univer- Vol. I. Y- I'<<5 INTRODUCTION TO MIDWIFERY tally affords in the urgent complaints of pregnant women, even in conftitutions which at other times do not well bear that evacu- ation, occafion hath been taken, to attribute all the confequences of pregnancy to a plethora, of which the retained menfes were thought to be the caufe. But if it be true, that pregnant women have fuch feverifh difpofition, we have no reafon to be Solicitous about the inveftigation of the caufe, as, by bleeding at proper times, and in quantities fuited to the conftitution and indications, both the effeas ot uterine irritation and plethora are generally leffened or removed. Particular kinds of diet are found to add to this difpofition to inflammation, and to increafe irritabitity. Of thefe the princi- pal is animal food, though it is ufually recommended, together with liquids of a cordial and nutritive quality, to women when pregnant, on the prefumption that they are then in greater need of fuch fupport than at any other time. To fome conftitutions, and under particular circumftances, thefe may be neceffary ; but if it be justifiable to draw inSerences Srom the appetites of preg- nant women, or if we may judge from the common confequences of fuch diet, we fhall foon he convinced, that it is improper ; for they have generally a diflike to animal food of every kind, and under every form ; and if prevailed upon to eat it incautioufly, are fenfible of much inconvenience. On the contrary, they ufu- ally prefer vegetables, fruit, and every thing cooling, which they eat and drink with avidity, and in which they indulge without prejudice. SECTION V. Pregnant women are not only encouraged to live more luxu- rioufly, but more indolently alfo, exercife being thought impro- per, unlets towards the conclufion of pregnancy, when it has been fuppofed to procure a more favourable delivery. Great care may in fome cafes be neceffary, but in general the contrary method of proceeding is the moft eligible and proper : for the lower clafs of women, who are by neceffity obliged to follow labourious occupations in the open air, and who are expofed to all the viciffitudes of the weather, not only pafs the time of their pregnancy with fewer complaints than the affluent, but have alfo more eafy labours. Much allowance muft be made to former habits of living ; but thofe who are in poffeffion of all the advan- tages of rank and fortune, which the eyes of inferiors are apt to look at with envy, muft ufe them with the moft cautious moder- ation, or they will Suffer for every unreasonable indulgence. By ON CONCEPTION AND PREGNANCY. 137 every kind of habitual irregularity the conftitution becomes loaded, or the aaivity of its powers leffened or perverted, and a difpofition to difeafe is often given, or all fenfe of natural enjoyment is loft. We have been accuflomed to confider parturition as a diftinct aa of the conftitution, unconneaed with any which precedes or follows ; but there would be more utility in confidering it as a part only of a procefs, which begins with conception, and termi- nates with childbed, or even with laaation. We fhould then preSume, that Such as the ftate of the body is at the time of conception, fuch will it probably be during pregnancy ; and, according to the ftate in pregnancy, will be that at the time of parturition ; and on this again will depend the recovery from childbed, unlets there be Some peculiar imperfeaion in the conftitution, or Some difeafe not dependent upon that ftate Should Supervene. On the due and regular exerciSe of all the funaions and powers of the body, their difpofition and ability to aa, ac- cording to their original frame, muft ultimately depend; and fuch as is their general condition at the time of labour, fuch will be that of the uterus, and of all the parts concerned in parturition. But if there has been indulgence in improper habits, or if exercife has been negleaed at all other times, there is little caufe to expea advantage from unfit and extraordinary efforts towards the con- clufion oS pregnancy ; as no other end can then be anlv/ered by Such condua, but that of difturbing the frame, and bringing on premature labour. In quadrupeds, which apparently Suffer little other inconvenience when they are with young, than that which arifes from mere increafe of bulk, their common purfuits arc negleaed, the gregarious difpofition is fufpended, and, if left to their own inclinations, they gradually leffen the exercife they ufe as they advance in pregnancy. SECTION VI. Vomiting is one of the moft frequent complaints to which women are liable in the early part of pregnancy, and it fome- times continues to, or returns towards, the conclufion. If it fhould not be violent, and occur only in the early part of the day, though very troubleSome, it is fo far from being detrimental, that it is generally found to be Serviceable, by exciting a more vigorous aaion of the uterus, and by bringing the ftomach into a better ftate. For the vomiting oS pregnant women is not always a mere effort of Straining, or a diScharge of the food and common humours of the ftomach, The matter evacuated fometimes *3« INTRODUCTION TO MIDWIFERY. (hews a very much difturbed, or a morbid Secretion of Such a kind as to be offenfive to the ftomach itfelf; and befides correa. ing or evacuating the offending humours, it is neceffary that we ufe our endeavours to change, or to appeafe the prefent aaion; before the indication to vomit be fuppreffed. In plethoric habits the aa of vOmiting may render bleeding neceffary, though the difeafe 'or ftate of which it is a fymptom might not require this evacuation.' 'For that reafon, and becaufe it leffens the irritability of the habit, bleeding will be neceffary in fome cafes of inceflarit vomiting, though in others it may not be either reqnifite or proper. ' But medicines of any kind are not wanted to reftrain the vomiting, except it fhould be extreme, fo that the ftrength of the patient is reduced, or other untoward confequences follow. Then the common means ufed for the re- lief of this fymptom in other cafes may be Safely and properly advifed for pregnant women; as the Saline draughts in the ftate of effervefcence, or mixed with fome abforbcnt earth, in the man- ner of the mifiura corallata of Fuller-, or magnefia in fimple pep- permint-water ; or the Seltzer water, whilft it effervefces with a mixture of lemon juice and fugar; or the acid elixr of vitriol in cold water; or fmall quantities of Colombo root; or chamomile flowers, joined with fome;aromatic, in fubftance or infufion. Mo- derate cordials are Sometimes required ; and of thefe the moft grateful is the confetlio alkermes, in fimple mint or cinnamon water.' Many other medicines of the fame kind may be direaed, in fuch forms as are found to be moft acceptable to the patient. ' In caSes of exceffive vomiting opiates are generally given, and often with great advantage. Perhaps no well groundecLobjeaion can be made to the occafional ufe of opiates, when violent pain, or any other urgent fymptom demands them."-' But I have per- fuaded myfelf that their habitual or very frequent ufe is preju- dicial to the foetus, either by debarring it from a proper Supply of nouriffiment, or by depraving that with which it is aaually fupplied; but of this opinion I begin to have fome doubt. The i Same observation hath been Srequently made on Spirituous liquors, and probably the effea oS both may be explained upon the Same principle. Local applications of various kinds have been recommended, to abate exceffive vomiting ; and content is readily given to their uSe, though without the expeaation of great advantage, becaufe no harm is apprehended from them. But a phyfician of great experience and ftria veracity informed me, that he had in thefe eafes, Seen the application of a piece oS folded cloth, moiftened ON CONCEPTION AND PREGNANCY. 139 with tinBura opii, to the region of the ftomach do much Service, when internal medicines of the higheft eftimation had proved ineffeaual. It is a general obfervation that the vomiting of pregnant wo- men is mofl frequent and importunate in the morning ; and the circumftance evidently depends on the change of pofition, which then takes place, and not the peculiar time. When the pofition is horizontal, the patient may not have the leaft fenfe of uneafi- nefs or disturbance qf the ftomach; but the moment fhe rifes from her bed, thefe come on, and continue till ffie again reclines, unlefs ffie is careful to bring the body erea by riling flowly. Confinement to an horizontal pofition is thereSore found both ne- ceffary and ufeful, not only when the ftomach is violently difturb- ed in confequence of pregnancy, but from many other caufes. When there is a naufea or inclination to vomit without any evacuation, a gentle emetic is the beft remedy: and this may be repeated, whenever the urgency of any fymptom requires it; ex- perience having fully proved, that emetics may be given to preg- nant women with perfea Safety. SECTION VII. Indigestion, and depravity, or lofs oS appetite, proceed from the fame caufe as the foregoing complaint, of which they are only different modifications; and the treatment commonly enjoined £cr their relief will be Suitable for pregnant women. Of that depravity of the appetite, which in pregnancy has ufually gone under the name of longing, the inftances recorded in books, and formerly reported in 'converfation, are incredible, and too abfurd to deferve, or, at leaft, at this time, to require a Serious refutation. Longing was not fuppofed to depend upon the fancy or other cir- cumftances of the mother', but to be a peculiarity in her appe- tite, produced by the influence of fome caufe exifting in the child. Nor was it fuppofed, that the effea was confined to the fimple refufal or gratification of the appetite, however extrava- gant it was, or however unnatural it might appear ; the longing of pregnant women was to be indulged, not merely through kindneft to the parent, but for the intereft oS the foetus alSo. If her wiffies and inclinations were not gratified, She might Suffer; but the worft confequences were to be apprehended on account of the child, which would either be retarded in its progrefs, or bear the mark of the thing longed for on fome part of its body ; as if there was a connexion between'the two beings incompre- hensible by us, and infinitely more exalted than is obServed under J 40 INTRODUCTION TO MIDWIFERY. any other circumftances. Nor was the obfervation of fimilar accidents in animals, or even in plants, confidered as a valid- ar- gument againft this extravagant opinion. In times and countries barely civilized, can we fufpea, that it was thought neceffary to adopt and to fupport the opinion of the power of the imagination, in order to Secure to pregnant women that indulgence and tendernefs of treatment, which their fituation was fuppofed to require ? Or does there really exift any myfte* rious content between the parent and the foetus in uterio in the human fpecies? I believe, that the opinion originated in the for- mer caufe; but that in the courfe of time, and by the habit of thinking and aaing in a certain manner, a general conviaion did take place, that fome content of an inexplicable and perhaps of a divine nature, not to be defined or illuftrated, really exifted. An opinion, which might have been ufeful and neceffary at the time when it was firft adopted, continued when there was no longer occafion Sor it, and became a Source of real disadvan- tage. For the minds of women were frequently difturbed, and themfelves rendered miferable, by the dread of an effea, the caufe of which was wholly imaginary ; fometimes alfo finifter purpoSes were intended to be anSwered by the pretence. It then became neceffary to examine the opinion, and it was proved to be groundleSs. In the early part oS my own HSe nothing was more common, than to hear an inundation of examples of the dreadful events which were caufed by difappointed longing', or to fee inftances of the great confufion and diftreft in families, from a perfuafion of its importance. But at the prefent time, and in this country, the term longing is Seldom mentioned, except among the loweft claSs oS people ; though the cauSe, iS any had exifted, muft have produced its effea at all times, and in all fituations. Something is, however, to be granted to longing, confidered as an appetite depending upon the constitution, of a certain ftate of which it may be efteemed an indication. IS we believe the doc- trine, that diSeaSes and tendencies to them were produced by an excels of acid or alkalefcent humours, we might readily under- stand, why one pregnant woman preters the moft Savoury and high-SeaSoned Sood, and another acid Sruits and cold water; and why they might both be indulged, not only without prejudice, but with advantage, as has been frequently obferved, as well as in the delirium of fevers from a fimilar caufe. The appetite, unfophifticated by bad habits, will probably never miflead us as to the quality of our food. It may rather be efteemed a guide implanted in us by nature, which we fhall never err in following, if we z€t with discretion as to the quantity. ON CONCEPTION AND PREGNANCY. 14* SECTION VIII. The heart-burn is a painful fenfe of heat in the throat and fauces, with fudden gurgitations of thin, four or acrid Saliva in the mouth. In Some caSes it Seems to be a mere SenSation arifing from the confent between the ftomach and uterus ; and in others to be caufed by an accumulation of ffiarp humours, Secreted in the ftomach by its wrong aaion. There is often reafon to think that it is occafioned by food, which is fait and high-feafoned, or otherwife hard of digeftion, and by fermented liquors ; and per- haps by fleeping in an erea pofition after a full meal. The medi- cines ufually direaed for this complaint are given with the inten- tion of abating or removing the SenSation, oS altering the proper- ties of the fluid colleaed in the ftomach, or of evacuating them. Thefe generally confift of the various kinds of abforbent earth, as the taftaceous powders,or magnefia, alone, or mixed with rhubarb; or lime-water, or Small dozes of faline medicines, of which perhaps the beft is the aqua kali, to the quantity ot twenty drops in a large glaSs oS cold water. But my highly reSpeaed Sriend Dr. John Sims has publifhed the following, as a Sorm of medi- cine which feldom fails to give immediate relief ; and many trials have convinced me that his opinion of the efficacy of this medicine is juft. R Magnef. uft. Aq. Ammon. pur. a 5j. -----Cinnamon. 5iij. -----Purae §yft. M. Sumat cochlearia ij vel iij ampla, ftepius in die, urgente cardialgia. When the complaint is violent, a gentle emetic is the moft effeaual remedy ; and, ffiould the difpofition to it originate in the debility of the powers of digeftion, fuch means are to be ufed, and Such medicines given, as promiSe to reftore and invigorate them. SECTION IX. Costiveness is another troubleSome complaint, to which preg- nant women are liable. It is oSten hurtful in its preSent elf ecu, and Sometimes in its conSequences, being not uncommonly the caufe of head-ach, fever, tenefmus, pain in the bowels, and abor- 142 INTRODUCTION TO MIDWIFERY. tion. Care muft therefore be taken to obviate coftivenefs by the conftant or occafional ufe of manna, magnefia, Senna, eleauary of fenna or of caffia, oleum ricini, Soluble tartar, Jeffop's-well water, and the like medicines. But I was formerly much more affiduous in preventing coftivenefs than I am at the prefent time, having obferved, that all women who go on properly, In the early part of pregnancy, are liable to this ftate of the bowels, which may have fome relation to the ftrong aaion of the uterus at that time. Coftivenefs may therefore be confidered as a ftate of the bowels corresponding with that of the uterus ; and we can never believe that to be injurious, which occurs fo frequently as to be efteemed a common confequence. The more gentle the means uSed fbr the removal of coftive- nefs, the more eligible they are, provided they anfwer the inten- tion. Aloetic medicines are forbidden during pregnancy, left they ffiould do miSchief by their SuppoSed deobftruent qualities : but they are in common uSe among the lower claSs of people, becaufe they are cheap, and conveniently given in the form of pills, and I have not obferved any bad effeas from them. The ftomach of pregnant women is often in fuch a ftate, that no in- ternal medicines can be retained, and we are obliged to have re- eourSe to clyfters, which are generally efficacious, and always SaSe. It is remarkable, that Small doSes oS the fitl cathartkus amarus, diffolved in plain water, or fimple mint-water, or in com'- mon emulfion, will oSten be kept upon the Stomach, when things leSs obnoxious to the tafle are immediately rejeaed. SECTION X. By long-continued coftivenefs the faces are fometimes colleaed ia fo large a quantity, and by long confinement in the retlum and lower part of the colon become jndurated to fuch a degree, that they cannot be voided by the common aaion of the inteftines; and the medicines ufually given, and the means ufed to procure ftools, prove insufficient for the purpofe. This complaint is not peculiar to women when pregnant, being found to occur in- difcriminately in either fex, if compelled by difeaSe or accident to remain for a long time in an horizontal pofition ; and it is not unSrequent in children, or even in animals. It has often beep mentioned by medical writers, though no proper name has been given to it. It is vulgarly called the ball-fiool. There is reafon to believe, that this complaint has often been overlooked in praaice; for though the column of indurated^-?.' ON CONCEPTION AND PREGNANCY. 143 Is fometimes enormous, a fmall quantity in a liquid ftate, efcaping between the column of hardened faces and the fide of the intef- tine, may be daily difcharged; So that no SuSpicion of the real nature oS this cafe may be entertained, unlefs the ftools be in- Speaed, or the patient be examined per anum. When it has continued Sor a certain time, and the common efforts oS the inteftines, though repeatedly excited, are not equal to the expulfion of the faces, their extraordinary aaion is raifed, which is attended with pain, periodical in its returns, and violent in its degree. This aaion continues till the difficulty is over- Come, or, by the effea of the long and fruitlefs aaion, the parts adjoining to the anus, and perhaps the internal parts, become in- flamed ; and, if proper and timely means were not ufed to pre- vent the mifchief, this complaint has fometimes proved fatal by bringing on a Sphacelation of the parts. Purgative medicines rather increafe this complaint, by impell- ing a great quantity of faces into the lower part of the inteftinal canal, when they cannot be difcharged. Suppofitories and clyf- ters, at leaft in the way in which they are commonly adminis- tered, cannot be received on account of the greatneft of the ob- ftruaion, to the removal ot which they are not equal. Effec- tual relief is only to be obtained by dividing the indurated faces into Smaller pieces, by manual affiftance, or by Some convenient inftrument conduaed into the anus, and uSed with circuniSpec- tion, and then by wafhing them away with repeated clyfters. In women there is left difficulty in the management of thefe cafes, becaufe the column of faces may riot only be broken by the finger paSSed into the vagina, but their exclufion very much affifted. SECTION XI. Perhaps women are by conftitution, and by the Sedentary lives they lead, more Subjea to the hemorrhoids than men. They ..re generally efteemed as indications ot too great SulneSs oS the habit, or as critical depofitions of fomething noxious, had it re- mained in the conftitution: they are alfo an ordinary confequence of long-continued coftivenefs, and, during pregnancy, they may be caufed or increafed by the derivation of a greater quantity of blood to the parts, or by the preffure made upon the veffels by the rnlarged uterus. When this complaint is in a moderate degree, the patient is foon relieved by gently purgative and diuretic medi- r'mes % and thofe compofed of Sulphur are, in this caSe, ufually nr ic-rredj though feme phyficians have SuSpeaed their propriety. V,.]. I. Z 144 INTRODUCTION TO MIDWIFERY. Cooling applications are alfo advifed, and of thefe the belt is a weak Solution oS the ceruffa acetata Srequently renewed. Should the patient be feverifh, or the hemorrhoids much tume- fied and painSul, bleeding, in quantities Suited to the conftitu- tion and the exigence oS the caSe, is neceffary; or one or more leeches may be applied to thoSe which arc moft prominent, if they do not difcharge Spontaneoufly. Emollient fomentations and cataplafms are Sometimes proper. In general, unaucus ap- plications do not agree; but ointment of elder flowers, mixed with an equal quantity of brown fugar, or a fmall quantity of fome lixivial Salt, is thought, in Some caSes, to have done much Service. When the hemorrhoids arc very numerous, and tume- fied even to Strangulation, immediate relieS may be obtained by firm and gentle preffure, between the finger and thumb, of each diftina hemorrhoid, till they are all compreffed, and reducible within the anus, fcarce any tumour remaining but the external covering. SECTION XII. t The Skin of women with child is often difcoloured in fpots or blotches, efpecially about the neck and face, which, though dif- agreeable to thofe who are Solicitous about fuch matters, is not otherwife important. Women have fometimes alfo a true jaun- dice, and, whether we attempt to remove the obftruaion to the due fecretion of the bile, by emetics, purgatives, or deobftruents, as they are called, there appears to be no reafon why pregnant women fhould not bear their operation, when they are neceffary. Men of discretion will readily See the impropriety of giving a medicine, the operation of which might be more dangerous than the difeafe, which it is intended to cure ; and the neceffity of ac- commodating its quantity to the ftate of the patient, as well as its quality to the difeaSe. SECTION XIII. Women with child are chiefly fubjea to thofe complaints of the interlines, which may be fuppofed to arife from their inert aaion ; but they are fometimes liable to thofe, which are occa- fioned by too much irritability. Yet the latter are far left fre- quent than the former, though a tenefmus, a diarrhoea, or dyf- enteric complaints, may happen at any period of utero-geftation. When thefe affeaions of the bowels are of fufficient confc- -ON CONCEPTION AND PREGNANCY. *4$ auence, to require medical attendance, the common mode of treatment is equally efficacious and confiftent with the fafety of a pregnaat woman, as under any other circumftances. When there is a feverifh difpofition, bleeding is proper; and when there are figns of difturbance in the ftomach, from offenfive humours, or preceding crapulous complaints, gentle emetics may be given, and the repetitions, if neceffary, may be unlimited. If there be much pain in the bowels, or frequent efforts to go to Stool, with little or infufficicnt evacuations, purgative medicines, of which perhaps the beft is the* imgnefia vitriolata alone, or joined with rhubarb, ought to be given, and occafionaUy repeated, according to the continuance of the pain, in any ftage of the difeaSe. Should the complaint remain after the evacuations, opiates are proper, mixed with fome mild aftringent medicines, as the miftura creta- cea with tintlura dnnamoni. In fome cafes ipecacuanha^ in imall dofes, not exceeding a grain, or even half a grain, mixed with fome abforbent powder or two or three grains of rhubarb, and given every fix hours, anfwers the purpofe of quieting the dil- turbance of the bowels, without procuring any evacuation. 