EY.:. m fi 1 C^Y'- Ydkm My^ , ■',;;. ■■■ i. ^^^ ? ^■Ou :/u~ ■SO ■;, QX.XX. -^L'j-j'O-^ Surgeon General's Office ^f? ?f aA-4. >V J%»27 a*V X -cvAe s: £> **i 7?~ 5*/.g„ C<^6>-0 No./ &X ■ O^-O ■-'■■'D> n£'p*%. ?». \ wg$r-*»- « *■" ^ %Yr^Ya ■■ i ■£*u*£ktf'% :i >> > fas jj£i£■■» jfijjgw^M < X - o it v.' f\^i *.' AN ESSAY, &c & THE MEANS OF LESSENING PAIN. AND jfactfttattng Certain Caaieg OF DIFFICULT PARTURITION. BY WILLIAM P. DgWEES. M. D. LF.CTtTREIt ON MIDWIFERI IS PHILADELPHIA, &C. VWVWVWMAiVW ---------ut si Coecus iter monstrare velit.—-Hon. W%W\.WVW*W>. SECOND EDITION. PHILADELPHIA: PUBLISHED BY THOMAS DOBSON AND SON, AT THE STONE HOUSE, No. 41, tiOUTH SECOND STREET. William Fry, Printer. 1819. ' Eastern District of Pennsylvania, to wit: I***"**! BE IT REMEMBERED, that on the ninth day of E-e- * Seal. | bruary, in the forty-third year of the Independence of the I********! United States of America, A.D. 1819, Thomas Dobson and Son, of the said district, have deposited in this office the title of a book the right whereof they claim as proprietors, in the words following, to wit. " An Essay on the Means of Lessening Pain, and Facilitating Cer- tain Cases of Difficult Parturition. By William P. Dewees, M. B. Lecturer on Midwifery in Philadelphia, &c "--------utsi coccus iter monstrare velit.—Hor. Second edition." In conformity to the act of the Congress of the United States, inti- tuled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned."—And also to the act, entitled, " an act supplementary to an act, entitled, " an act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies during the times therein mentioned," and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvanitt * N. CHAPMAN, M. D. fyc. 6jc. fyc. Dear Sir, Permit me to inscribe this humble Essay to you; and be pleased to look upon it as a sincere though feeble expression of the regard of Your obliged Friend, WM. P. DEWEE& Philadelphia, December 6th, 1818.. / PREFACE. J. HE greater part of the following pages were an Inaugural Dissertation; the principles and practice contained in them, were the re- sult of seventeen years extensive business and careful observation; the experience of twelve years since, has but confirmed them. The au- thor, therefore, conceived that, by republish- ing them with some additions and corrections, he ran no risk of doing mischief, should he fail in a sincere desire to do good. He is persuaded that, up to the preseni time, no remedy has yet reached us of equal efficacy, for the particular cases for which it is prescribed, as the one he ventures to re- commend in this Essay, and is fully convinc- ed there is none safer. He must, however, beg of those who may feel disposed to rely upon viii it, to give it a fair and unprejudiced trial; to carefully discriminate the several varieties and conditions pointed out, and to apply the means to the extent proposed, and in the manner and under the circumstances designated; with an attention to these injunctions he feels a perfect reliance that no one will experience a disappointment who may adopt it. The short time which was allowed to fur- nish a Thesis, prevented any correction of the press; in consequence of which many errors in the printing, as well as of the opi- nions, were unavoidably promulgated, and this perhaps to the injury of the author; he has, however, endeavoured in this edition to diminish the number of both. JoHN C. S. WINfcTR, MP' AN ESSAY, &c. HOWEVER easy the act of Child-bearing may be among savage tribes and certain indi- viduals in various states of society, we find it among others an operation of great pain and frequent danger. It is not intended here to in- quire minutely into the causes of the depar- ture of this act from its original simplicity, but merely to glance at some of the most evi- dent; among which we must regard civiliza- tion and refinement as the most prominent, if not exclusively the only ones. It is not compatible with my present purpose, to point out in what manner these causes have operat- ed to effect this change; I shall therefore only state, a change has been produced in the fe- B 10 male human system, which subjects it to pain and difficulty in parturition; to show in what some of these changes consist, and how to ameliorate them, is more especially the object of the present essay. The causes of difficult and painful labours are various, and may with great propriety be divided into two general heads; namely, those which arise from some imperfection of the Pelvis, and into such as may tend to interrupt the natural and healthy functions of the soft parts; the latter however only comes within our present notice. The soft parts concerned in labour, are those which are directly, and those that are indirectly employed;—the former are the uterus, vagina, perinseum; the latter, the abdominal muscles, those of the thorax, diaphragm, fyc. A short anatomical description of the Ute- rus, with some physiological remarks, are judg- ed necessary, that some of the opinions ad- vanced may be the better understood. 11 The Uterus is a hollow viscus, in which the great object of conception is perfected. From the phenomena of Labour, and by actual dis- section in the gravid state, we do not hesitate to say it is composed chiefly of muscular fibres and blood-vessels. Although it be ad- mitted on all hands that it possesses muscular fibres, yet anatomists are not so well agreed as to the manner in which they are distribut- ed. Dr. William Hunter, in his plates of the gravid uterus, delineates them as transverse in the body, but, as describing at the fundus, concentric circles round each orifice of the Fallopian tubes; therefore, according to him, there are two orbicular muscles, and a trans- verse one. Malpighi describes them as form- ing a net work, while Ruysch contends they appear in concentric planes at the fundus, forming an orbicular muscle.* This diversity of description proves, that * Mr. Charles Bell has attempted to elucidate this, obscure subject, but with as little success as his predecessors. 12 the distribution of muscular fibres in the ute- rus has never been satisfactorily traced, and that their accounts have been very much in- fluenced by the individual theory of these great men. Great patience has been exercis- ed, and much labour expended in these re- searches, by very many excellent anatomists, besides those just named, yet they have never been able with their knife to clear up this point; we must therefore have recourse to other means to satisfy ourselves; the only certain one it appears to me is, to deduce them from the action of the uterus itself; this at least warrants two distinct sets, the one circular, the other longitudinal. The circular fibres are those which run in the direction of the transverse diameter of the uterus; they most probably commence at the fundus, and terminate at the extremity of the os tincse. They act somewhat like a sphincter muscle, and are, as we shall prove by and by, inferior in strength to the longitudinal fibres, which are those running in the perpendicular direc- 18 tion of the uterus; that is, in lines more or less direct from the fundus to the termination of the neck: they serve to diminish the length of the uterus.* The uterus is usually divided into fundus, body, and neck. The fundus is made to com- prehend all that portion which is above the insertion of the Fallopian tubes; the body, that portion below the tubes, but superior to the neck; the neck that part which is pendant from the body, and terminated by the os tincje. This viscus is abundantly supplied with blood-vessels, which very frequently anasto- mose ; so much so, that when injected in the impregnated state, they appear scarcely any thing else. These vessels however are very different in size in different states of the womb; in the unimpregnated state they are * The uterus may have fibres running in very many more directions than the two just mentioned, but the two noticed will serve to explain the phenomena of labour sufficiently, without having recourse to them. 14 small, and much convoluted, though numer- ous; but in the impregnated state they are much enlarged, and become much straighter in then- course. The veins are much larger than the arte- ries; they very frequently anastomose; are without valves, and terminate on, or expand into sinuses of sufficient size, in some in- stances, to admit the extremity of the finger. It has been usual to consider the fundus, bo- dy, and neck, of the uterus as a single viscus, whose actions were similar and dependent on each other; I have my doubts of the proprie- ty of this combination, as it does not accord with many circumstances connected with this organ. Hitherto the physiology of the uterus has been but too carelessly considered; re- gard having chiefly been paid to the conse- quences of its action, rather than the mode in which these actions were performed. T do not flatter myself I have completely 15 and satisfactorily explained the various func- tions of this organ; but I hope to awaken at- tention to this subject in others, whose talents and leisure will better fit them for the inves- tigation. What will be advanced on this head, is offered with diffidence, conscious of the dif- ficulty that attends enquiries of this kind, and the impossibility of reducing speculation to mathematical demonstration. The office of the body and fundus, is diametrically opposite to that of the neck or mouth of the uterus in time of labour; while it is the duty of the former' to contract, it is that of the latter to relax; and on the more or less perfect estab- lishment of these different actions, other things being equal, depend the facility, or difficulty of labour. Before we proceed farther, let us inquire into the functions of these parts. From re- viewing the various changes which take place in the uterus from the time of impregnation, to the expulsion of the mass it has been mar 16 turing, we cannot fail being struek with the various resources it seems to possess, and the wonderful order it pursues, to give the greatest possible chance of perfection to the ovum; to secure it against accident; and finally, to cast it off when it can no longer be useful to it. The various changes which the womb un- dergoes in these several processes, have been pretty distinctly marked, and the various phe- nomena of labour pretty faithfully recorded; but we have yet to lament, that so little pro- gress has been made in the knowledge of re- medies to prevent or overcome the difficulties which but too frequently occur in the different stages of gestation, and parturition: this can only be acquired by a more minute investiga- tion of the laws of nature, and an attention to the influence of certain agents acting on the female constitution in general, but more par- ticularly on the uterine system, and especially, on the different parts of the uterus itself. To 17 believe in the influence of certain causes on the different parts of the uterus, may at first sight appear unphilosophical; and to suppose we shall ever have them under subjection, will be considered as Utopian; but notwith- standing this, I have no hesitation in believing that the time will arrive, when we shall be able to prescribe internal remedies with as much certainty for a preternatural rigidity of the neck of the uterus, and for a too feeble or too powerful contraction of its fundus and body, as we do now for an intermittent.* For I cannot help regarding the neck of the uterus as a distinct and independent part from the body and fundus, and as having its own pecu- liar laws and actions; and that this separation of powers, is absolutely necessary to the ex- planation of some of the phenomena exhibit- * A part of this conjecture has since been verified, by our knowledge of the use of the Ergot, of which we shall speak more by and by; indeed the influence of blood-letting where the neck of the uterus is preternaturally rigid, corroborates another part. C 18 ed by health and disease, and the influence of certain agents on these parts. -*. My reasons for thinking so are, first, that we find the fundus and body may be distend- ed to a great extent without affecting the ar- rangement of the neck; thus in every uterine pregnancy we see these parts gradually yield- ing to the influence of the ovum, until about the sixth or seventh month; while the neck remains very much the same as before im- pregnation. Secondly, that after the sixth or seventh month the neck undergoes its changes, while the fundus and body become in a great mea- sure stationary; so that two distinct processes, or rather the same process is performed at two different periods, and in different parts, in the order we have just mentioned. Thirdly, that the neck may be affected by disease, while the fundus and body may re- 19 main free, and the reverse; and the neck may contract, or relax, while the other parts are in opposite states: thus in women who are in the habit of aborting from some peculiarity of the uterus, we find that the body and fundus may be excited into action while the neck for a long time remains passive; and also, the neck may relax, and the body and fundus after some time may be excited to contraction. And in cases of atony of the uterus after a too sudden delivery, the body and fundus may contract while the neck is the only part in fault, and vice versa. The different conditions that the parts of the uterus may be in at the same time, where atony partially prevails, would seem to de- monstrate the truth of what is here advanced. It is a fact well known to almost every prac- titioner of midwifery, that each of the parts into which we have divided this viscus, may separately and independently of each other be in a state of contraction or of relaxation^ 20 and thus exhibit different phenomena and be productive of different results. Now were these parts not influenced by different circumstances, these things could not happen; since two distinct actions are going on at one and the same time; or one of these parts may be labouring under disease without involving the other. That a woman may carry her child to the full period allotted for its perfection (and that she may afterwards produce it with the least possible trouble) a number of circumstances must concur with the greatest possible regu- larity. That she may carry it to the full period of gestation, she must be exempt from all and every cause capable of exciting uterine con- traction ; or at least that degree of it which would, sooner or" later, terminate in delivery ;* * Mr. Burns is of opinion that when the uterus is once ex- cited to action, we cannot arrest it; than which, nothing is farther from the fact, and is of course mischievous in its tendency, as it may prevent the use of proper remedies. 21 and that delivery may be then effected with the greatest facility, the following circum- stances must obtain: First, there must be a subsiding of the ab- dominal tumour, and if at this time a finger be introduced through the os tincse, we shall find the membranes alternately tense and re- laxed; these circumstances are owing to the uterus now beginning to contract, and forcing the presenting part into the pelvis. Secondly, there must be a secretion of mucus from the vagina: in some instances this flows from it, several days previous to the onset of pains; but for the most part it only happens a few hours before they are felt. This mucus is secreted from the surface of the vagina, and perhaps from a portion of the neck of the uterus. Why these glands are excited to this duty may perhaps be difficult to explain, but their action appears intimately connected with a certain state, or condition of the os tincse; 22 thus we find, ceteris paribus, this secretion to be most abundant, where there is the great- est disposition in the mouth of the uterus to dilate or relax; and with this, is connected, the same disposition of the perinseum. It must be observed, that the secretion here spoken of must not be confounded with leucorrhcea, as this discharge is by no means favourable to this effect. Thirdly, the mouth of the uterus must yield easily, that the contractions of the body and fundus may not be exerted for too long a time unavailingly. The dilatation of the mouth of the uterus, when best performed, is either before or very quickly after the painful con- tractions of the uterus have taken place; this in general is done without the mechanical aid of the contents of the uterus. Fourthly, the body and fundus must con- tract with sufficient force, to make the child pass through the pelvis. 23 Fifthly, the perineum must unfold without much or any mechanical force, that the child may not be detained in passing through the os externum. Sixthly, there must obtain between the foetus and pelvis, a proper proportion, and the former must be well situated, that it may de- rive every advantage from the circumstances just enumerated. Having thus pointed out what ought to obtain, that labour may be short and easy, we shall proceed to investigate some of these phenomena: and first that of the Dilatation of the mouth of the Uterus. It is a fact very well known to accoucheurs, that some time before the period of labour, the mouth of the uterus is a little way opened: this does not universally obtain, though suffi- 24 ciently often to warrant the assertion, that it does for the most part. This first degree of dilatation, however, is by no means essential to a speedy delivery, since it is generally ac- companied with very firm and unyielding edges; this obliges us to enquire whether this state be the effect of a mechanical, or of what other power. In order to which, we shall re- mark, that there are two states of the os tinea? at this period; the one, as just mention- ed, attended by very resisting edges, and the other with soft and yielding ones; these are essentially different. In the former case, it must be regarded as the effect of the mechani- cal stretching of the uterus, the fibres of the neck of which have been sufficiently unfold- ed to widen this aperture so as to admit the extremity of the finger, or even a larger body; the uterus appearing, as it were, not to have sufficient substance to cover the ovum com- pletely. But this, in some other instances, may arise from another cause: thus, when the uterus is not so fully distended, we may also 25 pass the finger; but in this case it is owing to the neck and mouth never being so complete- ly shut after the first child, as in the virgin state; therefore this case can only happen where the uterus has been subjected to the influence of labour before. In the other case, we have mentioned the mouth of the uterus to be in a very different state; that is, its edges are pliant, and may by a very gentle force be enlarged. This depends on a very different cause, and must be regard- ed as a salutary step towards labour. Baudelocque* appears to look upon both these states as the effect of the same cause; for he observes that,«the orifice of the uterus " is almost always a little open before the " epoch of labour. We see the reason of this, " by following, step by step, the order of the " development of that viscus, and by attend- * Vol. 1. p. 336. Heath's Trans. D 26 " ing to all that passes at its orifice in the lat- " ter periods of gestation." In this paragraph he alludes to an explana- tion he has previously given, in which he en- deavours to explain the successive develop- ment of the uterus, and eventually the open- ing of its mouth at the time of labour; we shall therefore transcribe it, that our quotation may be the better understood. He observes, page 132, par. 199 and following, that "the fibres " of the fundus and body of this organ, are " more supple, and naturally more disposed to " unfold, than those of its neck, furnish almost " the whole of the amplification necessary be- " fore the sixth month of pregnancy; so that " till that time the uterus seems to borrow " nothing from its neck. It is at this epoch "that the fibres of the latter part begin to de- " velop, a nd contribute with the former to " the dilatation necessary for the convenient " lodgment of the fcetus and its appurtenan- " ces. From this time all the fibres extend a.7 " and unfold in the same proportion, and con- " tinue to do so for some time: but towards " the end of pregnancy, the dilatation of the " uterus is made almost entirely at the ex- " pense of the fibres of its neck; because " those of the fundus make a greater resist- " ance; and there no longer exists a perfect " equilibrium in the re-action of those two " parts, either on each other, or on the pro- " duce of conception. " As soon as that equilibrium is destroyed, " the fibres of the body, and especially those " of the fundus of the uterus, begin to make " efforts to expel the substances which consti- " tute the pregnancy, and do it in a manner " sensible to the touch. If we then introduce " the finger through the orifice of the uterus, " so as to touch the membranes of the foetus, "we find them flaccid one moment, and tense " the next; which clearly demonstrates this K alternate action." 28 " At this time the fibres of the neck of the " uterus sustain not only the whole effort of " the internal agents, which they participated " before with those of the fundus, but also the " effect of the re-action of the latter on those " same agents; which constrains them to un- " fold so rapidly, that in less than two months " the neck is developed, and entirely effaced. " If the cavity of the uterus becomes still " larger after this period, it is all at the ex- " pense of these fibres, now become weaker. " At first they distend and lengthen, then " they seem to range themselves by the side " of each other; which renders the uterus so " thin in this part, that the edges of its orifice " are often no thicker than two or three folds " of common paper. " It is by the same mechanism, that the di- " latation of the orifice of the uterus begins to " be effected, and labour pains manifested. If " the end of the ninth month of gestation is 29 " almost always the epoch of those pains, it is " because the order of the successive develop- " ment of the different parts of the uterus, as " I have stated it, is almost immutable. " The cause of this first degree of dilatation " being well known, must throw the greatest " light upon that which takes place in time of " labour; and shows us it is not immediately " and entirely the effect of that species of " wedge which the substances subjected to " the contractions of the uterus present to " its orifice."* From this it would appear that the opening of the mouth of the uterus at the commence- ment of labour, and also that degree of open- ing which exists long before this period, is the effect of the same cause; namely, the influ- ence of the body and fundus mechanically acting upon the orifice of the womb. But this cannot be the case for the reason just stated^ * Ibid. Yol. 1. p. 336. 30 namely, that the degree of opening may be the same, but the resistance of the edges of the mouth is very different; in the one case the circular fibres of the neck obstinately maintain their contraction; whereas in the other, they are in a greater or less degree relaxed; and that this relaxation is not the effect of this uterine effort acting mechanically is evident, since we find it existing where there is no portion of the ovum made to engage in it, consequently cannot act like a wedge. Besides were it owing to this cause, it would appear like a part that was yieldmg to a mechanical impulse, and would consequently exhibit marks of resistance; that is, it would still main- tain the action of contraction, and not that of relaxation. Indeed Baudelocque himself seems aware of this objection, for he observes, page 337, par. 616, "Although in many cases, " where the waters drain off prematurely, no " part of the child can engage in the orifice " of the uterus, yet it does not fail to open, in •; the same manner as if the bag formed by the 31 mi protrusion of the membranes were entire; " from whence we see that the action of that " organ is alone sufficient to effect the dilata- " tion of its neck. But it will perform it so " much the more" easily, as the uterus is more " distended, and as the body it contains is " more solid." Here he appears to abandon, in a great de- gree, his mechanical doctrine, and to confess the action of the uterus alone to be sufficient to effect the dilatation of its neck; but he does not pretend to determine what that ac- tion is; he conjectures in the next paragraph, that the soft and gradual pressure of the dis- tended membranes may have an influence on it; for " Independently," says he," of the force " which the membranes distended by the wa- " ters exert in the orifice, when they can en- " gage in it like a wedge, the soft and gradual " pressure which they continually exert on all " the neighbouring parts, determines a reple- " tion in them, which favours their develop- 32 " ment and renders it less painful." But unfortunately for this conjecture, should this determination take place, it would have a diametrically opposite effect; for the more turgid or engorged with blood the neck should become, the less disposed would it be to dilate. Of this we have abundant proof, when this part becomes inflamed.* Besides, the uterus in many instances di- lates as kindly after the evacuation of the wa- ters as before; of this the following history is a proof: Mrs.------- is always surprised by a dis- charge of the waters without any pain; but this so quickly succeeds, and the child so sud- denly expelled, that her nearest neighbour * It must, however, be admitted that during labour, or even before, there is some increase of determination to these parts, as there is an increase of action in their vessels, as we can sometimes determine by the touch; but this is never in- strumental to dilatation. 33 cannot get to her before it happens. This has obtained with all but her first labour. Were it necessary, we might multiply au- thorities to a great extent, to disprove this mechanical doctrine; but shall only give one, Dr. Denman, vol. II. page 37. " More than " one case," says the Doctor, " has occurred " in my own practice, to which particular at- " tention has been paid, for the purpose of " registering the observation, in which the " labour has commenced properly, and pro- " ceeded with much activity till the os uteri " was fully dilated, and then ceased altogether " for several days: at the end of that time the " membranes breaking, the action of the ute- " rus has returned and the labour been finish- « ed speedily, with perfect safety to mother " and child." Here we see the dilatation ef- fected without the wedge-like influence of the membranes or child. From what has been said, we trust it will E 34 appear that, in the most natural and favoura- ble cases of labour, the mechanical power of the ovum has no influence in dilating the mouth of the uterus. It must, however, be ad- mitted there are many instances where the contrary obtains; thus we see cases where the action of the uterus is so rapid and powerful, that the child is forced through the orifice with great violence, and risk of lacerating it; hut in these instances the mouth of the uterus exhibits a very different appearance from that where the dilatation is effected by a different agent. When the head, or presenting part, is made to force its way, the mouth of the ute- rus transmits it with great reluctance, and evident hazard j for it pertinaciously resists, as is evident to the touch; while on the contrary when it has dilated, agreeably to the laws of nature, it yields most willingly. It has most probably been owing to a proper distinction not being made between these cases, that the mechanical account of the dilatation of the mouth of the uterus has so universally pre- 35 vailed; but there is scarce a writer on this subject who does not furnish facts to disprove his own doctrine on this head. The cases just mentioned are to be looked upon as departures from the healthy and ordi- nary progress of labour; and are therefore not to be considered as militating against the doctrine we wish to establish. It may be ask- ed, how it comes to pass, if the membranes distended with their water are of so little consequence to the opening of the mouth of the uterus, that a painful and tedious labour most frequently follows where they have been prematurely ruptured? The answer we con- ceive to be easy. In those cases where the membranes are ruptured some time before the legitimate pains of labour have commen- ced, the uterus is oftentimes thrown suddenly into contraction, and this before it is prepar- ed, (if we may so express it) for the regular routine of parturition; consequently the neck is not in a disposition to dilate; not because it 36 fails in assistance from the membranes, but because all the preparative conditions are not complied with; therefore not properly pre- pared to perform all its duties. But it is by no means an invariable thing for a labour to be tedious after this early escape of the waters; unless indeed we date the commencement of the labour from this event; in this case the labour might, with strict propriety, be said to be tedious; as twenty-four, thirty-six, eight and forty hours, nay in some instances, a much longer period has intervened before the delivery was effected: we may therefore safely, we believe, lay it down as a rule, that a more tedious and painful labour does not ensue from the premature rupture of the membranes, unless the uterus is thereby im- mediately thrown into contractions; but should no pain succeed for some time, the labour will be, cseteris paribus, as in ordinary. After having endeavoured to show in what manner the mouth of the uterus is not dilat- 37 ed, it may be considered incumbent on me to point out in what way, in our opinion, this ef- fect is produced. This is confessedly a diffi- culty of some moment, but it must be at- tempted ; and should we fail to be satisfactory on this head, we shall experience but the fate of all who have gone before us. We trust, however, it will appear subject to certain laws, whose ultimate effect we have in our power to imitate; and this should be regard- ed as a matter of some consequence. But be- fore we proceed farther with this subject, we must stop to inquire into The different kinds of contractions of the Uterus. First, The longitudinal contraction:—this is performed by the fibres of the uterus, so called, or those fibres which run from the