1 he free and frequent ufe of opiates is in many of thefe cafes indiSpen- fable Clyfters, compoted of a decoaion of hnfeed, or of flower and water boiled to the confiftency of thin ftarch, or of mutton broth, are both comfortable and ufeful; and to any of thefe a few drops of the tinBura ofii may be occafionally added. Tenefmus, and alfo diarrhoea, are common attendants on abor- tions, of which they arc juftly efteemed to be fometimes the caufe. In thefe cafes it appears, that the exiftence of the irritation in the reBum is unfavourable to the proper aaion of the uterus, and may direaiy, or by content, become the caufe of abortion. Eme- tics, by relieving the prefent inconvenience, and by changing the feat of the irritation, will often prevent any il confequences, but the greateft reliance in fuch cafes is to be placed on opium, »: any of the ufual forms, efpecially in clyfters. SECTION XIV. The ftrangury, which is a frequent inclination to void the urine, and a painful difcharge of it in fmall quantities, is not an unufual complaint in pregnancy, in the early periods of which UTeems to be occafioned by the content between the uterus_and bladder ; but, towards the conclufion, by the mere preffure of the * See Cleghorn's Treatife on the Difeafes of the Ifland of Minorca. 146 INTRODUCTION TO MIDWIFERY. enlarged uterus. It is fometimes caufed alfo by the restraint, which women impofe upon themfelves, from motives of delicacy, when they are engaged in company. Under any of thefe cir- cumftances it always produces much inconvenience, and may terminate In a Suppreffion of urine, which, when the uterus is of a. certain fize, that is, about the third month of pregnancy, be- comes the caufe of its retroverfion. For the relief of the Strangury, it is in Some caSes neceffary to bleed, and in all to procure ftools by clyfters, or very gentle ape- rient medicines.' A Small quantity of oil of almonds, with man- na, in the common emulfion, and the addition oS a few grains of nitre, is a commodious and often an effeaual remedy. The com- mon emulfion with thefpiritus atheris nitrofi, or barley-water with gum arabic, may be drank at pleaSure; opiates are alSo Srequently neceffary. In a Suppreffion of urine the catheter muft be intro- duced; and of the retroverfion of the uterus we have already fpoken very fully. At the latter part of utero-geftation it is not uncommon for wo- men to have an incontinence of urine, not perpetually, but occa- fionally, when they ftand upright, or make any Sudden though flight motion, eSpecially iS they have a troubleSome cough. As far as either the Strangury or incontinence Of urine depend upon the preffure of the enlarged uterus, it will only be in our powef to alleviate them^ for the caufe muft remain till the time of deli- Very ; and the peculiarity of the complaints may be owing to the compreffion being cafua'lly made either upon the neck or fundus of the bladder. It is Some comfort to women to be informed, and I believe the obfervation is generally true, that affeaions 01 this kind are never produced, except in thofe cafes, in which the prefentation of the child is natural. SECTION XV. Thu fiuor albus was before mentioned as a complaint, to which women were at all times liable ; but in pregnancy the difchargC is Sometimes exceeding proSuSe, and has very much the appear- ance, as iS it was cauSed by, or accompanied with inflammation." It may then be occafioned by Some extraordinary SulneSs of the parts adjoining to the uterus, or by more than ufual irritation. It does not appear that any bad confequences, either to the mother Or child, follow this complaint, or that it requires any peculiar treatment. Perhaps, by the relaxation of thofe parts, which are to be dilated at the time of parturition, they may then make ON CONCEPTION AND PREGNANCY. 147 left refiftance; at leaft it is commonly obServed, that women who Suffer much from this Sympto'm during pregnancy have eaSy la- bours. It is alfo proper to obServe, that, in women who with a poSuSe diScharge are Subjea to miScarriages, an injeaion of the Kineum vitriolatum two or three times a day, into the vagina has great power in preventing them. I. SECTION XVI. No complaint happens more frequent to pregnant women than pain in the hips, with numbnefs of the inferior extremities. This feems to be occafioned by the outward preffure made by the en- larged uterus upon the iSchiatic nerves, and thoSe which paSs through the perforations on the anterior part oS the facrum. As It is found to be increafed in certain pofitions of the body, efpeci- ally when the patient is accuftomed to fleep on one fide, a change of the pofition generally affords temporary relief. At all events it is not in itfelf of fufficient importance, to require any medical affiftance, and is entirely removed foon after delivery. Erratic pains in various parts, efpecially about the face, ears, and teeth, fo often occur in pregnancy, as to be thought certain indications of that ftate. They are evidently occafioned by ute- rine irritation ; and, although they will fometimes be eafed by ather, by Solutions oS opium, or other Such local applications, or by blifters applied behid the ears, yet thete commonly afford only temporary relieS, and in Some inftances they aggravate the pain. The Same observation may be made oS the cramp, whatever part oS the body it may affea. This is a very pertinacious Symptom, and exceedingly troubleSome, eSpeoialiy in the night; but, being void of danger, has too little attention paid to it. In either of thefe cafes, real benefit is to be obtained only by bleeding, and the ufe of fuch means as abate irritation in general, or that of the uterus in particular, fuch as fmall dofes of tintl. opii, of the fyrup. papaver. alb. or the infpiffated juice of ckuta. SECTION XVII. The veins of the legs, thighs, and abdomen, frequently become yaricous in the latter part of pregnancy, to fuch a degree, in fome inftances, as to exhibit a flrangely tortuous, antl a very alarming appearance. Varices, which are both elongations and enlarge- ments of the veins, may be reafonably Suppofed to proceed Srom ?43 INTRODUCTION TO MIDWIFERY. the preffure of the uterus preventing the reflux of the blood \vf the veins; and perhaps they may often be efteemed as confe* quences of the general fulneft of the habit. They arc ufualfy accompanied with the cramp ; but which of thefe is the caufe o» effea has been much difputed. No detriment has been obServed to follow this very painful and. troubleSome complaint; but if 4ny thing is required to be done, it fhould be with the intention of emptying the vafcular fyftem, as moderate bleeding, gentle purging, and a fpare diet, in fome cafes it may be judged necef- fary to give fupport, by moderately tight bandage, to the veins of any part which are particularly diftended ; or fometimes to tie the vein above and below the tortuous part, but the time of preg. nancy is not the moft eligible for this operation. SECTION XVIII. Inquietude and want of fleep are very troublefome com* plaints towards the conclufion of pregnancy. They are alfo fret quently attended with flight pains in the region of the uterus, hardly to be diftinguiffied from the pains of labour, and other fe- verifh fymptoms. Thefe are moft grievous in the night, the pa- tient being reftleft, in fpite of a Strong diSpofition to fleep, and obliged to riSe frequently, and expofe herfelf to the influence of the cool air; yet, I know not for what reafon, after a Short repofe at the dawn of day fhe appears as much refrefhedj as after the moft quiet night. Perhaps the confinement of the air of the room, and the heat of the bed, may be the immediate caufes of thefe complaints j but I have generally confidered them as arifing from the conftant and ftrenuous demands for nouriffiment made by the child upon the conftitution of the parent: for it is remarkable, that thofe women, who fuffer moft on this account, though reduced in ap- pearance, bring forth lufty children, and have eafy labours. But if the mother has little uneafineft and grows corpulent during pregnancy, the child is generally fmall; and, if the child fhould die before the time of parturition, the inquietude entirely ceafes. In the firft cafe the abforbing powers of the child feem too ftrong for the parent; but in the latter the retaining powers of the pa- rent are Stronger than the abforbing ones of the child, fo that on the whole it appears natural, that women ffiould become thinner when they are pregnant. Nothing affords more effeaual relief to patients troubled with this inquietude than breeding in fmall quantities, with the occa- ON CONCEPTION AND PREGNANCY. »4J fional uSe of cooling and laxative medicines. Hoffmanns ano- dyne liquor, to the quantity oS thirty or forty drops, given in fome common emulfion, or in cold water, every night at bed-time, has been found ufeSul. Preparations of opium have little effe&, unlets they are given in large quantities and often repeated ; but a perfuafion that theSe are ultimately injurious to the foetus, or to the parent, has long deterred me from ufing them on thefe occa- sions. A glafs of cold water drunk at bed-time is not a con- temptible remedy ; or a towel dipped in cold water and wrap- ped round the hand, with one corner hanging over the edge of the bed, has many times been Serviceable in procuring fleep, by tentning the general heat of the body as a conduaor. SECTION XIX. Very few women, even thofe who are on other occafions pa- tient and refolute, pafs through the time of utero-geftation with- out ufing expreffions, which indicate fome degree of apprehen- fion for their fafety. This folicitude may proceed from the mere dread of what they expea to Suffer at the time of labour; or from reports inadvertently made of untoward accidents, which have happened to fome of their friends or acquaintance, who were in the fame predicament with themfelves. It is fufficient, in the firft inftance, to contrive amuSements for them, or to inSpire them with confidence, by pointing out the fortunate event of the generality of thefe cafes, and to impreft them with favourable Sentiments of the fkill and good fortune of the perfon, who is appointed to attend them. Sometimes, how- ever, this apprehenfion of danger arifes from another Source, and is caufed by uneaSy SenSations, which they feel, but cannot well defcribe. Then it is really a fymptom of difeaSe, and may be ranked with the terror, which attends the commencement of fome dangerous difeafes, of which it is one of the worft indications. Inftead of confidering it as an hyfteric affection not worthy of regard, we Shall find, on inquiry, that the patient has Some degree of fever ; as increafed heat, a white tongue and a quick pulfe, and frequently a fixed pain in fome part of the abdomen', or pe- ripneumonic fymptoms; or fome marks of local or general dis- turbance in the habit, though not in a degree fufficient to de- note any particular difeafe. By bleeding in fmall quantities, by cooling or appropriate medicines, by repofe and a well-regu- htod diet, both the lenfation and the apprehenfion may be remov- ed before the time of delivery, and a happy recovery from child- »5* INTRODUCTION to midwifery. bed enfued. If, however, the complaint be not property confi- dered, but flighted or ridiculed merely as lownefs of fpirits, the event may prove unfavourable; and on the recolleaion of the circumftances there may be room to lament that it was mif- conftrued or disregarded. SECTION XX. The funaions of the brain are often difturbed in the time of pregnancy, by which head-achs, drowfineSs, and vertiginous com- plaints, are occafioned; and Sometimes pregnant women have a true hemiplegia, as well as many other nervous Symptoms. TheSe have uSually been aScribed to a SullneSs of blood in the veffels of the brain, caufed by an obftruaion to its detcent into the infe- rior extremities, by the compreffion of the enlarged uterus. But thefe do not more commonly happen to thofe women, who are of full habits of body, than to thofe who are of different confti- tutions, and iS that was the cauSe, the effea muft be pretty gene- rally produced when women have arrived to a certain time of pregnancy. The palfy is always preceded by fuch fymptoms as indicate an uncommon degree of uterine irritation, on which it is reafonable to confider it may depend ; more especially as, though relieved, it is never cured during pregnancy, and Scarcely ever fails to leave the patient perfeaiy free foon after delivery, as has been proved in a variety of cafes. The blood of thofe women who become paralytic whilft they are pregnant, is always found to have the fame appearance as in the moft inflammatory diSeaSes ; and the other Symptoms indi- cate the like diSpofition. It is not thereSore Surprising, that heat- ing and Stimulating medicines are obServed to increaSe the com- plaint ; or that it ffiould be relieved by bleeding, by gentle purg- ing, by a cooling rsgimen, and by Such means as abate uterine irritation; not regarding the palSy as an idiopathic diSeaSe, but as a Symptom occafioned by pregnancy. SECTION XXI. It was before obfjrved, that anaSarcous Swellings of the infe- rior extemities often occurred in pregnancy, and that thofe fome- times extended to the groins and fides of the abdomen, and in fome cafes to the external parts of generation, which become ex- tremely painful, and tumefied to fuch a degree, that the patient OH CONCEPTION AND PREGNANCY. -I CI is unable to walk without much inconvenience. They appear to be occafioned in fome inftances by too much, and in others by too little exerciSe ; but more Srequently by the preffure made by the uterus upon thoSe lymphatic veffels, which are intended to drain the fluids from the inferior extremities. They have fome- times been unjuftly fuppofed to indicate fuch a general hydropic tendency as might deter us from bleeding the patient, even in cir- cumftances which would otherwife demand it. But in many of thofe abdominal complaints, which occur in pregnancy, it has been obferved, that the patient was fenfible of much relief when the legs begin to fwell; fo that in fome cafes this fwelling may be efteemed as a critical depofition upon the inferior extremities of fomething fuperfluous or injurious to the conftitution. Of the particular treatment which this complaint may require we have before fpoken. SECTION XXII. There have been a few inftances of women with child who have had a true afcites ; and thofe who have an afcites fometimes become pregnant. Some cafes are recorded, and many reported, in which the mode of treatment enjoined has been founded on an erroneous opinion of thefe two fituations; that is, of a dropfy being miftaken for pregnancy, and pregnancy for a dropfy. The former is not produaive of mitchieS in any other way, than by delaying the uSe oS Such means as might be confidered likely to cure the diSeaSe if adminiftered in its early ftate. But the con- fequences of the fecond error have been deplorable. For, if any aaive remedies are ufed on the prefumption of a dropfy, the child will of neceffity be often deftroyed, and an abortion or prema- ture labour occafioned; and when the operation ofthe poracentefis has been performed, it hath been known to prove fatal to the mother and child, and it always refleas great difcredit both upon the operator and profeffion. It, therefore, feems neceffary, to eftablifh this general rule, that no woman, at a time of life, or under circumftances which, in the moft diftant manner, fubjea her to a fufpicion of pregnancy, ffiould ever be tapped, or other- wife treated for a dropfy, till by examination per vaginam, or by waiting a due time, we are convinced that ffie is not pregnant; even though fhe may have before undergone the operation. It has been faid, but whether upon fufficient authority I know not, that a dropfy has fometimes t)een cured by pregnancy or par- turition. Vol. I. A a IJ 2 INTRODUCTION TO MIDWIFERY. SECTION XXIII. The manner in which the abdomen is diftended, with the degree ©f its diftention at different periods of pregnancy, has already been defcribed. This generally appears to be uniform, though ©ften on one fide more than the other ; and fometimes there are partial diftentionsi which are popularly attributed to the head, elbow, or fome other limb of the child, originally placed, or acci- dentally moved, out of the common fituation. It appears, that this opinion cannot poffibly be true, unlefs we prefume, that there is at the fame time a partial diftention of the uterus, which could Scarcely happen without fome important and dangerous confe- quences. As this cafe moft frequently happens when the abdtn men is enormoufly diftended, and as it has all the appearance of a ventral hernia, it is more propbable, that it is occafioned by the Starting of fome of the abdominal mufcles, or the partial yielding of the integuments, or by an occafional SpaSm oS the uterus. But the explanation oS the caSe is oS leSs importance, as it neither re- quires nor admits of any affiftance, either before or at the time of labour, and difappears before, or almoft immediately after de- livery. From the great diftention of the abdomen, efpecially in corpu- lent women, an umbilical hernia is very frequently occafioned, which, depending wholly upon the degree oS diftention, does not admit of any relief before the patient is delivered ; when the elaf- tic truSs, Suited to the fize and Sorm of the hernia, feems a more eafy and effeaual remedy, than any inftrument of the kind which has hitherto been recommended, though fome prefer a piece of ivory, formed like a feaion of a globe, and fixed upon the part by adhefive plaifter or any of the ufual bandages. This feems to be the only kind of hernia produced by, or which remains du- ring pregnancy; for unlets the other kinds adhere to the fac in which they are contained, temporary relief is afforded by that afcent and Support oS the iiiteftines, which neceffarily follows the enlargement of the uterus. SECTION XXIV. In fome cafes the whole abdomen is diftended beyond what it is able to bear without inconvenience; the fkin becomes inflam- ed, and fometimes cracks, fo that there is a little oozing from va- rious parts. The true fkin alfo cracks when the outiidc is not alter- ON CONCEPTION AND PREGNANCY. 153 #d,by which there remains upon the integuments of the abdomen of women, who have had children, a number of fmall cicatrices, as if the parts had been Scarified, or there had been flight longi- tudinal ulcerations. For the eafe, both of the diftention and confequent SoreneSs, Some unauous applications ffiould be rubbed over the abdomen every night at bed-time. The ointment commonly recommended Sor (this purpoSe is compofed of rendered veal fat beaten up with a fmall quantity of rofe water. By the extreme diftention of the mufcles of the abdomen thefe jure often the feat of pain during pregnancy, efpecially at their infertions; and it requires fome attention to diftinguifh this from the pain which may arife from affeaions of the fymphafs of the bffa pubis. When the weight of the abdomen in pregnant women is very great, and weakly fupported by the integuments, it be- comes pendulous, and occafious to the patient much pain and dif- ficulty in walking, and many other inconveniences. It is then of fervice, by a napkin or broad bandage, fuited to the purpofe, paffed round the lower part and middle of the abdomen, "to fup- port it with a moderate degree of firmneft, and then by a fcapu- lary to fling the depending weight over the fhoulders, by which the patient will be enabled to move and walk about with infi- nitely left trouble, and any inconvenience thence arifing will be prevented or removed. SECTION XXV. Instances fometimes occur of pregnant women being affea- - ed with the venereal diferafe : and we have generally been adviSed to follow a mode of treatment, by which the difeaSe was not intended to be perfeaiy cured, but moderated and reitraiued from further progrefs ; leaving the abfolute cure to be complet- ed, when the patient was recovered Srom the ftate ot child-bed. This method oS proceeding has been recommended, on the prc- fumption that dangerous conSequences would reSult either to the mother or child, if a quantity of quickfilver was ufed, during » pregnancy, fufficient to root out the difeaSe effeaually from the conftitution. If the patient has a gonorrhoea,, there is clearly nothing in the medicines prefcribed, or in the treatment, which can prove hurtful to either at the time of utero-geftation. But if there fhould be a confirmed lues, as friaions with unguentum bydrargyri properly instituted and purfued, which, as it was one of the firft, is yet acknowledged to be the moft efficacious reme-r dy; or if equal or greater confidence is placed in them than in *54 INTRODUCTION TO MIDWIFERY. any preparation of quickfilver internally given : it is reafonablo to think, and the opinion is confirmed by experience, that women might at any time of pregnancy go through a due courfe of them with perfect Safety. It is fcarcely neceffary to obferve, that me- dicines compofed of quickfilver, whether internally giyen or ex- ternally applied, are not at this time uSed with a view to pro- mote a Salivation, or any other profufe evacuation, but with the intention of filling the habit with that medicine, and retaining it as long as it is thought neceffary for the extinaion of the difeafe. The utility and propriety of this praaice is allowed by thofe, who differ widely m their explanations of the mode in which quickfilver is SuppoSed to operate. I may be permitted to ob- serve, that the principal cauSes of the failure of this medicine to anfwer our purpofe of perfeaiy curing the lues are either the hurry with which it is at firft ufed, or a conclufion often, though erro- neoufly made, that the difappearance of the fymptoms is a proof of a perfea cure of the difeafe ; whereas it frequently happens, that, if the friaions are not continued many days, or even feveral weeks, or, in fome cafes, perhaps, months, after all the fymptoms are gone, there will in a ffiort time be new appearances, which prove the return of exiftence of the difeafe. It has been fuppofed, that a child born of an infeaed parent could not at the time of birth he exempt from infeaion, and that the virus would be fo intermixed with its frame that there would fcarely be a poffibility of exterminating it. This is at leaft a very dubious point; becauSe it has happened to every perSon engaged in praaice in a city or large town, to attend patients oS this def- cription, who have nevertheless brought Sorth children which were perSeaiy healthy. I do not recollea one decifiye inftance of a child born with any fymptoms of the venereal difeafe upon it; and the contrary, I am perfuaded, is often fufpeaed from a knowledge of circumftances, which give rife to the fufpicion, ex- clufive of the fymptoms; though it muft be allowed, that a child has a chance of receiving the infeaion in the aa of parturition, by abforbing the virus in its paffage over ulcerated SurSaces. But, with regard to the firft opinion, it may perhaps be justifiable to reafon in this manner. If the infeaion is received, it muft be at the time of conception, or afterwards. If the prolific particles, whether in the male or female, were mixed with the venereal virus, the prolific properties would by fuch mixture be deftroyed; but if conception were previous to the infeaion, there feems to be no way in which the latter could be communicated to the child already conceived, all immediate intercourfe being fecludcd by the perfea cloture of the