fundus to the neck; it serves to shorten the uterus in the direction of these fibres; conse- quently to expose its contents more and more 38 by making them approximate the mouth; and this will be in proportion to the diminution of resistance at this part, and the force with which these fibres may act. The circular contraction:—this action is performed by the fibres so named; they, as it were, run round the uterus, commencing at the fundus, and terminating in the circle form- ing the neck: they tend to diminish the capa- city of the uterus in the direction of its trans- verse diameter, consequently have little or no immediate agency in expelling its contents. The simple contraction:—or when either of these sets of fibres act separately, as before labour more especially, when the finger is in- troduced through the os tincse, we find the membranes alternately tense and relaxed: in this case we presume the longitudinal fibres act alone, as there is no stiffening of the circle forming the mouth; or as when the waters have been evacuated, the uterus is made to 39 embrace its contents, and no pain for a long time is produced; we suppose in this instance, the circular fibres act alone, as there is no ef- fort to expel the contents of the uterus, which would not be the case did the longitudinal fibres co-operate with them. Compound contraction:—or when both sets of fibres act; their united action is proved, we conceive, when there is a hardening of the mouth of the uterus, and an evident depres- sion of this viscus with its contents }nto the lower part of the pelvis.. Tonic contraction:—by this we understand that uniform action which the uterus exerts to reduce itself to its original size; this ap- pears to be the effect of all the fibres folding themselves up after the distracting cause is removed. The spasmodic, or that contraction of the uterus which is for the most part accompani- 40 ed with pain. It must be remembered, however, that pain does not necessarily belong to this species of contraction, since some women are delivered without it. We should, therefore, agreeably to this fact, rather call this species the alternate contraction of the uterus, as it has a greater or less interval between each contraction: when this action is best perform* ed, it is, we presume, chiefly by the longitudi- nal fibres. It may here become a question, how are the fibres of the uterus enabled to perform this alternate contraction? Since we know that a muscle after having contracted, cannot repeat that contraction without being first relaxed and then elongated. Where resides this elon- gating power in the uterus? This enquiry, so far as I know, has never been made, but the necessity of determining it will immediately present itself, when the question is asked. To solve it, no doubt, is difficult, perhaps impos- sible, with our present imperfect knowledge 41 of the anatomy and physiology of this impor- tant viscus; but is it not justifiable, under such circumstances, to hazard a conjecture, how- ever small its approach may be to truth? If this be the case, and we are allowed to urge a crude opinion, we would say, we must look for this power in the blood-vessels and sinuses of the uterus. The first change the uterus suffers from im- pregnation is distention; the next, that of con- traction. The uterus is then put in a state of elongation by the powers within it, which, when it suffers to a certain degree, contracts; what is the effect of this contraction ? It ap- proximates its fibres; it expels a considerable quantity of blood from its sinuses and larger blood-vessels, into the general system of the mother; it diminishes the size of its blood- vessels ; it makes them become more convolut- ed; the uterus becomes paler, a proof of a lessened quantity of blood: the face of the woman becomes suffused, nay sometimes livid. r 42 To facilitate the departure of blood from the uterus during its contraction, the veins are not furnished with valves,* by which means * That this is the true reason why the veins of the uterus; are not furnished with valves, is rendered more than proba- ble by the following case, from the fourth volume of Medical Essays and Observations, p. 355, by Mr. John Paisley. " Upon the 9th of June, 1730, I was called to a woman in labour, about a middle age, of a low stature, and pretty fat, who had born several children; and found her in an exceeding low condition, with cold sweats, and severe faintings; her extremities cold, without any pulse, and unable to utter a single word, though she showed some signs of her being de- sirous to speak with me. The midwife that attended her, had gone off upon my being sent for, and left a young practitioner, whom she was training up in that business, who gave me the following account of the poor woman's case, viz: That she had been several days in labour, and that all along the mid- wife imagined affairs were in a very good way, and the child, as she thought, in a very right posture; though after the waters broke, the child's head had never advanced by the strongest pains. From the first day the woman passed no water; on the fifth the midwife sent for some stimulating medicine to pro- cure the discharge—this had no effect; another still stronger was sent for, with like want of success. In this state things remained until the sixth day at midnight, when I was sent for. I found her in the situation just described. It was evident when matters were brought to this pass, that the poor woman had not so much strength left her, as to bear the fatigue of being put into a posture for being delivered, and that it was impossible to afford her any relief. She died in a few minutes. Next 43 the blood is allowed to pass freely in the di- rection of any given impulse. What is the ef- fect of the subsequent relaxation? The fibres become longer, straighter, and more easily distensible; the sinuses and large vessels are less compressed, and transmit more blood in a given time; the face of the woman becomes paler; the uterus becomes again pretty sud- Next day I prevailed with the friends to have her opened, and after I had cut the teguments and laid them back, I was surprised to meet with a black membranous body like coagu- lated blood (which in reality it was,) coyering all the fore part of the uterus, though distended so much with the child. This I easily separated in one cake from the uterus, and when it was upon the table, it was about a foot and a quarter long, a foot broad, and a quarter of an inch thick. Whether this proceeded from the oozing out of blood from the sub- stance of the uterus, by the strong pressure when the pains were violent, or some other part of the abdomen, I do not de- termine, for I could not observe the least appearance of any ruptured vessels in either, after the most accurate search I could make; nor was there one drop of blood in any other part of the abdomen." In this case we imagine that some interruption was given to the equal flow of the blood during the contractions of the uterus, and that the vessels suffered some small ruptures though the apertures were not visible; and we believe that this would always take place were the veins furnished with valves. 44 denly charged with blood, as is evidenced by its deeper colour; its fibres are distracted or elongated by this influx of blood, and hence are enabled to contract. It may be urged against this opinion, that the uterus contracts for the most part more frequently, and more powerfully, as its sub- stance becomes increased in density,—as to- wards the close of labour; consequently the influx of blood must be much retarded, and of course its impetus or quantity insufficient to elongate the fibres sufficiently to allow of a new contraction. But in answer to this we must observe, that at this period of labour the circulation is very much increased, and although the absolute quantity in the uterus may be diminished, the velocity is very much augmented; and added to this, its irritability is much increased, therefore, less distention will be required. It may also be said, there are instances of the uterus ceasing to act for a 45 considerable time, and where we must suppose the circulation to go on in it. That the uterus in some cases will cease to act, is most true; but this by no means destroys the supposition we have been making,—as this part, like all others, may have its fibres in a condition in which they will not obey their ordinary stimuli __it may proceed from exhaustion, or from local plethora ;i stimuli will cure in the one instance, and blood-letting in the other. The irregular contraction:—or when a part of any set of fibres act; as in cases of what is called spurious pains. Having thus noticed in a general way the various actions of which the uterus is capable, we shall proceed to enquire into 46 The Relative Strength of the different Sets of Fibres. We have already observed that the longitu- dinal fibres wTere stronger than the circular; our reasons for thinking so, are, First, that were they of equal strength in all parts of the uterus, delivery could not take place, since the circular fibres would em- brace the body of the child, and thus retain it; their action being, as we have already said, to diminish the uterus only in its transverse diameter, consequently is at right angles with the longitudinal. Secondly, that when, from any circumstance, the power of the circular fibres is increased, either absolutely or relatively, there the la- bour does not advance; therefore the circular fibres are not to be considered as directly in- strumental in expelling the child. 47 Thirdly, as the circular fibres, from the di- rection of their action, do not immediately contribute to the advancement of the child, they must be considered as the weakest set, —since delivery takes place without their di- rect aid; the longitudinal fibres have then not only to move the child, but overcome their resistance.* Now let us apply these facts to the expla- nation of the dilatation of the uterus and the progress of labour. When the woman has carried her child to the full time of gestation, that process termed labour must ensue, that she may be enabled to part with it; for this purpose, one part of the uterus must yield or dilate, while another * This is particularly the case in the instances where the membranes are prematurely ruptured ; the uterus, by virtue of its tonic contraction, accommodates itself to the various inequalities presented by the child's body, and some of these are eminently calculated to retard labour; yet the longitudi- nal fibres overcome them. 48 must contract. The uterus is closed at bot- tom, and maintained in that situation by the contraction of the muscular fibres of its mouth, but these must relax that the child may effect its escape. We must therefore re- gard the circular and longitudinal planes of fibres, as a kind of antagonist muscles to each other. The longitudinal fibres yield more wil- lingly to impulse from within the uterus than the circular during gestation; owing perhaps to their greater length, or perhaps greater laxity;* they continue to yield until they are so much upon the stretch as to induce a dis- position to contract; this they eventually do. The circular fibres on the other hand, from their greater rigidity, most probably are put immediately upon the stretch; they therefore have a constant stimulus to excite their con- traction; hence the mouth of the uterus keep- ing closed. But so soon as the longitudinal fibres becomes uneasy, from distention, they * Hence perhaps the lengthened form of the uterus. 49 become refractory and will yield no more without resistance; they then contract, and continue to do so until the stimulus of disten- tion becomes still more powerful, which eventually brings on the period of labour. By the contraction of the longitudinal fibres, the length of the uterus diminishes; this puts the circular upon the stretch, since the uterus can- not diminish in one direction, while the mouth of the uterus remains shut, without augment- ing in another, therefore the circular fibres are a little distracted, and they immediately co-operate with the longitudinal, and force the uterus with its contents lower into the pelvis; in this instance, what we have termed the compound action of the fibres, takes place; this is proved by the edges of the mouth of the uterus stiffening during the contraction. This kind of action is reciprocated for some time; but the circular fibres eventually yield to the influence of the longitudinal; first, from their having expended a portion of their pow- G 50 er in maintaining a state of contraction so long; and secondly, their being absolutely the weaker fibre; hence the circular fibres which constitute the neck, relax; and hence the di- latation of the mouth of the uterus. It may be asked, if the contraction of the longitudinal fibres prove a stimulus to the cir- cular, how does it happen while the mem- branes remain entire, that they do not con- tinue this contraction until the membranes are ruptured, or even longer, since the stimu- lus of distention must be applied, as often as the longitudinal fibres continue to contract? To this we would answer, that, when these fibres are acting properly, the longitudinal are gradually getting the ascendancy of the circu- lar, or in other words, the circular contract less forcibly; in consequence of which, the mouth of the uterus becomes more dilated which allows the membranes to be pushed down during the contraction, as the liquor amnii will naturaUy be forced to that part 51 which gives the least resistance to its escape, and of course the uterus will be less distended transversely, and the circular fibres be put less upon the stretch; or what is the same thing, less stimulated; then as they are less stimulat- ed, by the uterus having more room for the disposition of its contents, they will contract less forcibly; and this diminution of force, in contraction, enables the membranes to pro- trude still farther, which again has its effects in lessening their contraction, by offering still 0 more room for the waters to retire in, during the contraction of the other fibres, and even^ tually they cease to act. Secretion of Mucus and yielding of the External Parts. During labour, and even before, in some in- stances, there is a considerable discharge of mucus from the neck of the uterus, and va- gina, which is extremely favourable to the 52 dilatation of the external parts. Previous to labour, and more especially during it, there is a more than ordinary determination of blood to these parts, which, when not excessive, stimulate the glands here situated, to an in- crease of action; hence the abundant flow of mucus. This mucus is sometimes tinged with blood, which arises from the rupture of some of the small vessels of the chorion, or pertiaps placenta. This mucus seems to serve a double pur- pose ;—first, it lubricates the passage, and by that means allows the child to pass more easily; and secondly, it facilitates the relaxa- tion of the vagina and perinseum, by diminish- ing the quantity of fluids sent to these parts du- ring this period; and thus acts like topical de- pletion, which we well know, favours relaxa- tion ; this we are inclined to believe is the chief use of this discharge. Were it merely to lubri- cate the passage, we could always obtain the same end by artificial means; but every body 53 knows this does not answer the purpose equally well. This fact is tacitly implied, if not acknowledged, by every writer on the subject of midwifery, when they caution against frequent touching lest you waste the natural mucus of the part; why this caution, if it were merely to moisten, since we have a number of substitutes? No, the fact is, frequent touching stimulates these glands beyond the secreting degree, therefore the parts become dry, for want of it; and rigid, because the parts have failed in this depletion. This is the true principle on which we should caution against indiscriminate touching.* * It maybe supposed that the quantity of mucus discharg- ed during this period is not sufficient to produce the end contended for, since the amount thrown off* would rarely perhaps exceed two or three ounces. This objection is more specious than solid, since we cannot always estimate the re- laxing or debilitating effect by the quantity of the fluid dis- charged ; for instance, the relaxation and debility that attend the seminal discharge could by no means be anticipated from a mere view of its quantity. 54 Of the Contraction of the Fwidus and Body of the Uterus. That the uterus may be enabled to expel its contents, as we have already said, the fundus and body must contract, while the mouth must relax. We have endeavoured to show how the latter was effected; let us now for a moment attend to what must be done by the fundus and body, that delivery may take place. When the mouth of the uterus is sufficient- ly dilated to allow the child to pass through it, the fundus and body must continue to con- tract ; this contraction is of two kinds, namely, the tonic, and the spasmodic or alternate. The tonic contraction is chiefly performed by the circular fibres; by this contraction, the whole of the internal surface bf the uterus- is applied to the body to be moved, and the lon- gitudinal fibres by this means are brought more closely into contact with it, and of course are enabled to act with more effect; this per- 55 haps is the chief use of the circular fibres at this period of labour, as they do not, in any instance, directly contribute to the advance- ment of the child, as we have already observ- ed, and shall now endeavour to prove more fully. We shall relate some circumstances attend- ing the contraction of the uterus which will deserve notice, and to the truth of which every accoucheur will bear testimony. First, that a considerable degree of contrac- tion may take place in the circular fibres with- out producing pain; thus, after the evacuation of the waters, and the uterus is closely applied to the body of the child, even to a degree that would render turning impracticable—yet no pain is felt. Secondly, when this contraction is violent, it throws the uterus into inequalities, and some- times divides it like an hour glass: this obtains 56 in a degree before the birth of the child, but more especially after it, and before the expul- sion of the placenta. In these instances, the contraction is obstinately maintained, but no pain is felt. Thirdly, if the finger be applied to the pre- senting part, during the continuance of this contraction, it is not found to advance. Fourthly, when this constriction is most violent, the longitudinal fibres act, for the most part, with more force; since they are not only obliged to effect the delivery, but also to over- come this additional resistance; another proof of their superior strength. Fifthly, this stricture continues without any intermission, as far as we can determine, for hours; but this does not suspend the painful and alternate contractions of the other fibres • nor does this constriction relax during this alternate contraction; therefore, much time is 57 lost and much pain endured from this circum- stance ; it however yields eventually, and from the same cause, and in the same manner as the mouth of the uterus does at the com- mencement of labour. Sixthly, when the painful contractions take place, the presenting part is pushed lower into the pelvis; but when this ceases, it most frequently recedes a little. From these facts, the following inferences, we think, are deducible. First, that the circular fibres may contract to almost any degree, without being attended with pain. Secondly, that their contraction alone, however violent, does not forward the child. Thirdly, that they do not possess the power of alternate contraction in the same degree as H 58 the longitudinal fibres; and that they may exert this power, it is necessary at first to have them distracted by some force or other. Fourthly, that the pain felt during labour, must in a great measure, if not entirely, de- pend upon the contraction of the longitudinal fibres. Fifthly,, that the changes the uterus has suf- fered from civilization and refinement, must be chiefly confined to its longitudinal fibres. From what has been said then, the spas- modic or alternate contraction of the uterus appears to be nothing more than an increased effort it makes to overcome the obstacles op- posed to its progress to a state of vacuity; and that the pain attending these contractions de- pend upon certain physical changes which the longitudinal fibres have undergone from the causes just mentioned. Why a particular set, or given direction of fibres should have suf- 59 fered more than another, may be impossible to determine; but that they have, we believe to be most certain. This change, however, is by no means confined to the uterus, as every straight muscle of the body appears to have participated with it, since it is admitted that the man of the civilized world has lost much of his original strength. On the other hand the circular muscles, as far as we can determine, have lost nothing of their primitive power; since it is more than probable, that the vari- ous sphincters,* among which we may reckon the circular fibres of the mouth of the uterus, perform their duty as effectually and as pow- erfully, as in the time of our first parents. Do not these facts emphatically account for women who have suffered these changes, having more tedious and painful labours, than those who have not undergone them,—as the women of savage nations, the women of Ca- » The heart, or intestines, may also be included. 60 labria, $c.; and without the necessity of hav- ing recourse to a physical necessity, derived from the erect position of man, or the pecu- liar construction of the pelvis?* The different actions we have assigned the uterus, must not be considered as exclusively belonging to woman;—as the brute, doubt- less, has the same. It is indeed true that the labours of the brute are not generally attend- ed with pain or difficulty, and this is urged against the idea of pain being of artificial origin, as they have also undergone great changes; but it must be remembered they have not suffered the same revolutions as man, or at least not in equal extent; but that the same general phenomena, progress, and casualties attend them, as occur to the human female, is most certain; and when causes occur, ca- pable of diverting their labours from their usual healthy course, the same difficulties * See Osborne's Essays; also Med. Mus. vol. i. p. 270. 61 take place, and are attended with the same symptoms; namely, pain. The influence of domestication has been perceived by those who are in the habit of raising cattle, horses, sheep, §c. and we are assured by them, that many lose their lives from the difficulties attending their labours. I have myself more than once seen the mare and cow suffer extreme agony in bringing forth their young; but it must be admitted, that this does not occur so frequently as to enable us to establish any proportion between their pain and difficulty, and that of the hu- man female; nor would it be of any use, were it in our power; all that is contended for, is, that those animals, which man has familiariz- ed by his care, and made subservient to his purposes, have suffered, if not in equal degree with himself, yet sufficiently to justify the po- sition—that they, in consequence of the habits imposed upon them, have been rendered less 65 healthy, and occasionally subject to difficulty and pain from parturition. What the ultimate effect of this familiariza- tion (if we may so term it) may be, we can- not pretend to determine: that it will be more extensive than it is at present, is rendered more than probable, from what we have al- ready witnessed. It is said their uteri alone, are capable of expelling their contents without pain, and without any assistance from the abdominal muscles; this may be true; as we are told by Van Sweiten* on the authority of Hemster- huys, "that the womb of a pregnant bitch, " the abdomen being open, by its own efforts " only, forced out the foetus; the diaphragm " and muscles of the abdomen remaining " quiet and yielding no assistance." But can we determine there was no pain attending the * Comment, vol. xiv. p. 49. w efforts of the uterus in this cruel experiment, since it was placed in a new situation? If pain attended, it will not be insisted on, as neces- sary to the delivery, but rather be considered as the consequence of the increased action the uterus was obliged to exert, to relieve itself of its load; for although the uterus, unaided by the auxiliary powers, may be capable of expelling its contents, yet it must surely be admitted, it will do it with more facility with them. The same may be insisted on, with the human female, since pain with them is nothing but the effect of a certain degree, or kind of contraction; neither is it the cause of the ter- mination of their labours, but the result of that cause—namely, contraction. Should an equal degree of contraction take place with- out pain, as with it, the labour would be ter- minated with as much speed and certainty. But can this happen with the human female ? Certainly it can, and does every day. The human uterus is as capable of expel- 64 ling its contents without the aid of the abdo- minal muscles as that of the brute, and also without the interposition of pain. Of the former ability, many instances are upon re- cord; many women labouring under ascites, have been delivered; 'here the auxiliary pow- ers could give no assistance: children have also been delivered after visible life had ceas- ed in the mother, by the aid of the uterus alone; here no assistance could be derived from the abdominal muscles. And of women being delivered without pain, it would be idle to cite them, as they must occur in every man's practice. Pain then, must be regarded as disease, since it cannot be proved necessary; this disease has its origin in the changes produced by civili- zation and refinement. In what do these changes consist? This we do not pretend to answer. We might say it is in a peculiar sen- sibility or irritability of the system in general, or in the uterus in particular. But would this 65 explain it? Would not this only be substituting one inexplicable phenomenon to account for another ? We only know with certainty that these different states exist, but why, or how induced, it is impossible to say. We know also, and may advance it without fear of contradiction, that the female system during pregnancy and labour, is much dispos- ed to that state termed inflammatory; and that slight causes will produce fever, or local inflammation.* This is acknowledged by all writers on the subject, and has led Dr. Rush to consider pregnancy and parturition, as dis- eases. That they ought to be considered as pro- ductive of disease, in but too many instances is certain; for there are but few cases, in which * Few facts are better established, than that the blood drawn from a pregnant woman almost always exhibits the "buffy coat"—with many qf the older writers this circum- stance was almost conclusive. I 66 we are not obliged to mitigate the violence, or shorten the duration of the symptoms they produce. The disturbances which sometimes arise from pregnancy demand the peculiar care of the physician in very many instances, that the patient may not succumb. I have not unfre- quently seen vomiting carried to great excess: and it was in one case seriously deliberated whether the membranes should not be ruptured to calm the system, when abortion took place spontaneously during the night and the patient was rescued from impending death. Besides the indomitable vomiting just spoken of, there is a fever which seems peculiar to pregnancy. I never yet have seen any remedy do any good in this state of the system. It has been reliev- ed in several instances by abortion; but I once saw it prove fatal. Here also it was thought justifiable to produce premature delivery, but the plan was not adopted; and that parturition is frequently followed by severe disease is within the observation of every practitioner. 67 It is not within our present view to speak of pregnancy as a cause of disease;* we shall therefore confine ourselves to labour and its consequences. To relieve pain, has engaged the attention of physicians from the earliest ages; and their endeavours have been rewarded with more success in every other instance in which it oc- curs than that which attends parturition. This has arisen, perhaps, from less attention being paid to it, than to the other states of the sys- tem in which pain exists, from an idea of its being inevitable, rather than from the impos- sibility or difficulty of subduing or alleviating it. " In sorrow shalt thou bring forth children," was the curse inflicted on our first parents for their disobedience; and from hence it was in- * We would wish merely to be understood here, that preg- nancy and parturition have their peculiarities; and that they modify disease to no inconsiderable extent, and also induce a greater liability to it. 68 ferred, that pain was not only unavoidable, but necessary; I have endeavoured elsewhere* to show the falsity of this conclusion; we shall therefore not dwell upon it here, but proceed to show, that the condition of women in this particular can be much ameliorated. The cause of pain and difficulty, for the most part, depends upon a certain condition of the soft parts that are subservient to labour; we shall therefore consider this subject under the following heads. First, where rigidity of the mouth of the uterus depends on the circular fibres maintain- ing their contraction for too long a time, but where no inflammation attends. Secondly, where the rigidity is attended with inflammation. * Medical Museum, Vol. I. No. 111. p. 170. 69 Thirdly, where the rigidity arises from previous local injury; either from mechanical violence, or from inflammation and its con- sequences. Fourthly, relative rigidity, or where it pro- ceeds from disproportionate powers, between the longitudinal and circular fibres. Fifthly, tonic rigidity, or where the circular fibres, remote from the mouth, embrace the body of the child too powerfully. Rigidity of the first kind. This particular state of the mouth of the uterus, may be divided into three varieties; first, where the subject is very young; second- ly, where the subject has passed the five and twentieth year, and in labour with her first child; and thirdly, where the uterus has been prematurely thrown into action,. 