os uteri. ON CONCEPTION AND PREGNANCY. TS5 Children brought forth by parents infeaed with the venereal (iifeaSe will often be born dead; but this event may commonly be imputed with more propriety to the Severity of the means ufed for the extirpation of the difeaSe, than to the difeafe itfelf. SECTION XXVI. When pregnant women have the fmall-pox, there is much dif- ference in the opinions entertained of the poffibility of the child being infeaed. Some have contended that, if the mother has this difeafe, the child could not efcape ; whilit others are perSuad- ed, that the child could not, according to the laws oS the animal economy, receive this diSeaSe. CaSes are recorded by various writers in confirmation of both the opinions ; and many inftan- ces have been communicated to me by men of integrity and at- tention, with the view of deciding this point; but the cafes are contradiaory to each other, and therefore prevent any prefent decifion upon the Subjea. When, by the multiplication oS well- attefted Saas, our knowledge is extended and correaed, ffiould it be proved, that the variolous infeaion is generally received by the foetus in utero, iS the parent has the diSeaSe when ffie is pregnant, we may then confider whether the knowledge of the faa can be turned to any praaical advantage*. It is an opinion almoft univerfally received, that, if a woman with child fhould have the fmall-pox, and mifcarry; or, if at the full time her labour fhould come on during the continuance of the difeafe; it would neceffarily prove fatal to the mother. The event has too often proved the truth of this obfervation ; yet it will probably ftand upon more juft ground, if it be ftated in this manner. Should the attack of the difeafe be violent, and the erup- tive fever run very high, patients may and have often efcaped the danger, at any period of utero-geftation, though the child were then expelled. But if a woman paffes the time of the eruptive fever, and labour or a tendency to mifcarry ffiould come on to- wards the crifis of the difeaSe, as Sar as my obfervation enables me to Speak, She will then certainly die. She dies, in truth, not be- cauSe fhe miScarries or brings forth a child, but ffie mifcarries or falls into labour becaufe ffie is already in a dying or very danger- ous ftate, and by thoSe circumftances the danger is infinitely in- creaSed. * Mauriceauyav/, that he himfelf was born with the fmall-pox uircn him. 15* INTRODUCTION TO MIDWIFERY. When other diSeaSes occur in pregnancy, the treatment to be direacd muft be Such as the particular diSeaSe may require, mak, ing due allowances Sor that State, by not preScribing any violent means, unlets the immediate Safety of the patient may render them absolutely neceffary. Every morbid alteration of importance which happens during pregnancy fuperfedes, if we may be al- lowed the expreffion, all the changes which depend upon that ftate ; and whoever aims to eftablifh the charaaer ot a SucceSsSul> praaitioner in midwiSery muft pay attention to the health ot his patients when they are pregnant. If there be no difeafe, or dif- pofition to it, the proceft of a labour is generally uniform and fafe. If any difpofition to difeaSe Should exift at that time, the labour may be rendered irregular and dangerous, or the immedi- ate cauSe of fome difeaSe peculiar to the child-bearing ftate, not by giving, but by diverting Such diSpofition to Some part rendered by parturition more SuSceptible of its influence. ON UTERO-GESTATION. »51 CHAPTER VIIL SECTION I. ON UTERO-GESTATION. It was formerly afferted and believed, that the proper fituation of the child in the uterus, in the early months of pregnancy, was fedentary; with the breech refting at the fuperior aperture of the pelvis, and the fore-parts of the child turned exaaiy to the abdomen of the mother. At or towards the time of parturition it was thought that the child, parti; i-by the increafed weight of the head, but chiefly by its own inftina and powers, made a revolution, and turned with its head downwards, in fuch a manner that the vertex was placed to the pubes, and the face to the facrum. In this pofition it was fuppofed to pafs through the pelvis. This change was called prefenting to the birth, oS which it was judged to be the Signal; and, Srom the terms ufed in different languages to expreSs the change, the opinion Seems to have been univerfal. By the examination of women who have died at different periods of utero-geftation, or in the aa ot child-birth, it is now ascer- tained, that Such as is the fituation of the child in the early part of pregnancy, fuch it will be at the time of labour, unlefs, which can very rarely happen, the pofition be altered by fome acciden- tal violence. Perhaps this opinion of the ancients was not found- ed on obfervation, but on the prefumption that Satal conSequences would reSult Srom the continuance of the foetus with its head downwards for nine months. They did not know, that there was a circulation of the blood; and of courfe were ignorant that an order of veffels exifted in the body, efpecially calculated, by preferving a particular communication between different parts, to prevent any injury to the foetus, either from its confinement or fituation. The natural pofition of the foetus In the uterus is fuch as to occupy the leaft poffible fpace, fo that the leaft poffible incon- venience is occafioned to the parent, yet with the utmoft eafe to its own body and limbs*. In the pofitions which are efteemed * *%Hulfi !T1 feipfum iotts conglobatus—Fabric, ab Aquapendente. i58 INTRODUCTION TO MIDWIFERY; natural there is an endleft variety, but they are moft commonly aSter this manner*. The knees are drawn up to the belly, the legs are refleaed backwards, the Seet croffed, and lying CloSe to the breech; the elbows are in contaa with its fides, and the hands turned up to its head, one of which is often placed upori the cheek or ear. The fpine is incurvated, and the neck being bowed, the chin refts upon its knees. There is that inflexion of the body into which we fpontaneoufly fall when we feek repofe; and as it is our pofition before we are born, it is that alfo to which we have an inclination in the decrepitude of old age. The fituation of a child, prefenting naturally, is with the head downwards^ refting upon the offa pubis, with One fide of the head towards the abdomen ot the mother, and the other towards the facrum, or in a Small degree diagonally. The bulk of the body of the child is not placed againft the fpine, but on one fide, moft commonly on the right, and the limbs turned towards the left, fo that the abdomen of a woman with -hild is, in general evidently diftended more on one fide than the other. When this circum- ftance, though a neceffary confequence of the proper fituation of the child, is obferved, a SuSpicion, wholly groundleSs, is often en- tertained, that its presentation at the time oS birth will be unnatu- ral. A Small degree oS permanent enlargement may afterwards be perceived on that fide on which the child has refted, in which alto, Sor Some time aSter delivery, the mother is Subjea to pains reSembling thoSe which are confidered as rheumatic. SECTION IL The term of utero-geftation is different in every claSs of ani- mals and the diverfity has been attributed to the nature and pro- perties of the parents or the offspring. Thofe, who were of opinion that it depended upon the parent, fought for the reafon in the ftruaure or conftitution of the uterus, the heat or cold- nefs, drynefs or moifture ot which, according to the doarines of the old philofophy, were fuppofed to be the caufes of the va- rieties : yet, if the term depended upon thefe, it would then re- main to he proved, how it happened that one form or conftitution * Addutlis ad abdomen genibus, flexis retrorfum cruribus, pedibus decuffatis, manibufque furfum ad caput fublatis, quorum alteram, circa tempora vel auriculas, alteram ad genam detinet; fpina in orbemfiec- titur, caput ad genua incurvato collo propendet; tali membrorum fitu, qualem in fomno per quietum quarimus.—Harv. Exercitat de Partu* ON UTERO-GESTATION. 159 Was capable of bearing diftention longer than the other. Thofe, who imputed the time of the event to the offspring, affigned to them the fame properties. It feems to have been generally believed, th:.t, by the long or ffiort continuance of the foetus in the uterus, the future fize, duration, and qualities, of different animals were in- fluenced ; and that thefe were moft perfea and permanent in thofe animals which had the longeft period of utero-geftation. It was alfo thought, and perhaps with truth, that the longer the time of utero-geftation, the longer the animals were before they came to full growth; and that on this depended their continu- ance in the mature ftate, without any natural tendency to decay, one period of existence regulating another*. In oviparous ani- mals the time ot incubation neceffary for the produaion of their young is not altered by the qualities of the bird by which it is. incubated, but follows its genuine nature ; as in a hen's egg in- cubated by a duck. This favours the opinion that the term is guided by the offspring, but it is by no means decifive: for the circumftances relating to the birth of oviparous and viviparous animals, though they may illuftrate each other, cannot, with any intelligence, be compared, before the egg is expelled. If the time of utero-geftation be not interrupted by accidental caufes, it proceeds in all animals with great, though not with exaa regularity, as is proved by thofe who are employed in breed- ing cattle, by whom a correa account is ufually preferved. But in the human fpecies there was fuppofed to be a confiderable latitude in this refpea,- and examples have been recorded with great confidence, by grave writers, of children born after a term much exceeding the common, and of others after a term far ffiort of it, which were neverthelefs in a perfea flate* This opinion hath alfo been countenanced to a certain degree by the laws or cuftoms eftablifhed in different countriesf. The common time of utero-geftation in women Is forty weeks, or nine calendar months ; and fome men of ability and candour have been perfuaded, that it is poffible for them to proceed as far as ten calendar months. By the laws of this country the term is not prccifely limited ; fo that if any cafe ffiould occur, in which this matter might be litigated, the decifion would rather * See Lord Bacon's Hiftor. Natural. f Spigelius Ulpiar.um juris confultum immerito reprehendit, quod poft decimum menfem editum neminem, ad legitimam hareditatem ad* mifcrit.—Harv. Exercitat. de Partu. Vol. I. B b 160 INTRODUCTION TO MIDWIFERY. depend upon the circumftances, or upon the confidence placed in the teftimonies of the medical witneffes, than upon any proof or conviaion of the nature of the thing to be decided. There muft in general be much difficulty in determining with abfolute precifion the time of utero-geftation in individual women. But I have met with Several inftances ot thoSe who, Srom parti- cular contigencies, Such as the caSual intercourse with their hut- bands, or their return to, or abSence from them, for a particular time, have been able to tell exaaiy when they became pregnant; and none of thefe have exceeded forty weeks. I am therefore perfuaded, that the term of utero-geftation is as accurately limited in women as in animals. I do not mean that it is completed to a minute or an hour, as has been SurmiSed, becauSe the birth oS the child may be delayed by a multiplicity of accidents. But parturition will be accomplifhed, or the parturient difpofition will take place, before or at the expiration of forty weeks from the time of con- ception. Nor does it Seem reaSonable that a law of nature which is not altered by the differences of age, by the diet, by the extremes of climates, by the Severities of flavery or the indigen- cies of luxury, ffiould be changed by circumftances of left impor- tance. But the examples of women who have brought forth their children apparently in a perfea ftate, and of a proper fize, before the full time of pregnancy, are innumerable. As there is no mark in the external appearance, or internal conformation, which enables us to determine with precifion whether a child has remained in the uterus its full time, this muft continue doubtful, except as far as we are able to judge by the general probability, or by the fize of the child. So many accidents occur, which may give to the uterus its difpofition to compel the child, that its pre- mature expulfion can never be the occafion of furprife ; not to mention, that there is in particular women a fpecific time, as the thirty-Seventh or thirty-eighth week, beyond which they never pafs in many fucceeding labours. Though it fhould be allowed that the natural term of pregnancy in women is forty weeks, there will be fome difficulty in making the calculation. The difappearance of the menfes is ufually the firft change, which occafions a SuSpieion oS pregnancy ; and might therefore be efteemed the era, from which we are to date its commencement. But, though women are more apt to con- ceive foon after than juft before menftruation, they may become pregnant at any part of the time between the two periods, when they did, and when they were expeaed to menftruate. In order to avoid any great error it ij cuftomary therefore to take the mid- ON UTERO-GESTATION. i6j die time, and to reckon forty-two weeks from the laft a& of men- ftruation, by which method, if we arc rightly inftruaed, we may avoid any egregious miftake. Women who give fuck, and who do not menftruate, fome- times become pregnant, and having no alteration by which they can make any reckoning of the time of their delivery, all is left to conjeaure. But there is ufully, in thefe caSes, a ffiort and imperSea menftruation, which denotes the time when the uterus was in a ftate fitted Sor conception. Some women alSo have conceived, who never did menftruate regularly, or in whom menftruation had been interrupted Sor many months. We can then only judge of the time when they conceived, by fuch fymp- toms and appearances as fhewed that they had acquired the dif- pofition to menftruate, and would have menflruated if they had not conceived. All calculations founded on the time of quicken- ing, the fize of the patient, and the like circumftances, amountiifg only to conjeaure, muft be very liable to miftake. Some inconveni mcies are produced by attempts to make exaa reckonings for pregnant women ; for, when the time fixed for their delivery is paft, the error creates much Solicitude and impa- tience. When therefore it is neceffary to give an opinion on this fubjea, it is better to mention Some time beyond that which we really fuppofe ; or, on the whole, it would perhaps be better, that labour fhouid always come on unexpeaedly. SECTION III. At the expiration of forty weeks the procefs of labour com, menceth ; and various opinions liave been given with a view of explaining its caufes. Of thefe opinions, which have been fup- pofed to conftitute a very important part of oblteric knowledge, v/e.ffiould not be ignorant, as it appears that the praaice of midwifery has really been very much influenced by them. It was faid by all the ancient writers, that a child was born by its own efforts, which it was incited to make by the neceffity it felt of breathing cool air, for the purpofe of moderating that heat which was generated by its long confinement in the uter :s ; or by the want of nourishment the Sources of which failed, or were become depraved ; or by the acrimony of the meconium and humours of its own body. By Some the cauSe affigncd Sor the txertions of the fetus was the want of room for its further growth and enlargement ; and that by its efforts it efcaped out of the uterus, as out of a prifon in which it had been conftrained, 162 INTRODUCTION TO MIDWIFERY. By others it was prefumed, that there was fome analogy between the ripeneft and falling of fruit, and the perfeaion and birth of a child. The peculiar caufe was unimportant, but from a general perfuafion of the principle, it was prefumed, that the eafe or diffi- culty with which labours were completed, depended upon the ftrength or aaivity ot the child. Another conclufion certainly followed : when the child was feeble the labour muft neceffarily be flow; and in cafes of unufual difficulty we might be affured, that the child Was dead, or could not poffibly be Saved. Of courSe, whenever the affiftance of art was required, there was no occafion to regard the child, the existence of the difficulty proving the death or impossibility of preferving the child. If we had no other circumftance, by which the praaice of the ancients could be compared with that of the moderns, this alone would decide in favour of the latter. Many expreffions are, however, in ufe at the prefent time, which are founded on this opinion of the ancients ; and it is not clear, that praaice is not, in fome inftan- ces, yet influenced by it. No faa is more inconteftably proved, than that a dead child, even though it may have become putrid, is commonly born after a labour as regular and natural in every part of the proceft as a living one; and that children, after labours accomplifhed with the moft extreme difficulty, will often be born not only living, but in perfea health. There rnuft then be fome other principle of birth befides the efforts of the child, which in faa appears to be wholly paffive. It was by later writers fuppofed, that the child was expelled by the aaion of the uterus, aided by that of the diaphragm and abdominal mufcles. This doarine, which I believe was firft advanced by Fabrkius ab Aquapendente*, is the bafis oS all the modern improvements in the praaice oS midwiSery; and it is So indiSputably proved, by the occurrences both in natural and diffi- cult labours, that its truth is now almoft univertally admitted. Ingenious men were not Satisfied with the observation oS the faa, but they endeavoured to difcover the principle of the aaion of the uterus, and to affign reaSons Sor its coming on at a particular time. It was SurmiSed that this expulSatory aaion of the uterus depended upon its form or ftruaure, or its inability to bear Sur- ther diftention; or upon its heat or coldneSs, dryneSs, or moifture; or upon the diftinaion otits muScular fibres, which were Said to be arranged in a peculiar direaion ; or to the effort to menftru- * Simul expultrix uteri facultas extemplo infurgit, excitatur.— See Chap, lxxxvi. ON UTERO-GESTATION. l6$ ate when the veffels oS the uterus were incapable of containing a greater quantity of blood than was already colkaed in them. Of thefe and many other opinions it would be uSeleSs to debate ; but, as all viviparous animals bring Sorth their young at regularly Stated times, and by proceffes generally alike, it would not be judging according to any philcSophical rule, to attribute as the immediate cauSe of parturition, or of parturition at any cer- tain time, a circumftance peculiar to any individual clafs of animals. The opinions of men upon the fame fubjea are often in direa opposition to each other: and Some, fearful that truth is not to be found in either extreme, have fleered a middle courfe between the doarine of the ancients and moderns. Thefe have fuppofed that child-birth is not completed folely by the efforts of the child, or by thofe of the parent, but by the conjunaion of their efforts. Of this opinion, which participates of the error of the ancients, there have been few fupporters ; and the arguments in its favour have been drawn from obfervations made in the firft inftance on vegetables and oviparous animals. How Sar the diScovery of the particular caufe of the birth of a child might lead to the improve- ment of praaice it is impoffible to determine. The knowledge of the faa, that children are expelled, has evidently been pro- duaive of much advantage : but the attempts to investigate the cauSe do not give us more SatisSaaion than old Avicenna, who, with great humility and devotion, Says, "At the appointed time, Labour comes en by the command of God." SECTION IV. It was before obferved, that pregnancy and parturition have ufually been mentioned as diftina operations of the conftitution. But it feems better to confider every change in the animal econo- my, from the time of conception to the birth of the child, as forming a Single proceft, confuting of feveral parts, each perfea in itfelf, and at the fame time a caufe of Some Subsequent change, neceffary Sor the completion of the whole; and, though there is no precife line to the different parts oS this proceSs, they readily admit of diftinaions, by which they are more eafily comprehend- ed, and more expeditioufly and accurately defcribed. Thus, pre- vious to the aa oS parturition, many changes take place in the conftitution, which indicate its approach ; and thefe have been called the pre-diSpofing figns oS labour. The time of their ap- pearance is different, being in Some women Several weeks, and in 164 INTRODUCTION TO MIDWIFERY. others only a few days, before the commencement of labour: but they univerfally take place, unleSs the labour be precipitated by fome accidental influence: and the more perfeaiy thefe changes are made, and the longer the time of their preceding the labour, the more natural and kindly will the proceft generally be. There is, firft, a gradual fubfidence of the fundus of the uterus, and whole abdomen, fo that women often appear, and really are, left in the ninth than in the eighth month of pregnancy. Thii is a good indication, becaufe it ffiews that the fundus and all the other parts of the uterus are difpofed to aa; and on the equality of this difpofition the efficacy of its aaion will very much de- pend. When there is none, or but little, fub^dence of the abdo- men, and the patient complains, even in the time of labour, that the child is very high, it is always unfavourable ; being a proof that the fundus of the uterus is in an inaaive ftate, or acting im- properly. There is, fecondly, a difcharge of mucus from the vagina, which in the beginning is of the kind often obferved in the fiuor albus; that is, a mere augmentation of the Secretion from the glands of the vagina and neighbouring parts; but, by a gradual alteration in fcme inftances it becomes extremely vifcid and tenacious. This is very remarkable in fome animals whofe bodies are expof- ed to view, efpecially in cows; and it is a fign that the parts con- cerned in parturition are in a ftate ditpoSed to dilate, which dif- pofition is farther improved by the difcharge. Thirdly, In early pregnancy the external parts of generation are in a natural ftate, or at Some periods rather more contraaed than uSual: but when the time of labour approaches there is a gradual enlargement and relaxation of them, with fome degree of protrufion. . This change alfo is to be obferved in animals only ; but, from their complaints, and the representation of their feelings towards the conclufion of pregnancy, there is every rea- fon to believe, that a fimilar change takes place in women. Fourthly, It was obferved that the breafts very readily and generally fympathize with the uterus in all its affeaions, and par- ticularly that they are enlarged immediately after conception. There is alfo a gradual change in them from that time to the ap- proach of labour, when they are perfeaiy fitted for the fecreti#n of milk; which, when Secreted in a more mature ftate, or in an increaSed quantity, may be efteemed a fign that the time of labour is drawing near. Some animals, the pecora Sor inftance, though the quantity of milk has gradually declined, have conti- nued to give fuck during pregnancy, without any apparent alte- f ON UTERO-GESTATION. l6$ ration In the quality of their milk, till they approach the time of parturition, when it was found to be much changed in its con- fiftence, colour, and properties, a new mode of Secretion being evidently eftabliShed. Fifthly, by the infertion and difpofition of the facro-fciatic li- gaments the principal firmneft is given to the connexion of the bones of the pelvis. In animals not with young thefe ligaments are very ftrong and rigid, and make a refiftance to any external preffure almoft as firmly as If they were offified. But when the time of parturition is at hand their ftrength and rigidity gradu- ally decline, and they feel Scarcely more firm than a duplicature of the fkin. In confequence of this relaxation of the ligaments, animals change their manner of walking, by projeaing the weight of the body on each fide alternately, rather than by advancing the feet. There is fuch an appearance as juftifies the ufe of the popular expreffion; for they literally Seem falling in pieces. In women thefe changes cannot be fo well obferved; but there are many reafon s to be drawn from their manner of walking, and from their representations, which would induce us to believe, that fimilar ones take place in them as well as in animals*. Sixthly, All animals, wild or domefticateci, aifiduoufly endea- vour to provide a fafe and comfortable habita:i'?n for their young, when the time of bringing them forth draws nearf. The aaions of mankind are always attributed to, and ufually proceed from, more dignified and commendable principles than thofe of animals. But in many natural aaions, which are too powerful to be con- trolled, or not without great difficulty, by inftruaions, manners, or cuftoms, they may often be obferved to aa inftinaively ; and this is in no cafe more remarkable than in fuch aaions as relate to child-bearing and to children. From inftina, therefore, and not reafon, it may be prefumed, the chofen and favourite em- ployments of pregnant women are thofe, which in fome way or degree relate to the expeaed blcffing ; and an unufual Solicitude about the preparation of fuch things as may be neceffary or con- venient to the child, in the advanced ftate of pregnancy, may be confidered as a fign, that the time of labour is approaching. * Sacri et petlinis oflfium cum coxendke copula, qua fit per fynchon- drofn, adeo emdlitur et folvitur, ut ditto offa facile exeuntifaetui cedar, t, et hiantia regionem totam hypo^iflruum ampliorem reddant.