70 Far. 1, or where the subject is very young. In this case, where the subject is very young, and has arrived at the full period of gestation. we very frequently find the soft parts con- cerned, to yield with great reluctance, and the labour become extremely tedious and pain- ful. This unwillingness to yield, may arise from the uterus not having acquired its com- plete development before impregnation had taken place, though sufficiently for the pur- poses of gestation.* If this be admitted, and of which we believe there can be no doubt, we shall very readily comprehend why its sub- * We do not imagine here any imperfection in the uterus; but merely that its development is not final, though suffi- ciently complete as not to defeat the object of sexual inter- course ; for we can readily conceive that a female shall be- come impregnated after the first menstrual secretion, yet that at this period the uterus had not received its ultimate development; for impregnation depends more upon the per- fection of the ovaria than upon the uterus; and we believe that the woman never menstruates until these bodies are sufficiently perfected for all the purposes for which they were designed, as in our opinion it is entirely through their instru- mentality that this evacuation has an existence. 71 sequent actions should be performed with less order, or more reluctance, than if it had re- ceived its ultimate finish. It is a fact well known, that the uterus is one of the last or- gans of the body which is perfected; and no doubt, connected with this perfection, is that of the vagina and perinseum. If then, impreg- nation should take place before this period, the actions of these parts will be less perfect- ly performed—as the actions of parts, must depend upon the condition of the parts them- selves; consequently, an uterus, £jc. so situated, cannot act with such order and effect, as when parts are completely formed, and whose actions of course are properly established, or can be properly established, when necessary to be called forth: hence, in very young girls or wo- men, we frequently find the labour very tedi- ous. The mouth of the uterus yields unwilling- ly; the contractions of the fundus and body are performed in a desultory manner; the perinseum dilates reluctantly, and is in great danger of laceration: the head or presenting 72 part will often remain stationary at the inferior strait, for hours, owing to the unwillingness of the soft parts to give way; so that for the most part they are stretched from the mechanical pressure of the child; the hemorrhoidal veins become much distended; the rectum is more or less protruded, and inflammation of consi- derable violence supervenes through the whole track of the vagina, which sometimes terminates in suppuration or gangrene. The circular fibres of the mouth of the ute- rus very obstinately maintain their contraction for a long time, either from their not having received their due organization, and therefore not acting exactly as intended by nature; or from the longitudinal not having, from some cause or other, acquired their designed strength, the circular will have a relative in- crease of it. A great deal of time is therefore employed, and much pain endured, before the mouth of the uterus will open; and even when it does, it seems more like being mechanically, than naturally opened. See cases i. ii. iii. 73 Far. 2,* or where the subject is not very young. The same general phenomena take place in this variety, as in the first. This kind in general however is rather more obstinate; the parts, from not having been employed early according to the design of nature, seem. to forget a part of their duty. This kind also is more disposed to take on an inflammatory action. Much may be done for this variety by proper regimen, ^c. a few weeks before la- bour is expected.! See cases iv. v. vi. vii. viii. ix, x, xi. Far. 3, or where the action of the Uterus is prematurely excited. Whatever is capable of exciting the con- * Here the subject is also supposed to have completed the term of gestation. t When consulted by females of this class, some time be- fore the period of gestation is completed, I uniformly have K 74 tractions of the uterus, can produce this va- riety ; it may happen at any period of gesta- tion; but it is designed only to speak of it, as it takes place at the latter period of gestation. This may occur in any subject, and in any pregnancy, as the uterus is always liable to be thrown into action. It would be useful could we always with certainty distinguish this variety from the two just mentioned; as at its commencement it would require very different treatment. This is not always very easy, more especially where there is a complete obliteration of the neck of the uterus. We can, however, for the most part, do it by the following marks. First, when the uterus is prematurely ex- cited to action, we can sometimes, (as at the found that much benefit was derived from their pursuing an antiphlogistic diet, keeping their bowels freely opened, and occasionally losing blood. I am persuaded, from many cases I have had of this kind, that this plan has saved them much pain. 75 eighth month) feel a portion of the os tincse: —Secondly, when we examine the mouth of the uterus, we find it rigid, both in the ab- sence and in the presence of pain :—Thirdly, when we pass a finger through the mouth of the uterus and touch the membranes, we do not find them so tense, as when the uterus is naturally disposed for labour:—Fourthly, the pains are more irregular in their accessions, and continuance; sometimes quickly following each other, then more slowly; now long and severe, then short and trifling:—Fifthly, there is no secretion of mucus, nor disposition in the perineum to relax:—Sixthly, there is no immediate subsiding of the abdominal tumour. When the uterus is thus thrown into action, if not quickly prevented, it will continue to contract until labour, strictly so called, takes place. When this happens, it scarcely ever fails being tedious and painful. It behoves us, therefore, to distinguish this state from the other, that we may, if possible, prevent the labour coming on. See cases xii. xiii. 76 Rigidity attended with Inflammation and Fever. The cases of difficult labour, attended with inflammation and fever, occur more frequent- ly than without them. The three varieties just spoken of, are all liable to these additional symptoms. First, from local irritation, either of the presenting part acting mechanically on the mouth of the uterus, more especially after the evacuation of the waters; or from the officious and ill-judged interference of the accoucheur or midwife, attempting by force to open it. Secondly, from improper diet or drink. When inflammation comes on, the woman becomes extremely restless, and does not en- joy that calm which is common at the cessa- tion of pain; the vagina becomes hot and dry; the mouth of the uterus thickens and becomes 77 more unyielding; the secretion of mucus, if it had taken place, ceases; the pulse becomes quick, frequent and hard; the respiration hur- ried; the head much pained; the face flushed; great thirst; the skin hot and dry, or profusely sweating. See cases vii. viii. ix. x. xi. xii. xiii. xiv. xv. Rigidity from local Injuries. The parts concerned in labour are fre- quently made to suffer by injudicious treat- ment or negligence, a degree of inflammation, that very much deranges their natural struc- ture. Should this inflammation terminate by resolution, it does not do it so completely, as not to leave a thickening of the parts, from which they sometimes never recover; this thickening, which is owing to an un- absorbed quantity of coagulating lymph, of- fers very considerable difficulties to the di- latation of the parts; they cannot assume their healthy or natural action while this is 78 present At other times, when inflammation has been considerable, an injury may be done to the neck of the uterus, $c. by the effusion of coagulating lymph, (agglutinating their fibres as it were) that they cannot ever after take on the healthy relaxation; and of course will yield with difficulty to the propelling powers of the fundus and body of the uterus. When inflammation has been more violent or unsuccessfully treated, it may terminate in suppuration or gangrene. In consequence of these unfortunate terminations of inflamma- tion, the parts, if the patient survive, heal up , so unfortunately, as to leave large cicatrices in the mouth of the uterus, vagina and os ex- ternum, which will offer immense difficulty to labour. These parts are also subject to laceration, more especially the vagina and perinseum. When these wounds heal they present very firm cicatrices through the whole extent of 79 the injury. These scars are sometimes so firm, and so unfortunately situated for labour, that they completely resist for a very long time, every effort of the uterus to expel its contents. See cases xvii. xviii. xix. xx. Relative Rigidity. The longitudinal fibres of the uterus may be rendered so inactive, that they cannot contract - with sufficient force to overcome the resist- ance of the circular. This may happen from a variety of causes, but we shall only notice one, namely, a kind of apoplexy of the ute- rus. This case is known, by labour having come on kindly at first, and gradually dimin- ishing in force; by the mouth of the uterus having a disposition to dilate; by its thicken- ing; by the presenting part not protruding during pain; by the pain extending itself all over the abdomen; by the woman's complain- ing of a sense of suffocation: by a hard and 80 full, or depressed or labouring pulse; by the irregularity of the pains both in force and fre- quency. The mouth of the uterus in these cases cannot open, although disposed agree- ably to the order of nature, as the fibres desti- ned to keep it shut are relatively stronger than those intended to open it. The contractions therefore of the longitu- dinal fibres, are feeble and transitory; the mouth of the uterus does not dilate, though not positively rigid; the abdominal tumour does not continue to subside; there is a secre- tion of mucus, and a disposition in the exter- nal parts to dilate, which perhaps pretty clearly points out the favourable situation of the mouth of the uterus; but it cannot dilate until the longitudinal fibres have shaken off their torpor; or in other words, until the cause of this torpor is removed; they then resume their healthy contraction, and the la- bour is for the most part quickly terminated. See cases xxi. xxii. 81 Tonic Rigidity. This only occurs where the waters have been drained off a long time, and the whole of the internal surface of the uterus is closely applied to the body of the child. Such is the nature of the circular fibres, that they always contract in such a manner as to come in con- tact with the substance present in the uterus; they do not however do this suddenly; it re- quires some time; and in proportion to that time, other things being equal, will be the intimacy of this contact. While the child is still in the uterus, it must necessarily present to it some inequalities: but such is the ar- rangement of nature in general to guard against this disposition of the uterus, that the body of the child is so placed as to offer as few as possible. But the care of nature in this particular must be often thwarted, by acci- dents of various kinds, which are capable of retarding the labour; for instance, suppose 82 the mouth of the uterus well opened, the wa- ters discharged, the head of the child some- what advanced, when something may happen. no matter what, that will delay the delivery of the head, or obstruct its progress; what will be the consequence ? the uterus will ap- ply itself to the body of the child, and be dis- posed to do it at all possible points; the head being in the pelvis, the neck of the child is more or less extended, and will offer a much smaller volume to the parts of the uterus near it than the rest of the body; the circular fibres will go on contracting at this part until they embrace the neck; this will divide the uterus into two chambers as it were, and in conse- quence thereof the labour will be delayed, and turning rendered impracticable; hence the difficulty of this operation after the wa- ters have been long evacuated. This peculiar contraction has been mentioned by authors, but none, as far as I know, have ever offered a remedy for it.* * See Baudelocque, Smellie, &c. 83 This case occurs sufficiently frequent to make it an object of particular attention; as many infants, I fear, have been sacrificed to the crochet, from this cause intercepting de- livery. See case xxiii. Having spoken as concisely as the nature of the subject would admit, of the various causes of rigidity, we shall now proceed to say a few words on the principal remedies which have been employed with a view to relieve it: they are opium, the warm bath and blood-letting. Opium. This has been, and still continues to be, the favorite remedy with most accoucheurs, for the rigidity of the os uteri; but we conceive, no- thing but theory has ever given it employment; it was supposed, that when the mouth of the uterus did not open kindly, it was affected 84 with spasm, and on this principle was opium exhibited; but as far as my experience goes, never with advantage. I have repeatedly tried it myself, and have often seen it employed by others, but without in a single instance, pro- ducing the effect for which it was prescribed; sometimes it evidently did harm. It must be remembered we are speaking of it, as given for the express purpose of dilating the os uteri, or disposing it to dilate. It has undoubtedly been used with advantage, in those cases where it was conceived the uterus was prematurely excited to action—it has suspended the contractions for the proper time, and when they were renewed, the uterus was healthily disposed, and the labour soon finished; but here it was given, not to dilate the mouth of the uterus, but to suspend the contractions of the longitudinal fibres. This medicine cannot, we conceive, ever be recom- mended with any chance of success, where the object is directly to make pains more efficient. 85 by taking off the resistance of the mouth of the uterus. Nor can this drug be considered as an in- nocent one; that is, if it does no good it will do no harm; on the contrary, we believe it to be extremely mischievous;* in many cases converting the rigidity without inflammation or fever, into those with them; this I have more than once seen, and but too frequently had reason to regret. Warm Bath. I shall beg leave to transcribe the observa- tions I have before made on this remedy, from 2d vol. No. II. of the Medical Repository of * I have in a number of instances seen opium exhibited with a view to mitigate the severity of pain, where the labour advanced slowly, and have never failed to observe that the force of contraction was diminished at the time it was re- quired to be the strongest. 86 New-York. It was written in consequence of a request of one of the editors of that work— Dr. E. H. Smith. " The warm bath is by no means a new remedy in that species of labour*, in which I have thought blood-letting of so much conse- quence. Few writers on the subject of mid- wifery have failed mentioning it, among other means to overcome the rigidity of the soft parts in laborious labours, that do not depend on a mal-conformation of the pelvis. The French accoucheurs more particularly make frequent mention of it; yet none of them, that I am acquainted with, have laid any particular stress upon its virtues in these cases, or place any great dependence on its effects. It has been rather recommended as a probable, than as a certain remedy, and stands upon much the same footing as opium—sometimes perhaps, succeeding, but much more frequently failing; * See Med. Rep. vol. 2. 87 with me it has ever been of little or no con- sequence; nor can I obtain a more favourable character of it from the friends I have con- sulted. " The result then, of my experience, enqui- ries, and observations, may be reduced to three heads: First, It being almost always inconvenient: Secondly, It being sometimes ineligible; and Thirdly, it being always limited and uncer- tain in its effects. " The very great difficulty that attends the warm bath, makes a very strong objection to its use; or, in other words, renders it almost impossible to be employed, as very few people are in possession of a suitable apparatus. It might, however, on extraordinary occasions be procured with some difficulty; but much time would be lost, particularly in the country, where this kind of labour is by far the most frequent. The lancet we may always have at hand." 88 " It is sometimes ineligible; occasioning in some instances, very profuse and alarming haemorrhages. A fatal instance of this kind happened not long since, in the practice of a physician in the neighbourhood where I for- merly lived. It was universally attributed to the warm bath; and the Doctor himself, in a con- versation with me, inclined to the same belief; at the same time assuring me he derived no advantage whatever from it, as the parts were no more disposed to yield than before; and the woman eventually suffered a lacerated perinseum. The warm bath in this instance evidently did mischief, by preventing the tonic contraction of the uterus from taking place, whereby the vessels were not contracted upon, and a fatal hsemorrhagy ensued. This is not the only instance in which it has done harm in this way. A Dr. Tom, who had an extensive practice in this line, and who was in the habit of employing the warm bath in these cases, informed me, he never failed producing a more than ordinary flow of blood from the uterus; and in some instances to an alarming 89 degree. He urged however, in defence of it that he knew of nothing better—Opium had al- ways failed with him—and that he considered the warm bath as a dernier resource, adding, he sometimes thought it had done good. Be- sides, cases occur where we could not leave our patients sufficiently long to derive any ad- vantage from the bath, were any to be expec- ted, without running a risk of the most dread- ful consequences ensuing: for instance, the case I sent you some time since.* In this case it would have been impossible for me to have left my patient a minute for her to have been placed in the bath, as it needed not only all my care, but likewise great exertion, to prevent the head of the child escaping through the anus, $c. Again, the inconvenience, nay, the almost impossibility of rendering the woman proper assistance when in the bath, will readi- ly occur, and will be an additional objection to its use. But above all, the extreme indelicacy * See Med. Rep. vol. II. p. 24, or case xvii. of this Essay. M 90 that must appear when employed in that situa- tion, were it practicable, would be sufficient to render it the dread of the woman, and the aversion of the modest practitioner." " With me, and my friends, it has always been limited and uncertain in its effects; so much so, (as I have already observed) as to be of little or no consequence, its influence having never extended beyond partially relax- ing the more external parts, and even this continuing but a short time after the bath has been desisted from. I have never known it to have the least effect on the neck or mouth of the uterus; nor can I find it has ever done so, unequivocally, in any instance, as far as my inquiries have extended. It frequently pro- duces no effect whatever, not even on the ex- ternal parts. And should it even relax these, no great advantage would be derived as long as the mouth of the uterus continued rigid; and I cannot find it has ever had this effect. The yielding of the neck of the womb ap- 91 pears very often to be a distinct process, from the relaxation of the other soft parts; at least they do not always keep pace with each other; having frequently seen the uterus well dilated, with a very rigid os externum, and vice versa; the one attended with an increas- ed secretion and discharge of glary mucus; whereas the other is not accompanied with these marks. The vagina and external parts sometimes, after having been well relaxed, become again rigid and unyielding; but the uterus, after having been once well dilated, never (as far as my observations extend) closes, and makes resistance, until after the expulsion of the child; so that it appears that all these parts are not influenced at all times, by the same laws or causes. " It may at first sight perhaps appear a pa- radox, that in some cases I should fear the warm bath producing a too great discharge of blood from the uterus, and directly after as- sert) that in no one instance could I find it 92 had any effect on the os uteri. But I do not perceive any contradiction here, as every body must admit, that the development of the neck of the womb, or its perfect expansion, must be a very different process from its tonic contrac- tion. In the one instance, a peculiar arrangement of the fibres which constitute the neck or mouth takes place, so as to allow of the passage of the child, ^c; whereas, in the other instance, the power which reduces the uterus to its ori- ginal size after the expulsion of its contents, and by which a too great discharge of blood is prevented, is diminished,—hence hsemor- rhagy. And we may safely, I think, in some instances conclude, that the warm bath, al- though it does not produce relaxation, may yet prevent contraction. " Besides what I have urged above, I must not omit telling you I have experienced, in the most convincing manner, the superior efficacy of blood-letting, to the warm bath. A case occurred that put the two remedies, I 93 think, to a very fair trial. A woman had been a long time in labour, and from the rigidity of the parts concerned, the midwife, enter- taining no hope of a speedy delivery, thought proper to send for a physician. He ordered the warm bath, and thirty-five drops of lauda- num; these not succeeding as he expected, the woman was again ordered the bath and the anodyne. Several hours were spent in this way; the woman every hour or two was pla- ced in the bath, and took fresh quantities of laudanum; but all without benefit. I was now called in. It was agreed that the woman should be very fully bled; this was done. When upon the loss of about thirty ounces of blood, she grew very sick and faint; her friends became uneasy, and would not allow the bleeding to be carried to complete fainting. I was obliged to tie up the arm and rest satisfied with what was already drawn; this fortunately proved sufficient; for the parts began immediately to relax, and in about three quarters of an hour, she was made the happy mother of a living child." 94 I shall only add, that subsequent experience has more fully confirmed me in the opinion that the warm bath by no means offers a sub- stitute for blood-letting. Blood-Letting. This remedy is by no means a new one in labour; but employed for the express purpose of diminishing pain, and subduing the various species of rigidity just spoken of, and carried to an extent that will insure these objects, that is, diminishing pain; disposing the os uteri to dilate, the external parts to unfold, and cicatrices to yield; originated, as far as I am acquainted, with myself. This remedy was suggested to me by accident, but has ever since been employed from reason and expe- rience. In the summer of 1789, I settled at Abing- ton, and was quickly introduced to a large 95 share of obstetrical practice; in September of of that year my attendance was bespoke for Mrs. H. W----, whom I was informed had suffered every thing but death from her la- bours ; the crotchet had several times been em- ployed to effect the delivery of her children. She looked forward with great solicitude and apprehension, and indeed almost considering herself a certain victim to the approaching la- bour. I had also very great fears for my patient, as I was young, and had not had much expe- rience ; these forebodings were presently very much augmented, by my being called to her under a severe hsemorrhagy from her lungs, which quickly reduced her to a state of extreme debility. Before she recovered from this state of weakness she was taken suddenly in labour, which increased my apprehensions almost to despair, lest she should die under my hands. As I approached the house, I was met by seve- ral of her friends, who with great earnestness begged me for God's sake to make all possible haste; I proceeded immediately to her bed side. 96 and in about fifteen minutes delivered her of a fine healthy child; no accident supervened; she had a much better getting up than could possibly have been expected, from the extreme state of weakness she was in, when surprised by labour. As this was so very different from all her former labours; as it was easy, rapid, and safe; and more especially when a result so very different had been expected, I could not help being very powerfully struck with the circumstances. I had to reason very little on the subject, for it immediately occurred, it could be from no other cause than relaxation, produced by the excessive and alarming hse- morrhagy. I quickly resolved to take advan- tage of Ihis kind hint, by endeavouring to imitate this good example. I had not to wait long before I had an opportunity of putting my new plan in practice; a Mrs. M. M-----, who had suffered in almost an equal degree with Mrs. W-----, in her labours, was under 97 the care of a midwife; she had been in labour ten hours; I found her with considerable fe- ver; a hot and dry vagina, and rigid os uteri; pains frequent and severe, but without much bearing down, as it is termed. I immediately bled her pretty freely; but this had not the effect, of either relieving her fever, or giving disposition to the mouth of the uterus to relax. At the expiration of half an hour, I again bled her to a considerable extent; that is, until she became very sick and weak; upon examina- tion I found the mouth of the uterus suffi- ciently opened; the vagina moist; and the external parts completely disposed to yield; the pain from the contraction of the uterus considerably diminished; and the labour was shortly terminated. This case I considered of immense consequence, as it appeared to put me in possession of a certain remedy for this kind of labour. It would be unnecessary to relate all the cases in which I advantageously employed N 98 this, 1 had almost said divine remedy; many of the women of Abington speak of it in rap- turous effusions of gratitude. In December, 1793, I again returned to this city, where I have continued with all my former success, to employ this remedy, even in cases where reason could scarcely bid us hope for it. We can, with a confidence that should only be produced by experience, recommend this operation, not only as a safe, but a certain re- medy, for all the objects we have just con- templated ; and we feel the more security in doing this, since it met the approbation of the late venerable and experienced professor of anatomy and midwifery, Dr. Shippen; who declared with a candour which did him ho- nour, he could have spared much pain and misery to many of his patients, had he used the lancet more freely in tedious and painful cases from rigidity. We shall now proceed to relate a few cases. 99 selected from many, which will illustrate the practice, in the various kinds of rigidity we have spoken of. Var. 1. CASE I. Miss V-----, aged fourteen years and six months, was taken in labour January 14th, 1790. She had been in labour thirty-six hours before I saw her; that is, she complained of pains for that period, though they were not very severe; about twelve hours before I vi- sited her, the waters were discharged; the mouth of the uterus very little opened, and the external parts not favourably disposed; the pains were now very severe, and the head was pressed pretty far into the pelvis; she was extremely costive, and had passed no wator for many hours; an injection was or- dered, which operated freely; the catheter was obliged to be introduced, and nearly a quart of water was drawn off; she was much relieved by these discharges; an hour was given in hopes a favourable change might 100 take place in her labour; there was no heat of any consequence in the vagina; she had been very rarely touched; she had frequently, by the midwife's advice, been placed over warm water, and fumigated with burning onion-shells, (a favourite remedy with the old women of the country) but all to no purpose; I bled her fifteen ounces; this produced some little change on the mouth of the uterus, but not sufficient to allow the head to escape, more especially as the mouth contracted and stiffened with each pain; in an hour she was bled as much more; this produced sickness at stomach, which was my signal for stop- ping; upon the next examination the parts were found sufficiently dilated; there was a short suspension of the pains, but they soon returned, and were found of competent force, though much more tolerable; the labour soon terminated. CASE II. 1790, June 10th. Mrs. S. F. aged fifteen years and a few months, had been in la- 101 bourten hours, when I was called; the head had nearly escaped from the uterus, and was applied very forcibly against the peri- nseum; the os externum small and rigid; the head, as I was informed, was thus situated more than three hours, without the least ob- servable alteration; the midwife very judi- ciously made a firm pressure against the ex- ternal parts. She was bled very liberally; the parts almost immediately yielded, and the head passed without difficulty or laceration. This labour, without doubt, was rendered safe and mild by the bleeding, as I am persuaded that it would have been protracted much lon- ger, besides the risk of laceration. CASE III. 1792, June llth. Mrs. F-----, aged seven- teen, very small of her age, never menstruat- ed until after marriage; was taken in labour with her first child; pain came on very gra- dually for the first few hours, then augmented very considerably for some time, and then 102 subsided almost altogether; this flagging of the pains was considered as a proof of weak- ness, and to obviate it, stimulating drinks were liberally given; pepper, thyme, ginger and onion-tea, had each their trial, without advancing the labour. Her friends became alarmed, and I was