—Hdtv. Exercitat. de Partu. f Ac cedent e pariendi tempeflate adfolita loca revert antur: utflubula vel nid-s Cms tuto cxtruant, ubi foetus pariant, fovcant, alantque.—• Harv. Exercitat. de Partu. l66 INTRODUCTION TO MIDWIFERY. SECTION V. Before we proceed to the hiftory of labours, it is neceffary (hat we ffiould fpeak'of the operation, if it deferves the name, by which we are to acquire our information. This is defcribed by the term examination,or examination per vaginam. When insti- tuted at the time of labour, it is popularly called taking a pain, which explains the opinion entertained of it by. women. Con- cerning this operation two things are to be obServed ; firft, the manner in which patients are to be examined : arid,' Secondly, the information to be gained by the examination. The pofition in which women are placed, When it is thought neceffary to examine them, varies in different countries. In Some the examination is made when they fit in a chair or Stool contrived for the purpofe ; in others when they kneel by the fide of a bed; and in others in a recumbent pofition. But in this country, at the prefent time, almoft univerfally, women repofe on a couch or bed, upon their left fide, with their knees bent, and drawn towards the abdomen', and tins is by far the moft convenient, as1 well as decern. It is not requisite, or poffible, to enumerate every circumftance, to which it is neceffary to pay attention ; but it muft be an invariable rule, never to propofe an examination per vaginambut as a matter of abfolute neceffity, and in the prefenceof fome attending perfon. It is alfo to be performed with the utmoft care and tendernefs, and the ftriaeft regard to decency ; for, unimportant as the operation in itfelf really is, an opinion i« formed by the manner of doing it, of the fkill and humanity of ^ the praaitioner, and of the propriety of his condua. An examination per vaginam may be needful to difcover and diftinguiffi difeafes of the uterus and contiguous parts ; to afcer- tain whether a woman be pregnant, or how far fhe is advanced in her pregnancy ; to determine whether the be in labour, or what progrefs that has made ; if the presentation of the child be natural ; if the pelvis be well formed or diftorted ; and on many other occafions. The ftate of'the parts examined, under all the/incidents before, recited, is different ffom the natural; but of the deviations of every kind, and in every degree, it is impoffible to form a judg- ment, unlefs we have prevloufly obtained an accurate idea of their natural ftate. This forms the true ftandard by which we are to judge of every change, natural or morbid; and the faculty of discriminating the various difeafes or alterations can only be ac- quired by frequent praaice, no abftraa rule being fufficient for ON UTERO-GESTATION. t6f the purpofe. It may indeed be faicL, that, in fome difeafes of the uterus, efpecially tliofe difpofed to become cancerous, the os uteri is enlarged, or elongated, indurated, thickened; fiffured, fportgy, and uncommonly tender when touched, or .patulous, or with the labia fomewhat reverted ; lying tod low in the vagina, or firmly attached to the adjoining parts. But in others, as the polypus, hy- datids, inflammation^ or a glandular enlargement of the uterus, the ftate of the parts, (except the fimple enlargement of the uterus) or the fenfation they give^ cannot be defcribed by words* without an antecedent agreement what thofe fhall be called which we have before felt or feen. We are often able to diftingiiifh the changes made in the body of the uterus by an examination per anum more perfeaiy than by any other method; As it is extremely difficult, if not impoffible, to determine, by an examination per vaginam in the early part of pregnancy, whe- ther a woman be with child, it is then prudent to evade the ope- ration ; becaufe it is always expeaed, that we fhould afterwards fpeak with precifion and confidence. For the fundus of the uterus being the part firft diftended in conSequence of conception; and the cervix, which is the only part we can feel, not beginning to fhorten in any diftingUiffiablc way before the termination of the fourth month of pregnancy; not to mention the natural varieties in the ftruaure and fize of the parts in different women, and the alterations which may be caufed by the attachment of the placenta to different parts of the uterus, or by thofe difeaSes which reSem- ble pregnancy, we fhall See Sufficient reaSon for putting off this kind of inquiry. A cautious praaitioner will not therefore, on any account, examine before the proper time, becaufe he cannot gain information, to fupply him with proper ground on which to form the opinion required of him, that will not be extremely fub- jea to error. Perhaps this limitation may not be Sufficiently itria, and it is better to fay, in general terms, that the longer we defer the examination, the greater probability there will be that We ffiall not be deceived, or difappointed of the information we want. In all cafes likewife of doubtful prognoftic, it is proper to avail ourfelves of every advantage, which a knowledge of the collateral circumftances can afford, before we give our opinion. Nor is there left difficulty, when we are affured that a woman is with child, in deciding, by an examination per vaginam, how far fhe is advanced in her pregnancy. An opinion of this muft be formed on the eftimation we make of that portion of the cervix nteri, which we fuppofe Should remain undiftended at any indivi- dual period of pregnancy. But as the cervex uteri naturally va- ri35 in its kngth in d.;»>;vu: women, of courfe the portion which Vol. i. C\: 1^8 INTRODUCTION TO MIDWIFERY. remains undifturbed at any precife time muft vary ; and all that' can be juftly faid upon the fubjea will only deferve the name of conjeaure. It is therefore more prudent, not to hazard an opinion fingly upon the information gained by an examination per vaginam, when any determination of importance is to be made; but, as in the former Statement respecting the exiftence of pregnancy, to aa with caution, and to colle& all the informa- tion we can get from other circumftances, before we prefume to give a decided ©pinion. When a woman is at or near the full period of utero-geftarionr it may be determined whether fhe is in labour by the State of the os uteri. By the dilatation of the os uteri during the continuance, and not by its relaxation in-the abfence of a pain, we are to judge that the patient is in labour: for a confiderable degree of relax- ation of the os uteri is fometimes found to take place feveral days, or even weeks, before the commencement of labour ; though it is generally in a contraaed ftate, till it is diftended in confe- quence of the preffure made by fome part of the ovum urged upon it by the aaing uterus. By, the time which has been re- quired to produce a certain degree of dilatation, we may gueft with tolerable exaaneft the general duration of a labour, pro- vided the aaion of the uterus ffiould continue with equal ener- gy ; becaufe on this, as well as on the ftate of the parts,.the pro- grefs of a labour muft depend. But fo many unexpeaed cir- cumftances occur, which may accelerate or interrupt a labour in its progrefs, that it will ufually be a proof of wifdom, to be Silent upon this Subjea ; at leaft not to advance our opinions with con- fidence, but to offer them, when demandsd, with hesitation and rcferve. The manner in which the child prcfents may generally be dis- covered by an examination in the beginning of labour; for, though we fhould not be able to diftinguiffi any part through the mem- branes, in the intervals between the pains (when only the attempt for this purpofe ought to be made,,) if the head prefents it may be perceived through the anterior part of the cervix uteris refting upon the offa pubis, in fome cafes fo early as the fifth month of pregnancy. When any other part prefents, we can in general only diScover through the membranes that it is nob the head, by its SmallneSs and the want of that refiftance which is made by the head ; and if we can feel no part prefenting, though it docs not certainly follow, it is not amift to conclude, that it is not the head; and then in our report to the friends we fhall exprefs our- felves with Some doubt, and be prepared to give affiftance at the time when the membranes break, if the prefentation fhould be fuch as to require it. isn UTERO-GESTATION. f6f After an examination per vaginam, our opinion is conftantly (demanded as to the proSpea of an eafy or difficult labour. VL :the prefentation of the child be natural, the pelvis well formed, ,the foft parts in a relaxed ftate, and the patient free from difeafe, we may fafely aflure her friends that all the appearances are pra- tnifing, and that the labour wiH be -finiffied, in all probability, with perfea fafety both to the mother and child. But of the flownefs or celerity of a labour great experience and attention can only give that maturity of judgment, which enables us to form an opinion with tolerable precifion; yet the Same experi- ence having often {hewn the uncertainty of any determination, Will point out the propriety of leaning rather to the fide.of doubt than of confidence. It is not a little extraordinary, how often we may obferve labours proceeding in regular circles of time, as four, fix, twelve, or twenty-four hours, from the firft alarm or token; or how frequently their progrefs is fufpended in the day rime, particularly in very warm weather, as will be more parti? cularly obferved. lyq INTRODUCTION TO MIDWIFERY. CHAPTER IX. SECTION I. 0# LABOUR. Hating given a defcription of all the parts concerned in partu- rition, and ffiewn the peculiarities of the female conftitution, having enumerated the principal alterations produced in the con- ftitutions of women during pregnancy, and having farther taken notice of all the previous changes, we come in the next place to the confederation of a Labour. This term is generally "ufed to fignify every aa performed with difficulty or pain v ont by long eftablifhed cuftom it has been appropriated in this and many other countries to parturition, the circumftances of which it is well fuited to defcribe. Before we proceed to the hiftory of labours, it is requifite that we fhould divide them into claffes or kinds ; and though objeai- ons might be made to a very ftria arrangement, fome appears to be both convenient and neceffary, for the purpofe of enabling us to convey our Sentiments with perfpicuity to others, and for real jife in praaice. With thefe intentions, labours may be divided into four fol- lowing claffes: i. Natural. 2. Difficult. 3. Preternatural. 4. Anomalous. Under one or other of thefe diftinaions every kind of labour which can occur may be reduced. SECTION II. Natural labours, which have had their denomination from their frequency, or from the ffiortneft of the time required for their completion ; from the regularity of the manner in which. DN LABOUR. **« £hey proceed, or from their being accomplished by the unaffifted efforts of the conftitution, form a Standard by which we are to judge of every other clafs. It therefore neceffary, that we fhould obtain as precife an idea of thefe as the Subjea will allow. We will then fay, that every labour fhall be called natural, if the head of the child prefents, if the labour be completed within twenty- four hours, and if no artificial affiftance be required. Should any of thefe three leading marks of the definition of a natural labour be wanting, it muft come under Some other denomination. Thus, iS any other part except the head fhould prefent, the labour would be preternatural; if it ffiould be pro- longed beyond twenty-four hours it would be difficult; and if the circumftances were fuch as tp require affiftance, though the labour might be completed within one hour, it would be anoma- lous, or muft be referred to fome other clafs. The prefentation of the head of the child conftitutes an effen- tial part of the definition of a natural labour 5 yet this may happen in various ways. The moft common pofition of the head, and that in which it is expelled with the greateft facility, is when the hind-head is difpofed to turn towards the pubis and the face towards the hollow of the facrum. But the face is fometimes inclined towards the offa pubis, and the hind-head towards the hollow of the facrum ; or there may be an original prefentation pf the face; or one or both arms may defcend together with the head. TheSe differences in the pofition of the head do not con- ftitute labours of another clafs 5 but they are to be confidered merely as varieties of natural labours, provided the other circum- ftances correspond j experience having Sully proved, that, in any pf thefe pofitions, the head may be expelled by the natural efforts with perfea Safety to the mother and child, though not generally with fuch eafe and expedition as if the hind-head was turned towards the pubis. It muft alfo be obferved, though another part of the definition be taken from time, that it is poffible for one woman to make greater efforts, and to undergo more pain, in two hours, than another may in twenty-four. Then the defi- nition will be imperfea ; as almoft all general diftinaions muft be, when they come to be examined and tried by individual cafes. A natural labour was the laft thing well underftood in the praaice oS midwifery, becaufe Scientific men, not being formerly employed in the management of common labours, had no oppor- tunity of making observations Upon them. 'Praaitioners were then engaged in qualifying themfelves for mrr.i-.31 exercife'cif their J7* INTRODUCTION TO MIDWIFERY. art, whenever they might be called in to give affiftance, and not in making nice diftinaions or inveftigating the particular cafes, in which only it might be neceffary to exercife it. SECTION III. We have before given an account of the changes which preced* labours, and are now to give a detail of the fymptoms which accompany them. The firft fymptom which indicates a prefent labour is anxiety or that diftrefs which ufually arifes from the apprehenfion of danger, or doubt of fafety. This does not feem to be confine^ to the human fpecies, but to be common to all creatures, as they univerfally fhew fignsof dejeaion and mifery at this time, though they fuffer in filence ; and even thofe animals which are domes- ticated Strive to conceal themSelves, and refute all offers of affift- ance. This anxiety, which is probably occafioned 4>y the firft changes made upon the os uteri, and by the conSent between the vital organs and that very irritable part, is often exceedingly increafed by an original timidity of difpofition, efpecially with firft children ; or by the difcovery of untoward accidents happen- ing to other women under the fame circumftances, with whom a fimilarity of fituation is the caufe of a moft interesting Sympathy. From motives of humanity, as well as profeffional propriety, it is therefore at thefe times neceffary, by fteady condua, and by arguments fuited to the patient's own notions, or the peculiar cauSe of her fears, to remove her apprehenfions ; and, by toothing and encouraging language, and by attention to her complaints, though not indicatory of any danger, to afford her every confola- tion in our power. This anxiety is greateft in every woman in the beginning of labour, for the ffrarp pains which attend its progrefs generally excite other Sentiments in her mind. But we are at all times to be on our guard, that her fears or Amplications for relief do not prevail with us, to attempt to give affiftance* when our Interpofition is not required, and when it muft neceffarily be productive of mifchief. 2. At the commencement of labour, and fometimes on the return of every pain, women have frequently one or more rigors, with or without a fenfe of aaual cold in their inferior extremities, or of the whole body. Thefe are not to be confidered as figns of fhe acceffion of difeafe, but as the effeas of an increafed irritability fpread through the whole frame; or perhaps as proofs, that all the powers of the conftitution are Summoned to contribute ON LABOUR. »73 towards die important procefs, which is carrying on. Thefe ngors are void of danger, and they are moft apt to occur when the or uteri begins to dilate, and when it is upon the point of being fully dilated. But in the courfe of a labour, perhaps in all other refpeas natural, but more efpecially in thofe which are either difficult or very lingering, when there is one flrong and diftina rigor, it is oSten followed by fome difeafe, dangerous either to the mother or child 3. When the head prefents, and fcarcely in any other pofition of the child, women have generally fome degree of ftrangury in the latter part of pregnancy ; and this fymptom is increaSed on the approach oS labour, by the preffure of the defcending head upon the cervix of the bladder. Should the preffure be very great, or of long continuance, a fuppreffion of urine may be occafioned before or in the time of labour. To prevent the inconveniencies, which might arife from a diftention of the blad- der, either to the part itfelf, or by obftruaing the paffage of the head, it is neceffary to urge the patient to void the urine frequent- ly ; and in cafe of a fuppreffion, to give relief by introducing the catheter. On the other hand, fhould the preffure by the head be made upon the fundus of the bladder, there will be an involun- tary difcharge of urine at the time of her enduring every pain ; pr, if there fhould be any extraordinary agitation from a cough, or any fimilar caufe, before delivery, there will be the fame confe- quence, which is very diftgreeable and troubleSome, but not dangerous. '. 4. It is not unuSual for patients to have a tenefmus, or one or two, or more loofe ftools in the beginning or courSe of a labour. Both thefe Symptoms may be occafioned by the content between the os uteri and the fphintler of the anus, or by the preffure made upon the refium, as the head enters into or paffeth through the pelvis. There is in the minds pf all women a popular prejudice and unreafonable dread of complaints in the bowels through every ftage of pregnancy, parturition, and childbed; and of courfe there is never any objeaion, but, on the contrary, a willingnefs to ufe fuch means as are advifed to Supprefe them, or reftrain any diSpofition to a diarrhera. The error has ariSen Srom their con- founding the loofneft, which often accompanies the laft ftage of the puerperal fever, with that which proceeds from any other caufe. But the diarrhoea which attends the beginning or courfe of alabour is fo far from occafioning or Srom indicating-any dan- ger, that the patient is evidently relieved by it; a greater freedom being given to the aaion of the uterus, more room made for the paffageof the child, and any feverifh difpofition thereby remov- 174 INTRODUCTXO* TO iftDWlFERY. ed or prevented. If, therefore, the patient fhould not at thai time have ftools fpontaneoufly, it is very found praaice to dire& one or more emollient ctyftcrs for the beforementioncd purpofes. Nor are thefe the dnly good ends which are anfwered by clyfters* for they Soothe and give a proper bent to the parts when too much or improperly irritated; and ferve alfo as a fomentation, which, by its warmth and moifture, may give or amend there difpofition to dilate. In very flow labours, when the head of the child has dwelt for a long time in one pofition, it is not unufoal for the. pa- tient to have one or more copious and loofe ftools immediately before the advancement cf the head, after which the labour is foon concluded. 5. The uncoloured mucous difcharge from the vagina, which pretty generally occurs before labour, on its acceffion is ufually tinged with blood, or a Small quantity of pure blood is difcharged. This fanguineous difcharge, which varies in quantity and appear- ance in different women, is popularly called a.fhew, and it hap- pens more particularly at two periods of a labour ; when the os uteri begins to dilate, and when it is finally dilated. In the firft inftance it is probably occafioned by the feparation of a few of thofe veffels, by which the membrane, which conneas the ovum to the uterus, was originally bound; and in the fecond by the ef- fufion of fome blood before extravafated in the Subftance of the os uteri; for this part in fome cafes acquires an uncommon thick- nefs from that caufe, independent of any edematofe or inflamma- tory tumefaaion. In many cafes there is no coloured difcharge in any period of a labour, and then the dilatation generally pro- ceeds more flowly; for the difcharge is not only a fign, that the parts are in a ftate difpofed to dilate, but it alfo improves that ftate. It is not only in coIout or quantity that there is found much difference, either in the fanguineous or mucous difcharge, but alfo in the cortfiftence and tenacity of the latter ; it being in fome cafes thin and watery, arid in others thick and extremely fcifcous. 6. But all thefe fymptoms are not pofitive proofs of the exift- ence of labour; for we cannot confider a woman as being in ac- tual labour, unlets fhe has the ufual pains. Nor does all pain in the region of the uterus certainly prove that a woman is in labour, becaufe fuch pain may be excited towards the conclusion of preg-. nancy by various caufes befides the aaion of the uterus. 