sent for; I found her with much fever, severe pains, profuse sweats, hot vagina, swelled labia, and rigid os tincse. I proposed to bleed her, but this she would not permit; she was placed in the warm bath by way of substitute; mild drinks were given, and her bowels were opened by injection. Warm water was frequently thrown up the vagina, but without any observable effect; I again proposed the bleeding, but it was again re- jected. As I had observed that bleeding had done good almost in the proportion to the sickness it excited, I thought of giving emetic tartar in small doses until nausea was produc- ed ; I soon brought the stomach to this state, which was kept up with considerable severity for two hours, but without any good effect. I 108 now urged the bleeding as the only chance of benefiting her; to this at length she reluc- tantly submitted: she was bled twice in an hour, the last of which was copious, and had the long looked-for effect; the uterus dilated almost instantly after the bleeding, and the external parts yielded without any difficulty: the child was delivered in half an hour. Var. 2. CASE IV. 1790, August 30th. M. M. in labour with her third child; she had suffered very severe pains for thirty-six hours; the waters had been evacuated twelve hours; the vagina hot, and dry; the external parts much swoln; the mouth of the uterus thick, firm, and but little dilated; much fever; bounding pulse; severe head-ache; great thirst; much anxiety and restlessness; I bled about fifteen ounces, but with no evident advantage; at the end of an hour she was bled twenty ounces more; this seemed to affect her considerably; but its use was but transient; she was presently bled 104 twenty ounces more; she became extremely sick; the parts quickly dilated, and she was delivered in half an hour more. CASE V. 1799, February 1st. Mrs. M. A-----, aged twenty, with her first child; the first part of her labour was quickly performed; that is, the mouth of the uterus opened easily, but the perinseum offered immense resistance—it was very thick and dense, and as soon as the pain ceased, the head of the child would recede very considerably: several hours were spent in the expectation that this part would yield; my patient became very uneasy, and I pro- posed bleeding—she consented most willing- ly; I was obliged to send for a bleeder for her, as I could not be spared from the peri- nseum, lest when pressure was removed, it would suffer laceration. After about twenty ounces had flowed, I found an evident change in the parts, and before ten more were drawn, the child was delivered. 105 CASE VI. 1798, February 17th. Mrs. S. C. aged forty, with her first child; she had been long in la- - bour before I saw her, and suffered much pain; she had pains in very quick succession; the waters were still undischarged; the uterus opened to about the size of a quarter of a dol- lar, its edges very firm; no disposition in the external parts to relax. She was bled very largely, (forty ounces), and was delivered in half an hour. CASE VII. 1796, June 13th. I. S-----, aged thirty-two, with her first child. She had been fourteen hours in labour; the head was low in the pel- vis, and escaped from the mouth of the ute- rus ; it pressed violently against the perinseum, which showed no signs of quickly yielding. She was bled, standing on her. feet, twenty ounces; she became very sick; the parts yield- ed soon, and the head passed with a few pains, o 106 CASE VIII. 1799, May 18th. Mrs. T. aged forty-one, with her first child. She had suffered pain for two days and two nights without any apparent advancement of the labour. I was sent for, and from the little appearance of relaxation, and the desultory returns of her pains, I ra- ther thought it would go off for a few days. With a view to prepare her for the exhibition of an anodyne, I bled about sixteen ounces,« and she fainted; there was a suspension of pain for an hour or a little more; at the end of this time they returned in quick and regu- lar succession, but with considerable abate- ment of severity. She was delivered in less than another hour. Many more cases similar to the above, might be given, but we deem these every way sufficient for the purpose for which they are intended. 107 CASE IX. 1791, January 5th. Mrs. A. H. C. in labour with her second child. She had suffered many hours, without evident advantage; she had great thirst, fever, and anxiety; she had slept none from the time she had been taken; skin parched; the vagina hot; the mouth of the uterus nearly closed; no secretion of mucus. She was bled to sickness; this was produced by a very few ounces, as she was much alarm- ed at it—no change was produced; she was tfgain bled in an hour, with some advantage; that is, there was less fever, pains not so se- vere, the parts less hot; but the uterus remain- ed in statu quo; she was again bled in ano- ther hour, with the happiest effect. The child was soon delivered, and the mother had a rapid convalescence. CASE X. 1797, July 10th. Mrs. Le B——, in labour with her third child: the arm presented and i08 had been down twelve hours; much fever. dry skin, great restlessness and anxiety, face much flushed; pains not frequent, but very severe; the vagina hot and dry, for she had been much handled; the child's arm very much swelled, and the mouth of the uterus was contracted closely round it, and was very rigid; there was no possibility of turning, under these circumstances. She was bled up- wards of eighty ounces in five bleedings, in as many hours; the last bleeding produced faint- ing ; the mouth of the uterus relaxed, and the child was turned without difficulty. This lady feels her after pains in her right knee; this has obtained with all her children—they are as regular as when felt in the region of the uterus. CASE XL 1802, January 29th. Phoebe Hall, a black woman, in labour with her seventh child: arm presented and had been down several hours; the arm considerably swelled, as the midwife had exerted much force on it; the mouth of 109 the uterus contracted closely on it; I got Mr. Carter, now Dr. Carter, to introduce his hand into the vagina and place a finger in the mouth of the uterus; he did this with some difficulty, as the uterus was very rigidly clos- ed on the arm. I tied up her arm and let her bleed until he should tell me the mouth of the uterus was sufficiently dilated; when I had drawn from forty to fifty ounces she became sick and faint; at this instant Mr. Carter cried out with rapture, the uterus was sufficiently opened—upon examination this was found to be the case; the turning and delivery was soon accomplished. It must be observed, that labours attended with fever, have always been found to require considerably more bleeding than where none attends; and it has also been found best in these cases, to draw blood at two or three times, letting the last be carried either to fainting or sickness. 110 Var. 3. CASE XII. 1790, January 29th. Mrs. M. L----, with her first child, aged twenty; after having stood all day at the ironing table, was seized with pretty regular pains. There was no sub- siding of the abdominal tumour; no secretion of mucus; the os tincse was not entirely effa- ced. There was very little tension of the mem- branes during a pain; from these circum- stances I was disposed to believe the uterus had been prematurely excited into action; she was ordered to lose twelve ounces of blood, to keep quiet, and receive an enema of a gill of water and a tea-spoonful of lauda- num—pain soon subsided, she went a fort- night longer, and her labour proceeded kind- ly, and was not of long duration. CASE XIII. 1790, August nth. Mrs. C----, pregnant of her third child, aged twenty-eight; after a severe fright was seized with pains; as her Ill midwife was engaged at the time she was sent for with another patient, I was called on; from her not getting her midwife, she became very much alarmed, and her pains ceased for six hours. At the expiration of this time they returned; and soon after the midwife arrived; she examined her, and found nothing like la- bour; she therefore gave her a large dose of laudanum, which not having the desired ef- fect, was repeated, in the course of two hours; her pains became more violent; she had much fever, and attended with delirium. I was again sent for; upon examining the state of the uterus, I was pretty certain it had been forced into contractions by the fright in the first instance; and continued in this situa- tion by the improper conduct of the midwife; but things had now come to that pass, that it would have been in vain to have attempted stopping their progress. The mouth of the uterus was thick and hard, and opened to about the size of half a dollar. As there was so much fever. I thought proper to bleed and 112 purge her; these had a good effect, as her fever and delirium were diminished, but the uterus was still firm, and not augmented in size since she was examined before; (six hours) I again bled her pretty largely, the delirium went off entirely, the uterus opened, and she was delivered in less than an hour. I am disposed to believe this case would have had a serious termination from the vio- lence of the symptoms, had she not been bled very liberally: she lost about fifty ounces at the two bleedings. This case also serves as a contrast to the case preceding; for I have no doubt but what the bleeding which preceded the anodyne, enabled the latter to produce its beneficial effects; and I am also equally certain that had a bleeding in this latter case been premised, the patient would have suffered abundantly less, and gone some time longer. 113 CASE XIV. 1805, February 13th. Mrs. C----, with her first child; she had been forty-eight hours in labour when I was called; the waters had dis- charged fourteen hours—her pains severe but irregular; the mouth of the uterus opened to about the size of a quarter of a dollar, but very rigid; the vagina, ^c. very hot and ten- der; pulse frequent and hard—she supposed she had just entered her eighth month, and was seized with pains in consequence of a fall; a midwife was sent for, and she endea- voured by stimulating drinks,* frequent and rude touching, to provoke labour. She was bled twice in four hours, to the amount of twenty-two ounces; received a purgative in- jection, which operated well, but without pro- ducing any change in the uterus. The head * This patient took, by the directions of her midwife, in the course of forty-eight hours, three pints of wine, one of brand- dy, a large quantity of strong black pepper tea, with a view to force her labour as it is termed. P 114 presented naturally. Two hours more were allowed to pass, with a hope of things doing better—but no alteration being produced, I made Mr. King (a young gentleman who staid at my request with the patient) tie up her arm while standing on her feet, and take blood until she nearly fainted; she was then laid in the bed, and after an exemption from pain for about fifteen minutes, they came on very ra- pidly; the mouth of the uterus was found completely dilated, and the child was deliver- ed in a quarter of an hour more. CASE XV. This case was kindly furnished me by Dr. Shaw, I shall therefore relate it in his own words. Dear Sir, The following is the statement of Mrs. M. Q----'s case; I give it you as correctly as circumstances will admit. 115 Saturday, 5th October, 1805, this woman walked from the country to Philadelphia, a distance of twenty-three miles; agreeably to her calculation she was entering her eighth month of pregnancy. On Friday the llth, symptoms of labour were felt; that is, she had pain in her back, sides, fyc. accompanied with alternate flushes and chills; these symptoms continued until Monday, when she was attack- ed with an haemorrhage from the uterus. A midwife was sent for, who mistaking her case, immediately attempted delivery by rup- turing the membranes and discharging the waters, but finding her efforts ineffectual, after doing considerable violence to the vagina and neck of the uterus, by her frequent and offi- cious examinations, left the woman undeliver- ed and without pain. She remained in this situation until the following Wednesday after- noon, at which time I was called to her; slight pains had returned, and on examination I found the parts very much swelled, and painful to the touch—the mouth of tjie uterus 116 was not dilated more than an inch in diame- ter. About half past ten o'clock, P. M. her pains became stronger, but the mouth of the uterus showed no disposition to dilate— agreeably to your friendly advice I had her taken out of bed and placed in an erect pos- ture ; a vein was opened in her arm, and by the time sixteen ounces of blood were drawn syncope came on, and she was immediately replaced in bed—after she revived, her pains increased, but the mouth of the uterus still remained contracted; at half past twelve o'clock (Thursday morning) about six ounces more of blood were taken, which also pro- duced fainting; she was now examined, and I found the mouth of the uterus dilated to about three inches—after she had recovered so as to take a little wine and water, a few small pains came on, and at ten o'clock she was safely delivered. Yours sincerely, WILLIAM SHAW. Oct. 22d, 1S05. 117 We might easily increase the number of cases of this kind, were it necessary; but as these cases resemble so exactly those already related, after the uterus refuses to be tran- quillized, that to give more would be mere repetition. We would, however, suggest two rules in the management of these labours; first, always try to quiet the uterus, when we have reason to believe its action has been pre- maturely excited, by first bleeding, and then giving laudanum by injection. Secondly, when we find we cannot suspend pain, to be careful to abstract all stimuli as much as possible; to have the bowels well opened; and allow the circular fibres of the mouth to be a little fa- tigued (which we can determme by their readily yielding, when the finger is made to stretch them in the absence of pain) before we employ a large or. a sufficient bleeding to effect the farther dilatation. Bleeding alone, sometimes quiets this pre- mature commotion of the uterus, as the fol- lowing case will prove. 118 CASE XVI. 1806, January 10th. Mis. C-----, aged nineteen, and subject of case xiv.; pregnant of her second child, was attacked- with pains, which she bore all night; in the morning I was called to her; she seemed to suffer much, but from examination was certain the pains were premature; her pulse was full and tense; she lost twelve ounces of blood, which very much diminished her pains, but did not sub- due them: in the evening, her pulse continu- ing still active, she lost as much more, and was very soon entirely relieved. In about a fortnight after, she was again seized in the same manner; she was again bled and obtain- ed ease: at the expiration of another fortnight she was again attacked; these were the ge- nuine pains of labour, and she was delivered in about two hours. 