'FJbefe pains are therefore diftinguiffied into two kinds, true and falfe *: but the feat, the manner, and the degree of thefe pains, often re- Semble each other fo nearly, that it is very difficult or impoffible to diltih£uifh 'them,- unlets by an examination per vaginam, or by waking for the event. ON LiBOUR. 17^ - The true pain of labour ufually begins in the loins, or lower part of the "back, furrounds the abdomen, and terminates at the puber, or upper part of the thighs; and it fometimes obferves a quite contrary direaion. In Some cafes the pain is confined to one particular Spot, as the back, abdomen, thighs, or inferior extre- mities ; in others the pain is Seated in fome part far diftant from the wterus, as in the knees*1 heels; or feet. In fome the ftomach is affeaed; in others* though very rarely; the brain ; and then convulfionsi or fome derangement of its funaions; are brought on. In ffiort, the varieties of pain as well as its effeas, are innu- merable ; and thefe have been explained b'y what we really do know, or fancy we know, of the influence of the nervous fyftem. The pain attending a labour is periodical, with intervals of twenty, fifteen, ten, or five minutes, according to its progrefs, and as regular as the clock, but with a longer or Shorter duration, ac- cording to the aaion of the uterus, on which it depends ; and the more the pains are multiplied the better it is for the patient. For, if an effea of great importance to the conftitution is to be produced, the more flowly it is made* provided the flOwnefs of the progrefs does not depend on any morbid caufe, the more gra- dual will be the change, and of courfe the danger, Which fudden Violence might produce, will be avoided or leffened; the divifion of the pain being equal to the diminution, nearly in the fame proportion as rapidity is an addition to force. It is an old ob- fervation, confirmed by daily experience, that, after the comple- tion of flow or lingering labours, patients ufually recover better, than after thofe which are quick; not to mention, that they are left liable to the untoward accidents which precipitation may im- mediately produce. Thofe who endure any kind of pain exprCfs their luffering by fome peculiarity of manner, or by fome tone of toice* which to a nice Obferver will generally difcover the part affeaed, together with the kind and degree of pain. Sharp pain is univerfally ex- preffed by an interrupted and acute tone of voice ; obtufe pain by a continued and graver tone, unlefs the expreffions are controll- ed by an acquired firmneft of mind, which oh particular occa- sions may enable it to rife above the infirmities of the body. The expreffions of pain uttered by wOmen In the aa of parturition may be confidered as complete indications of the ftate of the pro- ceft, fo that an experienced praaitioner is often as fully matter of the ftate of his patient, if he hears her expreffions, as by any mode of examination. He muft however underftand and make allowances for the peculiarities of different patients, or he will Vol. I. Dd J7$ INTRODUCTION TO MIDWIFERY. be deceived ; becaufe in tender conftitutions, the fenfations be- ing quick and the refolution faint, the mode of expreffion will be according to the fenfe, and not in proportion to the degree of $bfolute pain. In the firft ftage of a labour the change confifts in the dilatation of the parts. Forcible or quick dilatation gives a fenfation fimilar tp that produced by the infliaion of a wound,, and it is equally expreffed by an interrupted and acute tone of voice. Thefe are popularly called cutting, grinding, or rending pains. When the internal parts are dilated, and the child or contents of the uterus begin to defcend, the patient is by her feelings obliged to make an involuntary effort to expel; and the expreffions are then made with a continued and grave tone of voice, or ffie is mute. Thefe are called bearing pains. But there is an intermediate period of a labour in which there is in the firft inftance fome degree of dilatation, and afterwards an effort to expel; and then there will be the expreffion which denotes Sharp pain, combined, or imme- diately Succeeded by a graver tone of voice. When the. child firft begins to preft upon and to dilate the external parts, the expref- fion becomes again acute and vehement; and, laftly, the expul- fion of the child is often accompanied with an outcry of Suffering beyond what human nature appears able to bear; or the pain u endured with Silence. The knowledge of thefe circumftances, though apparently trifling and contingent, is really of fome im- portance in praaice, and permanant; as far, at leaft, as the free- dom or reftraint of the breathing can operate. If, for example, on any principle the patient was induced, in the begining of labour, to retain her breath, and to make Strong efforts to expel, the order of the labour would be inverted, as it would alfo be when the parts were dilated, and the expulSatory power want«d, if'fhe ffiould exclaim. The pains of labour or childbirth, and the aaion of the uterus, are terms ufed fynonymoufly; but they are not exaaiy the fame' thing. The aaion of the uterus, by which its contents are com- preffed into a lefs fpace, and would be excluded if there was any opening for their paffage, firft takes place as a caufe ; and this does not feem to be,attended with pain. When fome part refills the paflage of the contents of the uterus, the exclufion of which is the effea to be produced, there will then be pain proportion- ate to the aaion, to the fenfation of-the refilling part, and the. refiftance made. There is no way by'which we can eftimate the degree of force but by the refiftance ;' nor the refiftance but by the pain attending it; nor the pain but by the expreffion. Judging by induaion of the Sorcc exerted, by the expreffion of the ON LABOUR. 177 pain, we fay m common language a weak pain, a Strong pain, or a woman is delivered by her pains ; and the purpofe of convey- ing our meaning is anfwercd, though the expreffions are not ftriaiy logical. We may fuppoSe the parts, through which the child muft paSs, So perfectly diSpoSed to dilate, that they would make little or no refiftance to the excluding force, and then a woman would be delivered with little or no pain, This obfer- vation will not only difcover the reafon of the great advantage obtained by a labour being flow and lingering; and why fome Woman are delivered comparatively without pain ; but, with this perfea difpofition to dilate, if the patient fhould be afleep when the aaion of the uterus came on, of the poffibility of her being delivered before fhe was quite awake. In the converfation of thofe who attend labours it is often fur- mifed, that women have much unprofitable pain. This ftatement is not only unfair as to the faa, hut the languange is very difpi- riting; and it is often affigned as a reafon for an interpofition altogether unneceffary, and often injurious to the mother or child. No perfon in labour ever had a pain depending on her labour, which was in vain. It may not be equal to the accompliffiment of the effea we want, or at the time we wifh, but every pain muft have its uSe, as preparatory to, or absolutely promoting, the effea; and, as we are not able to comprehend every poffible caufe of every ftate, by endeavouring to remove what appears to be one flight ill, it often happens that we occafion many, and thofe of greater confequence. Though the pains of labour return periodically, the intervals between them arejof different continuance. In the beginning die pains are ufually flight in their degree, and have long intervals; but as the labour advances they become more violent, and the intervals are ftiorter. Sometimes the pains are alternately Strong and weak, or two feeble and one ftrong ; and there is reafon tp think, that every variety has its advantage, by being Suited to the apparent or real internal ftate ot every individual patient. In every circumftance, which relates to natural parturition, it is impoffible not to See, and not to admire, the wiSdom and good- nefs oS Providence, in ordaining the power, and fitting the exer- tion to the neceffities oS the fituation, with a marked refpea to the fafety both of the mother and child. This perfea concidence between the caufe and effea ffiould afford a leffon of patience to thofe perfons, who when in labour become intraaable, and, by lofing their felf-poffeffion, add to the unavoidable evils of their Situation ; and to thofe praaitjoners, who, being led away by popular errors, aim to add to the ftrengthof the pains, or to quicken i7i INTRODUCTION TO MIDWIFERY. their returns, and aa as if they thought there was no other eyi| but that of a flow labour ; an opinion which in its confequence has done more mifchief than the moft Skilful praaice ever did good. SECTION IV. Though it was faid, that pain was, properly fpeaking, a eon? ftituent part of a labour, it was alfo obferved, that all pain in the region of the uterus, though periodical in its returns, was not a pofitive proof of the exiftence of a labour. For whatever distur- bance is1 raifed in the conftitution, efpecially in thofe parts con- neaed or readily contenting with the uterus, or with which the uterus may reciprocally content, towards the conclusion of preg- nancy, it is very apt to induce the fymptoms of labour, in a man- ner which makes it difficult to diftinguiffi between true and falfe pain. Yet the good of the patient, as far as relates to the proper condua of the enfuing labour, may depend upon the juftneft of the diftinaion ; for if the pain, which is falfe, be encouraged or permitted to continue, the aaion of the uterus would follow* and premature labour occafioned. ' * The cauSes of falfe pain are various ; as fatigue of any kind, efpecially too long Handing ; fudden and violent motions of the body; coftivenefs, or a" diarrhoea ; general feverifh difpofition; agitation of the mind,' and a fpafmodic aaion pf the abdominal mufcles. l Very frequently alfo the irregular and ftrong move- ments of the child, in irritable conftitutions, occafion pains like thoSe arifing from the aaion of the uterus at the time of labour. In fome cafes there is fuch a clofe refemblance between the true and falfe pains, that they cannot be diftinguiffied without an examination per vaginam. * If, during the continuance of a pain, no preffure upon, or dilation of, the os uteri can be perceived, we may conclude that the pain is not the confequence of the aaion of the uterus ; and whatever likeneft it may have, that is not true pain. But if there ffiould be preffure upon, or dilation of, the os uteri during the continuance of the pain, we may con- fider it as proceeding from the aaion of the uterus, and be per- fuaded that the patient is really in labour. In a few cafes, I have known the aaion of the abdominal mufcles fo regular and ftrong, that the whole volume of the uterus has been heaved up and down alternately, in fuch a manner, that it was Scarcely poffible to diftinguiffi between this ftrange fuccuflion and the proper aaion of the uterus. The means to be ufed for the relief of falfe pain muft be guid- ON LABOUR. «79 ed by the caufe. When it is occafioned by fatigue of any kind, immediate eafe will often be gained by a ffiort confinement iri an horizontal pofition. In plethoric habits, or with a feverifh difpofition, it will be neceffary to take away fome blood ; and, when the "patient is coftive, to procure ftools by emollient clyfters or gently opening medicines. In every cafe, when means adapt? ed to the apparent caufe have been uSed, it will be proper to give an opiate proportioned to the degree of pain, or to repeat it in fjnall quantities at proper intervals till thepatient ffiallbe compofed* SECTION V. It has been thought equally incumbent upon the prs aitioner ±0 promote the power and effea of true pain, as it was to quiet that which was falfe. This opinion is perhaps more univerSally popular than any other throughout medicine ; and having infeaed the minds of praaitioners, it has been as injurious as general. From this fource may be traced the opinion of the neceffity, and the abominable cuftom of giving affiftance as it is called, by dilat- ing the internal and external parts artificially; of giving hot and cordial nouriffiment during labour, even iii plethoric habits and feverifh difpofitions, by which the nature of the principle which fhould actuate the uterus is changed, the pains are rendered rderly and imperfea, and the foundation of future mifchief difficulties, in one form or other, invariably laid. Hence alfo was derived the doarine of the neceffity of patients helping themfelves, as it is called, by urging with all the voluntary force they are able to exert beyond the diaates of nature ; as if a labour was a trick to be learned, and not a regular proc§fs of the conftitution. Women ffiould be informed, that the belt ftate of mind they can be in at the time of labour is that of fubmiffion to the neceffities of their fituation ; that thofe who are moft patient aaually Suffer the leaft ^ that, if they are refigned to their pains, it is impoffible for them to do wrong ; and that attention is far more frequently required to prevent hurry, than to forward a labour. In every thing which relates to the aa of parturition, Nature, not difturbed by difeafe, and unmoleited by interruption, is fully competent to accomplifli her own purpofe; She maybe truly Said to diSdain and to abhor affiftance. Inftead, therefore, of defpairing, and thinking they are abandoned in the hour oS their diftreSs, all women ffiould believe, and find cemfort in the refleaion, that they are at thofe times under the peculiar care of Providence ; and that their SaSety in childbirth iscnSured by more numerous and powerful refources, than under :my other circumftances, though to appearance lefs dangerous. "^ ""and t8o INTRODUCTION TO MIDWIFERY. SECTION VI. In order to give a full and diftina view of a natural labour, it is expedient to divide the proceft into three periods or Stages. In the firft will be included all the circumftances which occur, and all the changes made, from the commencement of the labour to the complete dilation of the os uteri, the rupture of the mem- branes, and the difcharge of the waters; in the fecond, thofe which occur between that time and the expulfion of the child ; and in the third, all the circumftances which relate to the fepara- tion and exclufion of the placenta. In the beginning of labour the os uteri is found in very different ftates in different women. In Some it is extremely thin, and in others of confiderable thicknefs; in Some it is rigid and clofely con- traaed, but in others it is much relaxed, and fomewhat opened for feveral days, or even weeks, previous to the acceffion of labour. In fome cafes the os uteri remains fo high, that it can with difficulty be reached, in the centre of the fuperior aperture of the pelvis, pro* jeaed backwards or on either fide ; whilft in others it is Spread thin, and preffed very low before it begins to dilate. There is, in ffiort, every variety pf ftate and pofition, which a part con- ftruaed and conneaed like the os uteri can be thought capable of undergoing. The firft part of the dilatation is generally made very flowly, the aaion of the uterus, on which it depends, being feeble in its power, and flow in its returns; but the more perSea the ftate of refaxation is, with the greater facility the dilation will of courfe be made. This is at firft effeaed by the fimple preffure of the contents of the uterus upon the os uteri ; but when the dila- tation is made to a certain degree, the membranes containing the waters pf the ovum are infinuated within the circle of the opening os uteri, and form a foft pillow, which, at the time of every pain, aaing upon the principle of a wedge, operates with increafing force according to the fize it acquries ; in confequence of which the latter part of the dilatation ufually proceeds with more expedir tion than the former, unlefs the membrane containing the waters be previoufly ruptured. There is no poffibility of prognofticating how long a time may be required for the complete dilatation of the os uteri in any individual cafe; yet a tolerable conjeaure, fubjea however to many deviations, may be formed by a perfon who has had much experience. If, for example, after the continuance of the pains ON LABOUR. l8l for three hours the os uteri fhould be dilated to the fize of one inch; then two hours will be required for dilating it to two inches; and three hours more will be neceffary for dilating it completely, provided the aaion of the uterus ffiould proceed with regularity and with equivalent ftrength. But in fome cafes the os uteri will abide in nearly the fame State for feveral hours ; yet when the di- latation begins, it will foon be perfeaed. In others, after a cer- tain degree of progrefs, the aaion of the uterus will be fufpend- ed for many hours, and then return with great vigour; fo that all which could be faid on this fubjea would in faa be conjec- ture. With firft children this ftage often makes the moft tedious and important part of a labour, both on account of the time re- quifite for completing the dilatation of the os uteri, and becaufe the accompanying pain is more fliarp and harder to bear, than that which is attended with the effort to expel; which never fails to infpire the patient with the hope of being foon freed from the mifery which fhe endures. When the parts are to our appre- henfion in the fame ftate, there will be a wonderful difference in the manner of, and the time required for, their dilatation, in firft and fubfequent children. There might be much difficulty in ex- ploring and ascertaining the cauSe oS this difference: but we may preSume, that a part which is accuftomed to pertorm an office, or undergo a change, acquires a diSpofition to the office or change, according to the number of times it has performed that office, ox undergone that change. Something of the kind may be obferv- ed in new-born infants, in* which there is often a tardineft in ex- ecuting what may be confidered as the common funaions of the body. As a labour advances, the intervals between the pains become fhorter, and their force is increafed. At the time of each pain the patient is reftleSs, and Solicitous Sor the event; but when it ceaSes, by a happy oblivion, She Soon forgets it, and is unmindful of its return. in fome conftitutions the labour, inftead of ad- ding to the irratibility of the habit, and exciting its powers to ac- tion, occafions a degree of infenfibility ; or the patient falls into a found fleep the moment the pain begins to abate, from which ffie is awakened by its return. In others, the power exerted by the uterus, aided by that" oS the abdominal muScles and diaphragm, being insufficient for the purpofe of dilating 'the os uteri, or that part becoming unufually irritable by the frequent impreffions made upon it; then, by its content with the ftomach, extreme fickneft or vomiting is brought on, Sometimes after every pain, by which the labour is very much forwarded ; one fit of vorr.i*- l8z INTRODUCTION TO MIDWIFERY. ing, according to popular obfervation, doing more Service than feveral pains, partly by the increaSed preffure, and partly by the Succeeding relaxation. But when the os uteri is dilated, patients have very Seldom an inclination to vomit from any natural caufe. Vomiting very often attends the paffage of a ftone through the ureters, or the gall-dutls, from the fame Caufe, and with the fame effea. By regular returns of pain, or with the varieties before menw tioned, with many others which it is impoffible to enumerate, the os uteri becomes at length wholly dilated* Whether a ffiort or a long time be required for this purpofe, it is the duty of the prac- titioner to abftain from interfering in this part of the proceft. It may fometimes be neceffary to pretend to affift, with the inten- tion oS giving confidence to the patient, or compofing her mind^ But all artificial interpofition contributes to retard the event So impatiently expeaed, by changing the nature of the irritation and the action thereon depending; or does mifchief by inflaming the parts, and rendering them left difpoSed to dilate; in Short, by occafioning either preSent diSorder or future difeafe. For thefe reafons we muft be firm, and refolved to withstand the entreaties which the diitreSs of the patient may urge her to make, as we mull alfo the diaates of vehemence and ignorance in the by* Standers. Others may be impatient, but we muft poffeft our- felves, and aa upon principle. The event will juftify our con-* dua ; and, though there may be temporary diflike and blame, if we do what is right, there will be permanent favour and repu- tation. During the continuance of a pain the membranes containing the waters are turgid, preffed upon, and within the circle of the osuteri, according to the ftrength of each pain, by which the fur- ther dilatation is promoted; but in the abfence of a pain the membranes become flacid, and feem to be empty. Thefe differ- ent flsites of the membranes are readily explained by the obfer- vations before made, by our knowing that when the uterus is in aaion its cavity is leffened, and of courfe its contents are com- preffed ; but on the ceffation of the aaion the cavity of the uterus is -again enlarged, and the compreffion removed. Hence it be«* comes neceffary, When an examination per vaginam is made du* ring the time of a pain, that we fhould be cautious not to break the membranes ; and if any accurate investigation be needfulj, ei- ther of the Slate of the parts or of the pofition of the child, that it ought to be made in the interval between the pains, or protraa* ed till the-pain has ceafed. In a fliort time after the os uteri is wholly dilated, the mem- ON LABOUR. 183 branes are ufually ruptured by the force of the pains, and the waters of the ovum are difcharged in one large guffi or ftream. But in many cafes the membranes break fpontaneoufly long be- fore this period, without any material inconvenience. In Some they are not ruptured when the dilatation of the os uteri is com- pleted, but are protruded by each fucceffive pain lower down into the vagina, and then within the oS externum, which they alfo di- late ; and at length a fmall bag of water is formed without the os externum, which can ferve no farther purpofe. It is a commonly received opinion among the lower clafs of people, that the child ffiould be born fpeedily after the rupture of the membranes and the difcharge of the waters. This opi- nion is not founded on prejudice, but on found obfervation ; and was probably firft entertained by thoSe who were engaged in the care of breeding cattle, in which this is the order and ufual courfe Of parturition; and I believe it would more frequently happen in the human fpecies, if the progrefs of the labour were not by fome means Or other difturbed or interrupted. But it has been a cuftom, which at the preSent time is not unSrequent with praai- tioners, urged by the diftreft and Suffering oS thoSe whom they are" attending,or by the concern of friends, or by a perfuafion of its propriety and advantage, and fometimes perhaps by their own im- patience, to break the membranes before the os uteri is dilated. If thefe are ruptured fpontaneoufly or artificially before the os uteri is dilated, the child Cannot poflibly follow immediately; and all that is gained is by bringing the head of the child, inftead of the membranes containing the waters, into contaa with the os uteri. This cannot be confidered as any advantage, as it changes a very SoSt and accommodating medium, provided by Nature for the purpofe of preventing any undue violence upon a very tender part, for the hard and unaccommodating head of the child. Nor is this the only ill confequence which follows : by fuch proceed- ing we occafion a general derangement of the order of the labour, which is never done with impunity, as it may afterwards become the caufe of a laceration of the external parts, or even of an un- favourable feparation of the placenta. Moreover, by this pre- mature rupture of the membranes, we often defeat our own pur- pofe ; and, by disturbing, protract inftead of haften the labour. We will therefore agree in eftahlifhing it as a general rule for our own condua, that the membranes fhall never be ruptured ar- tificially, at leaft before "the os uteri is fully dilated, and be per- fuaded that it is afterwards unneceffary, unlefs thera ffiould be Vol. I. E e . 184 INTRODUCTION TO MIDWIFERY. Some cauSe more important than the mere delay of a labour,- or Some reaSon of more weight than thofe which have been com- monly affigned. SECCION VII. In the Second period or Stage of a labour will be included all the circumftances attending the defcent of the child ; the dila- tation of the external parts ; and the final expulfion of the child. Notwithftanding the definition of a natural labour, which was before given, it is not to be confidered as a procefs going on in one unvarying line, nor is every aberration to be thought of fuffi- cient importance to conftitute a labour of another clafs. In this refpea the definition of a labour may be compared to that of health, which, however correa in general, would not correfpond in all points with the ftate of any individual perfon, if fubmitted to a critical examination. In like manner, though a labour can- not come under the denominaltion of natural, without the three diltinguifliing features, yet we may probably nevef meet with any two labours in every refpea exaaiy fimilar. There are perhaps more frequent deviations in the firft ftage of a labour, than in any other, both with regard to the time and the manner in which the os uteri is dilated. Nor is the firft ftage concluded either by the dilatation of the os uteri, nor by the rupture of the mem- branes and the difcharge of the waters, but by the concurrence of thefe circumftances ; and the farther the labour is advanced before the membranes break, the better it afterwards terminates. For, before that event, there is left violence done to the mother, and left ftrefs upon the parts; becaufe, without much fuffering, they every moment acquire a better difpofition to dilate ; and, till that has happened, whatever may be its pofition, the child under- going no compreffion is free from all change of injury. When the membranes break, if the os uteri be fully dilated, the child, though refting at the fuperior aperture of the pelvis, either finks by its own gravity, if the patient be in an erea pofi- tion, or is propelled by a continuance of the fame pain by which they were broken; or, after a fhort refpite, the aaion of the ute- rus returns, and the head of the child is foon brought So low down as to preSs upon the external parts : properly Speaking, upon the internal SurSace of the perinoeum. In its paffage through the pelvis, the head of the child, which at the fuperior aperture was placed with one ear to the offa pubis and the other to the facrum, or with different degrees of diagonal direaion, undergoes va- rious changes of pofition, by which it is adapted to the form of ON LABOUR. I85 each part of the pelvis, with more or left readineft, according to its fize, the degree of its offification, and the force of the pains. With all thefe changes, whether produced eafily or tedioufly, in one or in many hours, the praaitioner fhould on no account in- terfere, provided the labour be natural. IS he attempts to cor- rea and to regulate every flight deviation, or uSes any artificial means Sor haftcning the proceSs, the events of his praaice will convince him, that he has exercifed his art on unneceffary and improper occafions. He will moreover be taught, though he may acquire momentary approbation by endeavouring tp remove every little preSent inconvenience, that diSeaSes then Sar diftant will be attributed to his mifcondua, and Sometimes not without reafon. In this ftate and kind oS labour he may with confidence rely upon the powers and reSources of the conftitution, which will produce their effea with left injury either to the mother or child, and with more propriety than can be done by the moft dexterous human fkill. The external parts yield in a Shorter or longer time, and with more or leSs eaSe, according to their natural rigidity, the degree oS diSpofition to dilate which they have afTumed during the la- bour, the Sorce and Srequency oS the pains, and the number of children which the patient has beSore had. But the prevention oS any injury to the mother when the child is paffing through the external parts being efteemed a circumftance wholly depending upon the care of the praaitioner, this part of our fubjea deferyes a Separate and particular inquiry. SECTION VIII. When the head of the child firft begins to prefs upon and di- late the external parts, every pain may be Suffered to produce its full and natural effea, without the hazard of mifchief, but when a part of the head is infinuated between them, and the anterior edge of the perinoeum is upon the ftretch, they are liable to be in- jured by the violence of the diftention. Any of thefe parts may be injured; but the perinoeum in particular is fubjea to a lace- ration, which may not only extend fo far as to occafion much prefent uneafineSs, but Sometimes very deplorable confequences for the remainder of the patient's life. It is therefore our duty to inquire into the merits of the different methods which have been recommended for the prevention of this accident, more efpecially as it admits of very imperfea relief when' it has hap- pened. 186 INTRODUCTION TO MIDWIFERY. Yet it is very remarkable, that none of the ancient writers* either advife any method by which this accident may be prevented, or any means to be-ufed for its relief, excepting fuch as were generally recommended for inflamed, ulcerated, or fiftulous parts. We may therefore prefume, that it is an accident which did not frequently occur in their praaice, or that it was efteemed of too little confequence to engage their attention. With refpea to the former opinion, it may be obferved, that whatever event is the confequence of any caufe, it muft at all times be produced under the fame circumftances, if that caufe continues to exift and to aa. But thofe who perhaps had not perfeaion in view, and formed no very nice rule for their own condua, might not be fenfible of, or pay due attention to, the deviations or accidents which occurred, and would not adjudgedifagreeable confequences to their own error or mifmanagement. They did not therefore advife any method of preventing this accident, becaufe they were ignorant of the caufe, or they undervalued it. - It may be further obferved, that the oldeft writers in midwifery lived before the Chriftian religion was eftablifhed, and in coun- tries in which polygamy was allowed ; when the death or in- firmity of one wife was comparatively of little importance to him who had many, equally, or in fome degree, dividing or partaking of his affeaion. But on the eftablifhment of the Chriftian religi- on, by which the felfifh and bad diSpofitions oS the human mind were intended to be reftrained or correaed, and its better quali- ties exalted, one wite only being allowed to one man, and fhe being SuppoSed to poffeSs the entire affeaions of her hufband, every difeafe or infirmity, which might render her perfon left agreeable to him, became of infinite confequence to their mutual happineft. Thofe only who in the prefent Slate oS Society have had an opportunity oS Seeing the many evils, which flow- from this alienation of affeaion, the caufe being perhaps unknown to the parties themfelves, can be fufficiently aware of the importance of this and many other accidents and difeafes, to which wemen are fubjea ; and ^vhich are often negleaed and difregarded, becaufe they are not attended with immediate danger,- Still the queftion remains to be decided, whether women are by any peculiarity of conftruaion naturally or neceffarily fubjea to a laceration of the perinaum ; or whether this accident be the confequence of erroneous opinions, and of alterations in the * In the works of sZros, who lived in the ipb century, and which were publifhed by Spachius, this accident is firfl mentioned, and an nwkward method of preventing it is recommended. ON LABOUR. I87 frame, occafioned by the peculiar manners of fociety; or of any adventitious circumftance whatever, at the time of delivery. It was before obferved*, that none of the claffes of animals are lia- ble to a laceration of the perinaum, except when extraordinary affiftance >, given in cafes of otherwife infuperable difficulty ; and it is well known, that the laceration in any degree does not univerSally, or perhaps generally, happen to thofe women, who are delivered before proper affiftance can be given. It is alfo tp be remarked, that, as far as relates to the ftate of all the internal parts, the changes which they undergo at the time of parturition are not only effeaually, but moft fafely produced by the natural difpofition affumed by the parts, or the inftinaive efforts of the parent. From a general furvey of the wifdom, order, and ben- ignity, fo clearly apparent in all the defigns of Providence, in every circumftance particularly which relates to the propagation of the different fpecies of animals, and the co-aptation, as it were, of that wifdom to the neceffities of thofe of every kind, we might perhaps be juftified in making this general conclusion, that wo- men, in every circumftance which relates to their fafety and well- doing in natural parturition, are not left in a more deftitute ftate than animals: for though it were proved, that women are liable to greater natural evils and difficulties in parturition than animals the proofs of thefe would equally fatisfy our minds, that they are alfo provided by nature with many peculiar refources, and with powers which are, in general, limited only by the degree of the difficulties which require their exertion. • Nevertheleft, Srom the Srequency of the laceration of the pe- rinaum, when women are delivered without affiftance, and Srom the difficulty with which it is Sometimes prevented, when the moft judicious and Skilful affiftance is given,it is belicvedby many, that women muft often be unavoidably fubjea to it, and that the prevention muft ever remain an object, of human fkill. Now with refpea to the firft Statement, that of the laceration happen- ing when women are delivered without affiftance, it does not fol- low that it is inevitable; for even then it may be the produaion of error in the patient herfelf, or herfriends. Becaufe, from the hurry and folicitude of their minds, and even by their fears, ffie may have been encouraged to make great voluntary efforts, When the head of the child was on the point of coming into the world, merely becaufe fhe was not affifted ; or, aSter the expulfion of the head, inftead oS waiting Sor the body to be expelled alSo, Some offi- cious perSon preSumed to extraa it without regard to time, or the * See Chap. II. Sea. VI. J 88 INTRODUCTION TO MIDWIFERY. direaion 6f the vagina. As to the difficulty or impoffibflity of pre- venting the laceration in fome cafes, we are to confider, that what may happen in a ftate oS Society, might not have happened in a ftate of nature : that the foundation of the accident may have been laid by Something done in the preceding Stage of the labour ; and that it may be very much doubted, whether fome of the methods praaifed Sor the prevention may not intfaa have been the cauSe oS the accident. But the condua of the praaitioner is not to be guided by re- fleaions on what his patients might do or bear, with conftitutions healthy and firm, and with minds untainted with prejudices ; but by due consideration of what they are now capable of doing or bearing : and he muft adapt his rules and his praaice to the ftate in which he aaually finds them. From Some natural or adventitious cauSe the laceration of the perinaum to a certain degree certainly does often unavoidably happen ; but as fo much of the future happineft of a woman may depend upon its pre- vention, we will grant, what in many cafes feems true, that it is always to be prevented by our fkill and care ; as no harm can arife from the opinion, though erroneous, if the affiftance we afford be judicioufly given. In the beginning of a labour, efpecially with firft children, it is not unufual to find the external parts clofely contraaed, and void of all difpofition to dilate : yet in the courfe of a few hours, even when they have undergone no kind of preffure or diftention, but merely by a difpofition affumed from their conSent with the internal parts, they become relaxed and SoSt. The longer the time therefore which paffes between the commencement of a labour and the birth of the child, the left liable to a laceration will the perinaum be ; for it is Scarcely ever lacerated in a very flow labour, whatever may be the fize of the child. But if it was poffible to hurry a labour in fuch a manner, that the head of the child fhould be brought into contaa with, and preffed forcibly upon, the external parts, before they had acquired the difpofition to dilate, they would be univerfally torn, unlefs the accident were prevented by art : and the chance of the accident would be according to the degree of precipitation, and perhaps many hours after the aa, by which the labour was hurried, was forgotten. When the head of the child is infinuated within the external parts, if thefe do not eafily yield to the occafion, it has been cuS- tomary to dilate them artificially, under the idea oS preparing them, to allow of the more fpeedy paffage of the head. During .-very pain, it is obvious that the parts undergo as much diftention a? they are capable of bearing without injury ; and this prepara- ON LABOUR. I89 tion, as it is called, leffening in faa the native difpofition to dilate, irritating, and caufing alSo an additional flreSs upon them, no- thing is more clear than that this method oS proceeding contributes to their laceration. All artificial dilatation of the parts, all at- tempts to Aide the perinoeum over the head of the child Speedily, are therefore to be forborne and avoided as pernicious. When the external parts are very rigid, we have been taught, that it is of great fervice to anoint them frequently and unfpar- ingly with fome unauous application, with the intention of giv- ing or improving that difpofition to dilate, which is wanting. If the parts are clothed with their proper mucus, as by the ufe of any application in the manner advifed, that would be abfterged, we fhall afterwards find ointments oS any kind a very poor Sub- stitute Sor that mucus, and that there is little profit from their ufe, under any circumftances. But if the parts, from any caufe, fhould become heated and dry, after the application of flannels wrung out of warm water, fome foft and fimple ointment may be ferviceable, by abating their heat, giving them a difpofition to fecrete their proper mucus, and of courfe favouring their dilata- tion. In fome conftitutions the different parts concerned are not c- qually inclined to dilate. Sometimes the internal parts dilate in the moft kindly manner, when the external are in a contrary ftate; and fometimes the internal are very rigid, when the external parts have the greateft aptitude to dilate, yielding to the firft impulfc of the head. There is in all infinitely more difficulty with the firft than with fubfequent children, not from rigidity only, but, if we may be allowed the expreffion, from ignorance how to di- late ; and from a certain degree of region evidently perceived in the parts during the continuance of every pain. It is there- fore often obferved, that the head of the child advances more, and with greater fafety, when the violence of a pain begins to: abate, becaufe the re-aaion of the parts is not then fo ftrong, as while the pain continues in full force. During a pain there is often reafon to expea, that the head oi the child would be excluded ; but the moment the pain declines the head is retraaed a confiderable way into the vagina, and the external parts clofe again. No other inconvenience arifes from this caufe than a little prolongation of the labour, which maybe irkfome, but cannot be injurious. If the parts do not diftend favourably, fhould the head of the child abide within them in the abfence of a pain, it may be expedient to repel it in imitation of this natural occurrence, for the purpofe of preventing the Ite- ration. tpd INTRODUCTION TO MIDWIFERY. When the head of the child is every moment expeaed to pafs through the external parts, we have been advifed by fome,- to forward the emergence of the head from under the arch of the" pubes. Others have on the contrary affured us, that it is more eligible to prevent, for a certain time, this emergence, by which means not only time is given for the parts to dilate, but the head of the child is brought to pafs through them in its fmalleft axis, and left diftention is thereby occafioned. Whoever has refleaed upon this fubjea Would hefitate as much to believe, that, in the general difpenfation of Providence, it ffiould have been left to human fkili, to guide the head of the child at the time of birth in a direaion different from that in which it moft commonly pre- fents, as that It could have been intended for the generality of children to have been brought into the world' by inftruments, or by any human invention. As far as my experience enables me to judge, neither of thefe methods ought to be followed, nor any other which requires a complication of artifice ; for,- after a trial of them all, perhaps not very justifiably, I am convinced, that the moft effeaual method of preventing a laceration, or any injury to the parts, is to be founded on the fingle principle of retarding, for a certain time, the paffage of the head of the child through them. This retarding may depend on the compofure of the pa- tient, and the fkill of the praaitioner; and thofe errors, of which the former may be guilty, the latter muft endeavour to obviate and correa*. When the head of the child is nearly born, the effort to expel is made inftinaively, and it is ufually vehement, the breath being retained for the purpofe of Strengthening that effort. The patient may alfo* from a perfuafion of its being neceffary and proper, or at the inftance of her friends, ftrive with much volun- tary exertion to add to the force of the pain, for the purpofe of expelling the child more fpeedily. If we prefume, that the dan- ger of injuring the'parts depends chiefly upon the rapidity with which the head may be expelled, and that thefe are only able to bear without injury fo much diftention as is occafioned by the in- ftinaive efforts, then all the additional voluntary Sorce is beyond what is either needSuI or SaSef. It is therefore requifite that we * The greateft degree of laceration, which ever occurred to me, was occafioned by the patient fuddenly withdrawing herfelf out of my reach, beyond the pofftbility of my giving any affiftance, or fupporting the part at the infant when the head of the child paffed over the perinceum; an accident egainfl which I fhould have been guarded. f See Chap. II. Sec. VI. O'N LABOUR. IOI fhould do away this voluntary force, by convincing the patient of its impropriety, and difluading her from exerting herfelf; or -leffen at leaft the voluntary effort, by urging her to talk or cry out during the time of pain, which will prevent her from retain- ing her breath ; or, if her fufferings are fo great that ffie cannot command her own aaions, then the efforts ffie makes muft be refiftcd on our part by the application of fome equivalent force, in the manner we fhall foon confider. When the patient has been outrageous, and the danger of a laceration very great, I have Sometimes gained a reSpite by telling her Suddenly, in the height oS a pain, that the child was already born. Every thinking man will endeavour to carry the principles he has confidered and approved in his remembrance, through the whole courSe oS his praaice ; but the methods by which his prin- ciples are purSued muft be caretully Suited to the particular exi- gencies of every individual cafe. Yet when principles are ac- quired, there muft always be confiderable difficulty in applying them to praaice ; for it is not unufual to fee them at variance in medicine as well as morality. In the fubjea of which we are now fpeaking there is a number of little circumftances, the knowledge oS which can only be learned by experience, yet for thefe we fhould be prepared by refteaion, when they occur in praaice. But it will generally be fufficient for the operator to refift the progreSs of the head of the child, during the time of a pain, by placing upon it the fingers and thumb of the right hand, fo form- ed that they may bear upon many points ; or, to apply the balls of one or both of the thumbs in fuch a manner that they fhall at the fame time fupport the foiirchette, or thin edge of the perinaum. But in firft children, when, from the vehemence of the patient, the ftrength ot the pains, and the rigid ftate of the parts, there is great reafon to apprehend a laceration of the perinaum, then, occafionally calling in the other means to our aid, we fhall be able to give the moft powerful and effeaual fupport, by applying the palm of the left hand, covered with a SoSt Cloth, over the whole temporary* and natural perinaum, and the right-hand employed as was before mentioned, with a Sorce competent to refift the exertions ot the patient during the violence of the pain. In this way we are to proceed, till the parts are fufficiently dilated, when the head may be permitted to flide through them in the floweft and gentlefl manner; and we are never to quit our attention, till it is perfeaiy cleared of the perinaum. Should there be any delay or awkwardueSs when the perinaum Aides over the face, the fore- * See Chap. II. Sec. VI. Vol. T. Ff *0,2 INTRODUCTION TO MIDWIFERY. finger of the right hand muft be paffed under its lateral edge, by which it may be cleared of the mouth or chin, before the fupport given by the left-hand is withdrawn. When the pains are ex- ceedingly ftrong, and the patient reftleft in her efforts, the head will fometimes be expelled with wonderful velocity, in oppofition to all refiftance we are able to make; but by this calm and Steady proceeding we may be affured that we Shall, under all circum- ftances, wholly prevent, or greatly leffen, all the evils to which She would have been liable, iS our condua had been different. It is neceffary to obServe, that theSe attempts to prevent the laceration of the perinaum produce fome effea upon the head of the child, and upon the parts of the mother. In the application, therefore, of the rcfifting force, we muft not only be careSul, that the pofition of the patient is proper, and fuch as will allow us to aa with advantage,but that we do not make any injurious or partial preffure ; becaufe, if a partial fupport be given to the perinaum, the head of the child is projeaed againft an unfupported part, and the danger of a laceration is increafed. The fupport muft be equally applied, and uniformly exerted, during the time of every pain; and then there will be no greater prejudice done by the preffure we make, than what might have been occafioned by the mere rigidity of the parts. When the head of the child is expelled, perhaps the confe- quences of an inftant tranfition from extreme mifery to total free- dom Srom pain, and to pofitive joy, are in no caSe, to which human nature is Subjea, more conSpicuous and interesting, though the delivery be not completed. It was formerly fuppofed necef- fary for the praaitioner to extraa the body of the child, imme- diately after the expulfion of the head, left it ffiould be deftroyed by confinement in this untoward pofition. But experience has not only proved, that the child is not on that account in any par- ticular danger, but that it is really Safer and better, both for the mother and child, to wait for the return of the pains, by which it will Soon be expelled ; and a more Savourable exclufion of the placenta will alfo by this means be obtained. In the courfe of a few minutes after the expulfion of the head, the aaion of the uterus returning, the fhoulders of the child advance, and the ex- ternal parts of the mother being again brought upon the Stretch, the praaitioner muft place the fingers oS his right-hand on each fide of the neck, and at the fame time with the left fupport the perinoeum with as much circumfpeaion as when the head was expelled ; he muft.then condua.the body flowly in the direaion of the vagina, till it is wholly extricated, though two or three pains are fometimes required for the expulfion of the fhoulders of the child, after the head is born. ON LA-BOOR, *93 The child is to be placed in fuch a fituation, that the external air may have Sree acceSs to its mouth, its head being covered; care being then taking of the mother, we muft proceed to tie the navel-firing in the manner recommended in the next feaion. SECTION IX. The operation of tying and cutting the navel-ftrlng when the child is born, though in itfelf of no great importance, was for- merly thought to require fo much fkill and judgment, as to give a profeffional name to thofe, who are now called praaitioners in midwifery. But every thing which relates to the treatment of the mother or child is of fome confequence; and even in trifling mat- ters there is a propriety of manner, the want of which may leffen the eftimation of every perfon's charaaer. It feems to have been a praaice with the ancients, to wait for a certain time after the birth of the child for the exclufion of the placenta, before the navel-ftring was tied or divided; and if the child was born apparently dead, or in a very feeble ftate, the pla- centa, when expelled, was laid upon its belly, as a reftoring, or comforting application. When the child revived but flowly, or when the figns of life declined, it became a cuftom to lay the placenta on hot embers*, or to immerfe it in hot wine; and the heat thereby conveyed was fuppofed to Stimulate the weak or de- caying powers oS liSe to more vigorous aaion. It has Since been the praaice, to divide the funis immediately aSter the birth oS the child; and the weaker this was, the more expedition it was thought neceffary to uSe; Sor, the child being SuppoSed to be in a ftate fimilar to that of an apopleaic patient, a certain portion of blood might by this means be difcharged from the dividedyi/«i>, and the imminent danger inftantly removed. There is another method which I have feen praaifed, the very reverfe of the pre- ceding ; for in this, the loft of any quantity of blood being con- fidered as injurious, the navel-ftring was not divided, but the blood contained in its veffels was repeatedly ftroked from the placenta towards the body of the child. In all thefe different methods, and many others founded on caprice, or on direaiy con- trary principles, children have been treated in different times and countries, and yet they have generally done well; the operations of Nature being very ftubborn, and happily admitting of confi- derable deviation and interruption, without the prevention of her ends. * See Peu Pratique des Accouchmsnts, Livre I. Chap. xii. 18. 194 INTRODUCTION TO MIDWIFERY. There is yet in all things a perfeaiy right as well as a wrong method; and, though the advantage or disadvantage oS either may be overlooked, the propriety and advantage oS the right mc» thod muft be evidently proved by individual cafes, and of courfe by the general refult of praaice. In this, as well as in many other points, we have been too fond of interfering with art, and have configned too little to nature, as if the human race had been deftined to wretchednefs and difafter, from the moment of birth, beyond the allotment of other creatures, Perhaps the changes which take place in the body of the child, immediately after its birth, at leaft the manner in which they are produced, are not perteaiy underftood at this time*. But we know it the child is in a healthy ftate, that it utually cries luftily and continually, when the air rufhes into its lungs, which are thereby expanded. This cry, which does not Seem to be oc- cafioned by pain but SurpriSe, is in its confequences extremely important, as it is the paufe of an exertion of all the powers of the child, and enables it to acquire a new manner of living, in- confiftent with, and very different from, that which it pofieffed before it was born. But the change from uterine life, as it may be called, to breathing life, is not inltantaneous, but gradual; and the uterine life continues till the breathing life is perfeaed, as is proved by the continuance of the circulation between the child and placenta for fome time after it has cried. As the breath- ing life becomes perfeaed, the uterine life gradually declines, and the manner of its declenfion may be proved by attending to the pulfation of the navel-ftring, which firft ceafes at the part neareft the placenta, and then, by flow degrees, nearer and nearer to the child, till at length it entirely ceafes ; So that the whole of the circulating blood ultimately refides in the body of the child, and the navel-ftring becomes quite flaccid. It feems reafonable to believe, that the continuance of the uterine life after the birth of the child was defigned for its preservation Srom the accidents 7 ufing art, before we attempt to give affiftance. On the proper management oS the placenta the liSe oS the patient may depend; and it is thereSore fitting and neceffary, that our condua Should be guided not by prejudice, but by the diaates of reafon and experience. After a natural labour, efpecially with a firft child, the pain which the patient has fuffered, and the exertions by which the expulfion of the child was affeaed, will have occafioned a pro- portionate degree of temporary fever, and ffie will be in the fame fituation as if ffie had undergone fome exceffive fatigue. By the birth of the child fhe is freed from her fuffering, and it muft be our firft employment to reftore tranquillity to her mind, to calm the hurried circulation of the blood, to recover her from her fa- tigue, and to bring her as foon as we can into a natural ftate ; and this is to be done by keeping her perfeaiy quiet, affording her at the fame time fome refefhment, fuitable to the circumftances to which ffie may be reduced. In the courfe of ten, and Seldom more than twenty minutes, the aaion of the uterus is again exci- ted for the purpofe of expelling the placenta, which is indicated by pain, left in degree, but in other refpeas like that of which ffie complained when the child was expelled. It Seldom happens that the placenta is either wholly feparated or expelled by the firft pain ; but when that has ceafed for a few minutes, it is again renewed; and, on examination, the placenta is often found defcended, or deScending, into the vagina, where it may with Safety and propriety be fuffered to abide, till it is wholly expelled by a repetition of the pains. But if the placenta fhould defcend very flowly, or the patient be much difturbed, the praaitioner may take hold of the funis*, and by gently pulling in the time of a pain, and in a proper direaion, by the moft moderate aaion, favour its feparation and defcent. But whether the placenta fhould defcend into the vagina fpontaneoufly, or be brought down by the gentle affiftance given, it ffiould he Suffered to re- main there till it Is excluded by the pains ; at leaft it ffiould not be extraaed before the hurry occafioned by the labour is wholly compoSed, and the uterus has had Sufficient time to contraa in Such a manner, as to prevent any undue, or alarming lots of * When the young has been afhort time expelled, carnivorous ani- mals, apparently feeling pain, lay hold of the navel-firing with their teeth, in order to extratl the placenta. It is probable that a. woman in a fate of nature would, with her own hands, give fomething like the fame nffflance ; and in the force I ufe to bring down the placenta, I always "bear in mind this circumflance. I98 INTRODUCTION, TO MIDWIFERY. blood. The placenta Seldom remains more than one hour In this Situation ; but, if it Should not be excluded at the end oS that time, we may again take hold of the funis, and aiding the force of a pain, in the gentleft and floweft manner, bring the placenta through the os externum. We muft even then be cautious to bring down the membranes very flowly, and as perfeaiy as we can, that any coagula formed in the cavity of the uteris may be enveloped in them, and one principal caufe of after-pain be removed. Then the patient, being put in a comfortable ftate, and as little difturb- ed as poffible, may be left to her repofe. In this third Stage of a labour many inconveniences and many impediments to the exclufion of the placenta may occur ; the ge- nerality of which require a longer time to be given, and fome the affiftance of art, for the removal or prevention of danger. But of all thefe difficulties, and the means of giving relief, we Shall Speak more Sully when we come to the treatment of Uterine Hemorrhages. ON DIFFICULT LABOURS. 199 CHAPTER X. CLASS SECOND. SECTION I. ON DIFFICULT LABOURS. From the foregoing hiftory of a natural labour, and from the tenour of what has been on different occafions advanced in the preceding chapters, it appears, that parturition is a procefs of the conftitution, which, generally, does not require any affiftance; and that when it is natural, it ffiould be fuffered to have its own courfe without interruption, for the very fame reaSons which render all interpofition with other natural operations unneceffary, impro- per, and Srequently prejudicial. Whence then ariSes the necef- fity or expediency of eftabliffilng midwiSery as an art Sor the re- IieS oS the human Species ? or in what reSpeas has Society profit- ed by the establishment ? Certainly not on the preSumption that women are by nature deftitute of thofe powers, which at the time of parturition are in all other creatures generally equal to the exigencies of their fituation; nor when thoSe powers are fairly exerted, every caufe producing its effea, in the order and in the manner which the parts by their conftruaion were Sramed to perform and undergo ; nor, when there exift no uncommon im- pediments, by which the effeas to be produced by the natural cauSes are, or may be, obftruaed. But as the aid of medicine becomes neceffary, when from fome defeatve, or irregular exer- tion of the native powers of the conftitution ; or Srom Some ad- ventitious cauSe oS obftruaion; or from fome infirmity in the conftituent parts of any of the organs of the body, the funaions of any part are fuppreffed, impeded, or in fome way rendered ir- regular or imperfea, to the detriment of that part, or of the conftitution, or to the prevention of any effea neceffary to be produced: for the fame reafons, and in like manner, the affiftance ot the art of midwifery, Scientific or manual, may be required for the relief of fuch irregularities or difficulties as occur in the Vol. I. G g 200 INTRODUCTION TO MlDWlFERV- aa of parturition. // muft however be acknowledged, that all thi errors of pratlice do not proceed from ignorance of the art. Some of them may juftly be imputed to our entertaining too high an opinion oftbe art, or too much confidence in our own dexterity, or too little dependanct on the natural efforts and refources of the confiitution. In all creatures in which there is a difference of ftruaure, there muft be a difference in the cond»a or manner in which every funaion of the confiitution will be performed, which is at all conneaed with, or dependent upon, fuch variety in ftruc- ture; and a difference in the procefs of any funaion, efpecial- ly if this ffiould be rendered more complex, and of courfe more liable to aberration, may become the pre-difpofing cauSe oS Such deviations Srom the natural courte of that funaion, as may re- quire the affiftance of art: though the very fame funaion, pro- ceeding or being performed in a natural way, might be void of danger, and require no affiftance whatever. The knowledge of the peculiarities in the ftruaure of the human fpecies, or of the Specific circumftances in which the constitutions oS women differ Srom thoSe oS all other Semale creatures, may therefore be confidered as affording the only juft and true bafis, on which both the theory and praaice of midwifery ought to be founded. Be- fore we proceed then to an inquiry into the particular cafes, which may demand the affiftance of art, or determine upon the manner in which that art can be exercifed with the greateft propriety and advantage, a ffiort review of thofe peculiarities will be neceffary and ufeful, that we may be cautioned to avoid the abufe of the art, or the exercife of it, except in thofe cafes in which that affift- ance, which art can afford, is absolutely required. The firft and moft obvious circumftance, in which women dif- fer from all other female creatures, is the erea pofition of the body ; of the confequence of which, with regard to the pelvis, and fome difeafes to which women are particularly liable, notice has been already taken*. In the original conftruaion of the pelvis in quadrupeds, with a view to parturition, there feems to be a neceffity for regarding its capaciouSneSs alone ; becauSe if even more than fufficient fpace were provided for the paffage of their young, no attitude into which they put themfelves, or into which they can be compelled by any accident, during utero-gefta- tion, would fubjea them to difficulty or danger on this account. But from the erea pofition of the human body, if the cavity of the pelvis had borne the fame relative fituation and proportion to the fize of the foetus as in the quadrupeds, women would have been liable to many and great inconveniences. For the weight of the ovum and enlarged uterus muft, in advanced pregnancy, * Set Chap. I. Setl. v. and Chap. IV. Seel. i. ON DIFFICULT LABOURS. 101 have been occafionally fuftained by the foft parts, which becom- ing thinner and left equal to that office, according to the advance- ment, premature labour, as well as many other inconveniencies, muft oSten have been occafioned. For this, and perhaps Several other leSs obvious though probably equally important reaSons, all of which it would b# difficult to inveftigate, there undoubtedly is in human beings a greater difference between the dimenfions ot the cavity oS the pelvis, and the head oS the foetus at the time pf birth, than in animals ; and this difference, confifting chiefly in a greater proportionate Size oS the head muft eventually become the cauSe oS more painSul and difficult parturition. As there is no effea throughout nature without fome adequate caufe, as well as fome wife end, perhaps thei moft fatisfaaory proot oS the existence of this disproportion may be drawn from the conftruaion of the head of the human foetus, which being in- completely offified at the time of birth, is capable of having its form changed, and its fize diminished, without any injury, from the compreffion. TheSe effeas are produced in fome degree in almoft all labours, but very remarkably in thoSe which are com- pleted with difficulty ; Sor in Such, the Sutures not only accede, but the edges oSthe bones will ride over each other in a very ex- traordinary manner, yet without any apparent prejudice to the child. From this original and comparative relation between the cavity of the pelvis, and the head of the foetus, women therefore feem to be naturally more liable to difficulties in parturition than animals ; which difficulties may be efteemed as an allay for the advantages obtained by the erect pofition ; or becaufe their off- fpring were fo framed as to be capable of greater excellencies than animals; which excellencies may depend upon this conftruaion and fize of the head. Independent of this incomplete offification and its confequences, great numbers of children muft have been inevitably deftroyed at the time of birth, or the parents muft have died undelivered. Nor is this provifion only fufficient tq anfwer the end of mitigating thofe evils, to which women are by their ftruaure naturally and neceffarily liable ; but it is generally equal to the relief of thofe, which are occafioned by morbid alter- ations in the fize of the cavity of the pelvis. 2. The intercourfe between the parent and foetus, while it abides in the uterus, though generally alike in all viviparous ani- mals, has Some variation in each claSs. The ovum is in all con- structed for a temporary ufe, but in a moft beautiful and perfea manner for the purpofes for which it was ordained. The varia- tions may exift either in the uterus or ovum. In the uterus of the different claffes of animals, the moft obvious 202 INTRODUCTION TO MIDWIFERY. variety is in the form. Animals might, perhaps, be nearly as well arranged, and the clafs to which they belong as well deter- mined by the form of the uterus, as by any external or other internal mark. Such are the form and ftruaure of the ute- rus, fuch will be the properties ; and of courfe in every ani- mal in-which there is a difference in form, ftruaure or of pro- perties jthereon depending, there will be fome correfponding difference in the circumftances of parturition ; fo that if an in- quiry was attentively made, it is probable we ffiould not find an exac\ likenefs in the parturition of any animals, which vary ei- ther in genius or fpecies. The uterus in all animals may be confidered as. the bed or foil, in which the foetus is conceived, nourifhed, preferved, and accom- modated, till it arrives at a ftate of perfeaion, and the part by which it is ultimately expelled. For the completion of thefe ends, there muft be a perfea coincidence, at leaft a correfpond- ence, between the nature of the foetus to be thus conceived, nou- rifhed, preferved, and accommodated, and the form and proper- ties of the uterus, by which thofe offices are to be difcharged, as is proved by hybrids; and if the cafe were otherwife, there would be no conception. The varieties in the Sorm of the uteri in dif- ferent animals are progreffive, from thofe of the loweft tribe, which arc horned or convoluted, to the human, which when un- irrmr'gnated is pyramidal, becoming more oviform according %o the degree of its diftention. On the form of the uterus not only the accommodation of the foetus may depend, but the term of utero-geftation alfp ; or the power which every individual uterus has of bearing diftention only for a Specific time. Yet iS this were allowed, it would Still remain to be proved, why an uterus of one form became capable of bearing diftention tor a longer time than that of another. Complicated with, or dependent on form, is the fubftance or thicknefs of the uterus; and on this again the power which the uterus is capable of exerting at the time of parturition. The ute- rus in women is of greater thicknefs, and of a firmer texture in the unimpregnated ftate, than in animals oS an equal fize ; and in theSe it is Said to become Somewhat thinner, in proportion to its diftention ; whereas in women it retains its thicknefs, it it does not become rather thicker during pregnancy. It appears that by this thickneSs is gained the medium oS that power, which is exerted by the human uterus in the aa of parturition, and without which women could not in many cafes have been de- livered. But if there had been occafion in animals for the exer- tion of an equal degree of power, they could not have been de- ON DIFFICULT LABOURS. 203 livered-; as there is not in them a medium, by which fuch power could have been exerted, and the form of the uterus would alfo have been left favourable for its operation, had it exifted. This thicknefs oS the uterus, notwithstanding its diftention, is chiefly preferved by the gradual enlargement of the arteries, veins, and lymphatics ; and their enlargement is moft confpicuous about that part to which the placenta adheres. The quantity of blood circulating in the human uterus and the adjacent parts, during pregnancy, is very great; and itprobably undergoes in the uterus itfelS Some preparatory change, beSore it is conveyed to the pla- centa, where it may probably be Subjea to farther alteration ; So that it may be prefumed, that the uterus performs the office of a gland altering and preparing the blood, before any part of it, or any thing Secreted from it, is abSorbed or taken up by the vef- fels oS the placenta, Sor the uSe of the foetus, as well as that of the containing part of the ovum. On the quantity of blood circu- lating in the uterus may alfo depend its aaion at the time of la- bour ; for if the placenta be loofened before the child is born, and the blood has a free difcharge, there is Seldom any efficacious ac- tion, though the uterus may be, in all other refpeas, in a ftate of perfea health. In our prefent inquiry, the principal part of the ovum, which deferves attention, is the placenta, and of this there is an endleft variety in the different kinds of animals, according to the nature and properties of each parent and the offspring. In the belluoe, the office of the placenta is performed by the whole membrane of the ovum being thickened, and becoming proportionably vafcular; in the pecora the placenta is divided into many lobules, compoSed of long and vafcular fibres, called cotyledons or cups, affixed to as many temporary eminences of the internal furface of the uterus; in the fierce it furrounds the uterus like an internal belt; and fo on, with great variety, in the different claffes of animals. But in the human fpecies, the placenta, as the word implies, is in one flattened mafs, of a circular form, becoming gradually thinner towards the edge, and adhering to the uterus with a broad fur- face. When any portion of this is feparated, the orifices of many of the large veffels of the uterus are opened, and a confi- derable quantity of blood is immediately difcharged, far beyond what could poffibly be loft in any animal, though of a much lar- ger fize ; and if the uterus were to continue diftended, the ori- fices remaining open, there would be a dangerous or a Satal he- morrhage. For not only the blood circulating in the uterus would be immediately poured out oS its veffels, but all that which is contained in the body might be drained, and the patient fpee- IC4 INTRODUCTION TO MIDWIFERY. dily periffi, if fhe was not relieved by art; and yet no animal ever was or could be deilroyed, or brought into danger, by this cir- cumftance. From the fame caufe alfo, the uterine difcharges continue a longer time, after delivery, in women than in animals; the irregularities and interruption of which may become the caufes of difeafe, and are proofs that, independent of fafhion or cuftom, there is a neceffity that women fhould, for their own fafety, be feparated from fociety for a certain time after delivery; or guarded againft fuch condua or accidents, as might caufe a fuppreffion of thofe difcharges. On account alfo of the form of the uterus, and the particularities of its aaion, of the bulk of the placenta, and the manner of its connexion, it is more likely to be retained or awkwardly expelled in women than in animals; and its retention may be followed by worfe confequences. 3. In the confideration of this fubjea, the paffions of the mind are of too evident importance to efcape attention, On a variety of occafions, thefe, in human beings, to a certain degree, in a na- tural ftate, and much more when heightened by all the refine- ments and perverfions oS Society, are Sound to be capable oS pro- ducing the moft extraordinary effeas ; by Suppreffing or SuSpend- ing for a certain time the aaion of any, or of all the powers of the conftitution; by occafioning them to aa with irregularity, and at improper times; and in Some caSes alSo by exciting them to aa with too great energy and Sorce. But animals Suffer neither from the recolleaion of the paft, nor dread of the future ; and aaing according to their nature, the good or evil of the prefent moment probably to them appears to be the principal part of their exiftence. In the paffions we may then difcover Sources of dan* ger and disturbance, inJthe pregnancy and parturition of women, from which animals are wholly exempt; and the obfervation is fo general, that care is univerfally taken to prevent the communir cation of any intelligence to pregnant women, or to thofe who are in, or about to be in labour, which can either diflreft, or much agitate them. To this principle or cauSe may alSo be re- ferred the many nervous affeaions, to which women are fubjea in the ftate of childbed, and for fome time after they are deli- vered, when the animal powers are reduced, and the fenfations quickened. But it muft be allowed, that the greater degree of thefe evils are not to be attributed to phyfical infirmities, but to moral errors. A confideration of their unimpaired conftitutions, and lets ex- quifite feelings, will likewife diScovcr to us the reaSon, why the l>vver orders oS women have more eaSy and Savourable births, than thoSe who live in affluence ; the Sramc of whofe bodies, and the ON DIFFICULT LABOURS. 20$ fenfibility of whofe minds are altered, and often depraved, by the indulgence of parents, when they are infants, and by their own luxury, when they are adult. The conftitutions of thofe who are hardy are better able to fuftain the common accidents of child- bearing, and they fuffer left becaufe they are ftronger, and have left feeling and apprehenfion. When the Egyptian midwives were charged beSore Pharaoh with difobedicnce to his orders, be- caufe they preferved the lives of the Hebrew children, they plead- ed in their excufe, that the Hebrew women were not like the Egyptian, " they were lively, and were delivered beSore they (the midwives) could come to them." Befides other motives, the He- brew women were flaves, accuftomed to labour and hard living, yet they had more children and eafier labours than the Egyptian, who, we may preSume, Suffered all the evils arifing Srom indo- lence and habits of indigence*. The fame obfervation will alfo explain the reafon of many of thofe evils, which women in the higher ranks of life fuffer; particularly why fewer women die in child-bed in the country than in cities, where even thofe of the lower clafs are often compelled to live in unwholefome fituations, and, too often plunging into grofs indulgences, therefore fuffer the fame or a worfe Sate, than the delicately luxurious. 4. We are laftly to confider, that women are by conftitution, and by habits ot education and living, Subjea to diSeaSes, to which animals are not liable ; which diSeaSes may create new cauSes of difficult parturition, by increafing natural evils, or by weakening thofe powers, by the operation of which difficulties ffiould be overcome. All thefe diSeaSes it is unneceffary, and per- haps impoffible, to enumerate ; but that, which by affedting the bones in general, and thoSe of the pelvis in particular, has the greateft influence on labours, is deterving oS eSpecial notice. * Among many wife obfervations and judicious inferences, made by Adam Smith in his Wealth of Nations, there is one taken from the fate of population in the northern parts of Scotland. He fuppofes, that women in the lower orders of fociety breed the greateft number of children s but that thofe in the higher rear more of thofe which are bred. The fame obfervation has been made of the Ruffians. It has been attributed to the fcantinefs of provifon ; but I believe it is very much owing to the coldnefs of the climate, as, with equal difficulty of Procuring the means offubfflence, in Ireland and many parts of"Eng- land,/or inftance, children born in health feldom die. Mr. Gilde- mefter, fecretary to the embaffy, affured me, that the children of the lower orders of the Portuguefe, who live very miferably, which are born in winter, generally die, but fuch as are born in ft turner are as com- monly reared. 206 INTRODUCTION TO MIDWIFERY. By the Rachitis is not only underftood the diSeaSe of children properly fo called, but the ofleofarcofls, or mollities oflftum alfo : this being the only difference between them ; that, in the former, the bones, in the infantile ftate, are prevented from acquiring fuch a degree of firmnefs, as will enable them to fuftain the weight of the incumbent body; without yielding and becoming diftorted ; which diftortion may remain to adult age, even though greater ftrength may have been afterwards acquired r but, in the latter, the bones having been properly formed and offified, becomes foft again, at any period of life, in confequence of the abforption of the offific matter, by which the moft extreme degrees and fright- ful kinds of deformity have been fometimes occafioned; the pro- grefs of the difeaSe being Sometimes indicated by the increafing difficulties oS Succeffive labours*. From diftortion produced by either oS theSe cauSes, the cavity of the pelvis, which, in a natu- ral ftate, ffiould meafure upwards oS Sour inches, in its narroweft limits, may be reduced to two, or even to lets than one inch; by which the reciprocal proportion between it and the head oS the fxtus is perverted or deftroyed, and it is absolutely impoffible Sor the latter to paSs through the pelvis. This SoStneSs and conse- quent distortion ot the hones, being peculiar to, or infinitely more frequent in the human fpecies, occafions difficulties at the time of parturition, from which animals are almoft univerfally free. Even if animals were liable to it, from their pofition and the diminifhed weight which the pelvis fupports in quadrupeds, it could not produce the fame kind or degree of effea. From the frequency of the rachitis in cold or unwholfome climates, in crowded cities, and wherever the employments and manners of the human race weaken the conftitutions of the inhabitants; and from its rarity in warm and healthy fituations, or with ruf- tic employments and fimple manners, we may conclude, though we retain and aa upon the fame principles, that the events re- fulting from the praaice of midwifery muft be different in dif- ferent places, and that the authority of the bell writers muft in fome meaufure be local. On account of the original fmallneft of the cavity of the pelvis relatively to the head of the child, of the ftruaure of the uterus and placenta, of the paffions, and of the difeafes to which man- kind are by nature, or by the cuftoms of fociety, rendered pecu- liarly liable, the caufes of many difficulties and dangers, which attend parturition, will be evident; and of courfe the neceffity of eftablifhing midwifery as an art for the relief of women will be evinced. * See Chap. I. Sea. x. ON DIFFICULT LABOURS; toj flut to tender thefe obfervations, with others diffufed through this work, of greater utility, I fhall endeavour to reduce them into propositions in the Sollowing order: Submitting them at the Same time with all deSerence to Suture confideration. i ft. All viviparous animals bring Sorth their young with pain. 2d. The degree of pain, which they fuffer, will depend upon the degree of their fenfibility, natural or acquired, and upon the difficulty with which they bring Sorth their young. 3d. The difficulty with which they, in general; bring forth their young, depends upon their conftruaion. 4th. By their conftruaion, they are alto endued with powers capable of overcoming all the difficulties, to which Such construc- tion generally renders them liable. 5th. The proceSs of parturition in animals is therefore to be efteemed a natural procefs, requiring no other affiftance, than the exertion of thofe power &, which depend upon their con- ftruaion ; And 6th. From the very nature of their conftruaion, and from their modes of living, they will not in general be liable to any material deviation from the ordinary procefs of their partu- rition. 7th. The conftruaion of the females of the human fpecies is different from that of the females of any order of animals. 8th. The conftruaion of the females of the human fpecies is fuch, as to render them unavoidably fubjea, in general, to great- er pain and difficulty in parturition, than the females of any order of animalsi 9th. But by the conftruaion of the females of the human fpe- cies, and by the original formation of the head of the human foetus, provifion is made for overcoming all the difficulties, to which the peculiarities of their conftruaion may render them liable. 10th. With regard to the aa of parturition, when natural, women are therefore to be efteemed on a Similar Sooting with animals. nth. But as women are by their conftruaion, and by the cuftoms ot Society, rendered Subjea to difeafes and accidents, which increafe the natural difficulties, and produce new cauSes of danger attending their parturition, from which the females of every order of animals are free, 12th. It will follow, that the occafions, which require affift- ance at the time oS parturition, do, and muft, oS neceffity, occur more frequently in women, than in the females of any order of animals. Hh 2P8 INTRODUCTION TO MIDWIFERY. From thefe premifes, the expediency and neceffity of eftablifh- ing midwifery as an art for the relief of the human fpecies will appear, and the art be direaed to its proper objeas. SECTION II. Many general circumftances and appearances have been men- tioned, and confidered as preSumptive figns oS difficult labours;. and it will not be improper to enumerate theSe, though I appre- hend, that much ftrefs cannot be laid upon them with a view to praaice, or even to prognostic. If they were certain and invari- able, it would be incumbent upon us to underftand the degree and extent of their influence, and to apply ourfelves to the difco- very of fome means, by which we might prevent or remedy the evils which were threatened. i ft. The kind of labour, which any particular woman will pro- bably have, has been fuppofed to be indicated, in fome degree, by her complexion. Women with very fair, or very dark com- plexions, have been fuppoSed equally Subjea to difficulties or in- conveniencies in parturition ; whilft thoSe oS the intermediate Shades were confidered as having advantages in their Savour. Now, as Sar as any particular complexion can indicate a general ftate oS health, this observation is reaSonable and true, with ref- pea to labours ; thoSe who have the beft health, uSually paffing through that proceSs in the beft and SaSeft manner. But as thoSe who are of complexions in either extreme may have perfea health, and eaSy labours, any inSerence drawn Srom this principle muft be liable to many exceptions. 2d. By the general Size of the body, it has been conjeaured, that we might forefee whether an enfuing labour would be eaSy or difficult. This observation will ftand upon the Same ground with the Soregoing ; that is, it may hold good, as Sar as any particular fize may be found beft fuited for performing all thefunc- tions of the body, and for the general purpoSes of life. Thofe who are very tall, are not often very aaive, or capable of bear- ing much fatigue ; and thofe who are very ffiort, may have been cramped or become deformed in confequence of ill health in the early part of their lives : thofe, on the contrary, who are of a middle fize, or rather below it, being prefumed to be more gene- rally healthy, and beft adapted to the common occafions of life may be expeaed to have the beft labours, as they have fuffi- cient power, and a readier difpofition to aa. ON DIFFICULT LABOURS. 209 3d. The habits of life, and the difpofitions of patients, have been fuppofed to have fome influence in forwarding or retarding labour. Thofe women, who are indolent in their tempers and habits, perform all the funaions of the conftitution in a flow and indolent manner, and of courfe may be expeaed to have tedious labours. But thofe who are of lively difpofitions and aaive habits, being in the conftant exercife of their powers, have not only thefe powers ftrengthened and improved, but greater energy alfo; and the aaivity of the parts concerned in parturition will partake of that of the body in general. 4th. The regularity, together with the eafe or difficulty of a labour, may, in Some meaSure, depend upon the ftrength or weak- neSs of the faculties of the mind. But this muft be a very ge- neral observation, and can only hold good in that extenfive way, in which it is admitted in other occurrences oS life, in which weaknefs of judgment may pervert regularity Into diforder, fancy evils that do not exift, or add to the weight of thofe which are un- avoidable. 5th. Labours are generally affeaed by the climate, in which women are born and refide. In hot climates, all natural labours are Said to be more eaSy, than in thoSe that are cold; probably, becauSe the difpofition to relax and dilate is Sooner affumed, and more perSeaiy accomplished. But in cold climates, Srom the native or acquired rigidity and firmnefs of all the parts of the body, there will be occafion for greater exertion, though there may be greater power ; yet if the labours are flower, perhaps the feelings are left, fo that they may terminate with equal Safety, and probably, on the whole, without greater Suffering. In the Same climate there will generally be Some variations in labour at different feafons ; and I believe it is true, that in this country women have eafier labours in Summer than in winter, and that they are leSs liable to diSeaSes in the ftate ot child-bed. Such observations might be extended to a greater length, and diScuffed with more nicety; but they can hardly eScape the notice oS an attentive man, and he that is prudent will not efleem them qS too much value. END OF THE FIRST VOLUME. INDEX TO THE FIRST VOLUME. mUm A. Page. Abdomen, diftention of - - - 152 .........pendulous - - - 153 Aaion, expulfatory, of uterus - - - 124 ....;......*.....common - - - 125 Amnion - - - - - 122 Anafarcous fwellings - - - - 150 Animals, diftinaion of - - -in Anxiety - - - - - 172 Appetite, attention to - - - - 140 Areola - - - - - 131 Afcites, obfervations on - * - - 151 B. Ball Stool, what - - 126, 142 Bladder, ftone in - - - "34 Bleeding, remarks on - - - - 13CS Blood, firft Sormed - - - - 111 ......periodical discharge of in men - "87 Breafts, fympathy of - - - $31, 164 C. Cancer, remarks on - - - - 98 ......propofal for improving our knowledge of - 99 Caruncutae myrtiformes - - ~ 36 Catheter, ufe of - - - "74 Child, dimenfions of head of - - - 20 .....ftruaure ot head of - - - ib. .....expulfion oS body of, ffiould be left to nature - 192 .....management of - - - - 193 .....dead - - - - 162 .....circulation of blood in - - - 115 .....pofition oS head of - - - 21 Chorion - - - - - 121 Cicatrices in the vagina - - "45 Clitoris, enlargement of - - - "35 Clyfters, great uSe of - - - -14$ Ii INDEX. Coccygis, os Conception, figns of ..........opinions concerning Corpora lutea Coftivenefs - - Cotyledons - Cramp remarks on D. Decidua reflexa • - - Diarrhoea - Diet in pregnancy - DiSeaSes of the uterus Dropfy of the uterus ............perinseum ,...........ovaria E. Egg, incubation of - Emetics, Safe in pregnancy - - Erratic pains Examination, method of ...........to be deferred ...........reafons Sor ExerciSe during pregnancy Extremities, lower, fwelling of F. Faeces, indurated, colleaion of Fallopian tubes - Fear - Feverifh difpofition Fluor albus - ..........method of cure Foetus, formation of - ......circulation of blood in ......peculiarities of ......fituation of Funis umbiliealis G. Gall ftones Generation, external parts of ........................difeafes of ..........internal parts of difeafes of INDEX. Page. H. Head, expulfion of - - - - 191 .....affeaions of - - - - 150 Heartburn - - - - - 141 Hemiplegia » - - - - .-150 Hemorrhoids - - - - - *43 Hernia - - - - - 152 ..... peculiar kind of - - - -81 Hydatids - - - - - 59 Hymen, defcription of - - - " 3*> ......imperforated, cafe of - - - 3 7 ......peculiar to the human fpecies - - - 3°^ ......rigidity of- - - - - 3 7 I. Ilium - - - - 4 Inquietude - - - - - 148 Irritability, doarine of - - - XX1 ..........firft cultivated by Gliffon - - -130 Ifchium - - - - " - 4 J- Jaundice in pregnancy - - - - J44 L. Labia pudendi, abfceffes of - - - - 3° .....cohefion of - - - - - 29 .....fwelling of, - - ~ - ib. .....enlargement of - - ■- - - 2 8 Labours, claffification of - - - - 170 ........natural - - - - _ ib. ........difficult - " *99 ........approaching, figns of - - -163 ........fymptoms of - - - - 172 ........firft ftage of - - - 180 ........fecond - - - - - 184 ........third - - - " " l85 ........teft of.....J78 ........pains of - - - " - 170 ........caufes of - I^1 ........predifpofing figns of - - - 163 ........duration of ----- 169 Labour-pains, diftinaion of - - - 178 Life, fufpenfion of, principle of - - -109 .....different modes of - - - - 194 Ligaments, facro-fciatic ' - - - 6, 164 INDEX. Page, Longing - - - - - - 139 Lungs, heavier than water, no proof of a child being ftiliborn - - -. - - - 116 Lymph, discharges of - - - -123 M. Magnefia vitriolata, great ufe of - - - 142 Meatus urinarius - - - - - 27 Mechanics, application of - - - 22 Medicine, hiftory oS - - - ix .................in England - xiii Membranes, rupture oS - - --183 ...........cautions reSpeaing - - - 182 ...........deScription of - - - 121 ...........menftrual - - - - 90 MenSes, hiftory and deScription of - - 83 .......deviation of - - 86 Menftrual ditcharge, exceSs oS - - - 95 ..................obftruaion of - - 92 .................. innocuous - - - 85 ..................does not coagulate - - 88 ..................ceafes in pregnancy - - 134 ..................quantity of - - - 85 Menftruation, efficient caufes of - - - 87 ............final caufes of - - 89 ............ceffation final of -, -t 85, 97 ............painful - - 06 Midwifery, hiftory of x ..................in England *. - xviii .......... general obfervations on - - - 199 Milk, Secretion of - - - - - 164 Minerals, growth of «• - 206 Moles, remarks on - - - - 62 Mollities offium - - 206 Mons veneris - - - - -26 Mucous difcharge >■ - - 164, 174 N. Navel String, ftruaure of - - -117 ........... on tying and cutting the r 193 Numbnefs of lower extremities - - - J47 Nurfes fometimes pregnant - - - - 161 Nut, growth of - - - - - 108 Nympha; - - - - - - 27 ,....,.. enlargement of r - 28 INDEX. Page. O. Opiates, cautions refpeaing - - - 138 Os uteri - - _ „ . -180 Offa innominata - - _ 3 Ovaria, defcription of - - - - 38 ,......enlargement of - - 69 .......dropfy of - - - 63 .............treatment of - - - 64 .............inflammation, fcirrhus, and cancer of - 6§ .......menftruation prevented by extirpation ot (note) 70 .......Subftances found in them - - ib. pvum, human ftruaure of - - - 114 ......in animals - - - - - 201 ...... impregnation of - - - - -112 ......membranes of - - - - 121 ...... waters of . - - - - 122 P. Pains, erratic <■ - r - 147 ..... falfe - - - - 174, 178 .....kind of - - - - - 176 .....of labour all ufeSul - r - - 177 ..............effeas of - - - 176 ..............not to be interrupted - - 179 ..............periodical - - - - 177 Parts, external - - - - - 26 .....internal - - - - --38 Parturition, difficulties of - •► - - 199 ..........caufes of - - - 200 ..........predifpofing figns of - - - 163 Paffions, effea of - - - - -04 Pelvis, ftruaure of - - - 1 ......bones of, connexion of - -5 ......cavity of ----- i ......diftortion of - "23 ......form and dimenfions of - - - 19 ...... matter formed between the loofened bones of -17 ...... pofition of - - - - 15 ...... reunion of - - - - 13 .... *. Separation of - - - 7 ...............cafes of - - - 9, 11 Perimeum - - - - . - 27 .. .'......dropfy of - - "79 .........cafe of - - - - 80 .........laceration of - - - 37, 185 ..................prevention of - - »- 188 INDEX. Perinaeum, laceration of, peculiar kind of Peffaries - Phyficians, college of Phyfometra - Placenta - .......perhaps a gland .......expulfion of .......attachment of Polypus - - % .......cafes of Predifpofing figns of labour Pregnancy, diSeaSes of Principles, mechanical Procidentia uteri Propofitions Pruritus - Pubis offa - Quickening 0^ R. Rachitis - Reckoning of women ......... Sull time to be allowed Retrofkaion - Retroverfion of tho^iterus Rigors _ - - - S. Sacrum, defcription of Shew, what Situation of the child Skin, difcoloration of Sleep, want of - - Small pox, doubts refpeaing .........danger of in pregnancy Spaying, what, and effeas of Spirituous liquors, evil of Stomach, affeaions of Stones, gall - Stool, ball - - - - Strangury' - - . " .........general Sign of natural labour Swellings, edematofe Sympathy INDEX. Symptoms of labour 172 'Tenefmus - Term of utero-geftation - Tubes, fallopian - Tympanites - - U. Urethra, difeafes of - - - Urine, fuppreffion of - ......incontinence of - Utero-geftation, term of - - Uterus, aaion oS ....... arteries oS - .......aScent of .......cancer of - .......cavity of - .......changes of - .......defcription of - - - .......in different animals .......dropfy of - .......forms of .......gravid contents of .......hydatids of .......lymphatics of .......mufcular fibres of - ^ .......fituation of .......thicknefs of ... ........ how dilated in labour .......untimely dilitation of .......prolapfus of - \................never beneficial .......retrofleaion of .......retroverfion of - ..................caufe of - ..................cure of ...................fymptoms of ...................caufed by enlarged ovarium .......veins of - V. Vagina . - - . ......cicatrices 06 ......contraaion of ... ......examination bf - 111, III; 127, - J73 - 158 - 42 - 6t 34 73 i45 158 124 40 124 98 39 123 38 201 60 202 114 59 41 ib* 124 203 125 127 5^ 59 7« 71 74 ib. 72 6-7 40 38 45 44 166 TZs index; Page- Vagina, difeafes of - - - -4.4 ......hernia of- - - x - ' < ......polypi of .... - 4 Varices - - - - - - - *47 Vegetables, growth of - - - io7 ..........probably fubjea to fimilar influences with " animals ^- -'*..-- - - ' 109 Venereal difeafe", fuppofed cafe of - . - 44 ..............in pregnancy - - - J53 ..............to be cured in pregnancy - - - ib. "."..[.........not communicated by an infeaed parent - 154 Vertiginous complaints - - • -150 Veficula umbilicalis - - - - - 122 Vomiting in pregnancy - - - - 137 ........in labour - - - - - 18 £ W. Wakefulneft - • ■ - - - 48 Waters of the ovum • - - - - 122 ......by, or falfe - - - - - ib. ......evacuation of, followed by labour - -123 Wind emitted from the uterus - - - - 61 Women, erea pofition of 200' .......difeafes of .--»-- 205 END OF INDEX TO THE FIRST VOLUME. t M Me^L.H.sti wz 9l7o c 3