119 Rigidity from local Injury. Notwithstanding my frequent use of blood- letting in certain cases of difficult parturition, I was an entire stranger to its effects where the parts had suffered considerable derange- ment from inflammation or laceration, as no case of the kind had ever came under my no- tice until the time I was called to the subject of case xvii.; and perhaps I might still have ■remained ignorant on this head, had not my friend Dr. Physick proved, how much could be done in a forlorn hope, by bleeding ad deliquium animi. I have no doubt, from for- mer experience, but I should have employed this remedy to a very considerable extent in the cases under consideration, but must con- fess I think it more than probable I should not have ventured to produce syncope in cases of cicatrized vagina, $c. as relaxation could not be anticipated from any remedy, had not its safety been proved by previous experiment. 120 But I am now so well satisfied of its safety and its extensive usefulness, that I shoidd never, in cases judged proper for the trial, hesitate a moment to employ it. I have ear- nestly inculcated its safety, and I trust have proved its usefulness. I would remark here from long experience, that I have never known it fail in being serviceable, nor ever saw it in any degree do harm. The following cases will confirm its power, where had it failed, no resource would have been left but in the application of cutting instruments. There are instances on record, where this alternative has been employed, where I am disposed to believe, bleeding ad deliquium would have succeeded. Baudelocque, one of the most scientific and experienced accou- cheurs of the age, Vol. III. p. 205, par. i960, says, "Sometimes the pad which constitutes the neck of the uterus in the later periods of pregnancy and in the time of labour, is hard, scirrhous, incapable of any extension or dila- tation, so as entirely to hinder the exit of the 121 child. After a convenient delay to ascertain that the efforts of nature cannot overcome the resistance, and the administration of pro- per methods to relax it, it must be cut in several places, as some practitioners have done. Those incisions are preferable to rents, which might take place in it, and have never been attended with the same consequences." " The orifice of the uterus may be closed, either completely or incompletely, at the time of labour. Its perfect closure is always pos- terior to conception, but an incomplete one may exist before. In all cases, the orifice must be restored to its original state, and be open- ed with a cutting instrument, as soon as the labour shall be certainly begun."* * I have been most illiberally charged with misquoting Baudelocque, in these passages, by a writer in the Philadel- phia Medical and Physical Journal—I have carefully exam- ined the paragraphs, and find them word for word—I used Heath's Translation; the original I never saw but for a short time, to compare the translation in many parts with it. Q 122 Would it not be better in such cases always to try first the effects of blood-letting? And do not the following cases warrant a belief it would succeed? CASE XVII.* In June, 1796,1 was called to Mrs. T-----, in labour with her second child. The follow- ing account I received on my arrival, from the midwife. " She had been in labour sixteen hours; the waters discharged, six; the mouth of the womb but little opened; and when in pain the os externum seemed to close up. Many things had been given her to force the labour; but the child was still as high as ever. She had passed no water for twelve hours, and was very costive." I found her very feverish; complaining of great heat in her abdomen, and violent pain in her head. On examining per vaginam, I * See Med. Repos. Vol. II. No. 1. p. 24. 123 found, as the midwife had stated, that the os tincae was but little dilated, its edges very rigid and hot—as was the whole tract of the vagina; the rectum much distended by har- dened fseces, and the bladder considerably by urine. The head of the child was still above the brim of the superior strait; but could not exactly determine its situation with respect to the pelvis, as the os uteri was not sufficiently opened for this purpose. I immediately bled her twelve or fourteen ounces and ordered an injection, which pro- cured two stools, and a discharge of urine. I again examined her, and found the mouth of the uterus more dilated (it being now opened to about the size of half a crown) which ena- bled me to determine the precise situation of the head. It was a perfectly natural presenta- tion, and the vertex had now descended lower into the pelvis. The pains were very power- ful. The head at length cleared the superior strait, and the vertex was about to turn under 124 the arch of the pubes, but completely envelo- ped by the uterus—during pain the perinseum was much distended; the os externum, instead of yielding to the impulsive force of the ute- rus, rather closed, so that two fingers could not be retained; a seam or cicatrix, from her having had the perinseum lacerated in her former labour,* formed a kind of barrier; and the head, in consequence, was thrown to the right side of the inferior strait, where the parts were so extremely stretched, that I fear- ed each pain would make the head burst through them, in spite of every exertion to the contrary. From the oblique situation of the head with * The laceration ran from the inferior termination of the left labium, to about the termination of the sacrum. I judged of the extent of the injury by the cicatrix, which could be easily traced to this place. And indeed, conversing with the gentleman who had delivered her, he confirmed my supposi- tion. It was a long while healing; and her health suffered much from the excessive and long continued discharge. But from this she recovered, and when I saw her she appeared in robust health. She was about twenty-two years of age, of short stature, and rigid fibre. 125 respect to the vagina, the os externum, instead of answering to the axis of the inferior strait, mounted directly to the pubes; and conse- quently, the right side of the vagina, peri- nseum, and rectum, had to support the major part of the force exerted by the uterus and its auxiliary powers. In order to counteract their influence, I supported the external parts with my hands, and made, during each pain, a strong pressure against the head, and direct- ed the woman to suspend her voluntary powers as much as possible. Six hours were spent in this manner, without advantage; the os uteri still rigid, hot, and but partially dilat- ed ; the os externum still not disposed to yield; and the cicatrix as firm as ever. The head, notwithstanding my efforts to prevent it, advanced; so that the vertex, co- vered by a portion of the uterus, had partly emerged from under the pubes. At this period it was extremely difficult to touch the mouth of the uterus, as it had receded towards the 126 sacrum in proportion as the vertex had de- scended. The soft parts were very hot and dry; I began to be much alarmed for the fate of my patient. What to do I did not well know: I was ten miles from the city, and no one near me on whose judgment I could rely. In this (Jilemma I had nearly resolved on di- viding the parts, thinking this preferable to letting the head force its way through them, which I began to consider inevitable, when fortunately Dr. Physick's case of luxated hu- merus occurred to me, and determined me. to try the effects of bleeding ad deliquium animi. I represented to the friends of my patient, the danger of her case; the possible result of the bleeding; and the inevitable one did it not succeed. They agreed to the trial. I had her placed erect, while the midwife strongly sup- ported the perinaeum, $c. and opening a vein allowed it to bleed until she fainted.* She was then again placed on her side. * The quantity drawn was upwards of two quarts, 127 On examining her now, every thing appear- ed better; the external parts were perfectly soft and yielding, and the os uteri pretty lull? dilated: but no pains succeeded. I waited in this way half an hour (the patient continu- ing very faint) and no pain coming on, and the parts being now in a proper situation for delivery, I introduced the forceps, and deli- vered a living, and healtiiy child. The parts very readily yielded without laceration: the woman had a rapid recovery. CASE XVIII.* On the 12th of September, 1798, I was re- quested to visit the wife of Samuel Griffith, in consultation with Dr. Jones. Mrs. G. I was informed by the doctor, had been in labour sixteen hours; the waters were evacuated early in her labour; her pains, frequent and brisk; but there was not the least disposition in the soft parts to dilate, t * See Medical Museum, vol. II. No. 1. p. 27. t This patient, like the one whose case was formerly 128 I sat down to examine our patient, and found the os externum scarcely large enough to admit the finger, and it was mounted up closely against the symphysis pubis, in conse- quence of the perinseum being very much dis- tended by the head of the child. The os uteri was rigid and but little opened; a kind of bri- dle or small column of flesh ran from the in- ferior edge of the os pubis, and lost itself in the perinseum below; against this the head was firmly pressed. The head was situated naturally, and so far advanced, that the vertex given,* had suffered a lacerationof the perinseum to a very great extent; the parts after a considerable lapse of time healed up, but so unfortunately, as almost entirely to obliterate the the vagina. I was called upon for my advice when in this situation, and found the case truly distressing; the passage or vagina was contracted, so as not to exceed in size a com- mon quill; the parts extremely callous, and a constant and profuse discharge of foetid, acrid pus, kept the poor woman in a continual state of misery and ill health. My friend Dr. Physick was also consulted; by a persevering use of sponge tents, &c. the parts became sufficiently dilated to admit im- perfectly the venereal congress; soon after, she became preg- nant, and the consequences of this pregnancy, furnish the above case. * Medical Repos. vol. II. No. 1. p. 24. 129 was about to emerge from under the arch of the pubis, covered with the uterus; it had been thus fixed for nearly six hours previous to my seeing this patient; and all that had been done, was the occasional exhibition of tinct. opii: with steady pressure against the perinseum, to prevent the escape of the head through it. In this situation of affairs, what was to be done? My ingenious and much lamented friend, Dr. E. Smith, of New York, immediately after the receipt of my former case, suggested the trial of an infusion of tobacco, in similar cases, to supersede the use of such extensive bleed- ing as had been employed in it; affirming its effects were very similar to those produced by copious blood-letting; such as nausea, vo- miting, syncope, and consequently relaxation. The idea pleased me, and I was determined to employ it the first opportunity; the case under consideration, I believed to be as fa- vourable a one as could occur, and I accord- r 130 ingly proposed it to Dr. Jones; he cheerfully agreed to its trial; a strong infusion was made of the tobacco, and a quantity of it, with spme difficulty, after several ineffectual trials, was thrown up the rectum. It produced great sick- ness, vomiting, and fainting; but the desired relaxation did not take place; we waited some time longer, but with no better success. In the course of an hour, or an hour and a half, the more distressing symptoms produced by the infusion wore off, and resolving to give the remedy every chance in our power, we got our patient, with some difficulty, to consent to another application of it; its effects were as before—great distress, without the smallest benefit; the soft parts remaining equally rigid as before its exhibition. Supposing the bridle just spoken of might have some influence on the development of the external parts, I divided it, but without any evident good resulting from it. I now proposed the remedy that had so completely 131 succeeded in a former case—bleeding nearly to fainting; this was consented to. We had our patient placed upon her feet, taking care to have the perinseum well guarded during the operation. Upon taking away about ten ounces of blood, she became very faint;* she was immediately laid upon her bed; the most complete relaxation had taken place, the for- ceps were applied, and our patient was deli- vered, in a very few minutes, of a fine healthy girl. The mother was put comfortably to bed, and every thing went on in the ordinary way until the sixth day, when she was seized with a violent cholera morbus and convulsions, (to which complaints she was subject) and died in twelve hours. This case, notwithstanding its ultimately unfortunate termination, fully establishes the influence of blood-letting in this very distress- ing kind of rigidity, and proves it to act dif- * The subject of this case was a delicate woman, and wont to become very faint, upon the loss of a little blood, 132 ferentiy from tobacco, notwithstanding the latter produces nausea, vomiting, and syn- cope ; and also that the quantity of blood lost in some instances may be very small, to induce the desired relaxation. We conceive, that no possible blame can be attached to the bleeding in this case; as the woman was very well until the sixth day, when a disease, to which she was subject, car- ried her off. CASE XIX. On the 26th September, 1800, I was called to visit the wife of Michael Falkrod, at Frank- ford, in consultation with Dr. Ruan. She had been in labour twelve or fourteen hours, with her second child;* the pains frequent and strong, the waters discharged some time; the head was situated favourably, and completely occupied the vagina; the perineal tumour * With the first, she had suffered an extensive laceration of the perinseum. 138 large; the os externum not larger than a com- mon finger ring; and admitting the finger with some difficulty in the absence of pain; during pain it was thrown up against the in- ferior edge of the pubes, in such a manner as not to admit the finger, or allow it to be re- tained if previously introduced. Externally a large cicatrix was found running to the very verge of the anus; internally it could be trac- ed farther. This cicatrix prevented the unfold- ing of the external parts so effectually, that the repeated efforts of the uterus for several hours were insufficient to make them yield, though the head had been closely applied to them during that period. This patient was a strong healthy woman; considerable fever had been excited; the pulse strong, frequent, and hard. I proposed bleed- ing ad deliquium, to which Dr. Ruan consented. We immediately opened a vein, and took about forty ounces of blood, but as her pains were so rapid, we were obliged to take it from her in 134 a recumbent posture, and no disposition to syncope was manifested. This quantity howev- er had some effect, as there was evidently a beginning relaxation, and an abatement of the violence, and frequency of the pains. We now agreed upon a second bleeding, and to have it taken in an erect situation. We, with some difficulty, effected this; when upon taking five and twenty or thirty ounces more she faint- ed; she was laid upon the bed, and in a few minutes, by the forceps, was delivered of a fine healthy boy. Our patient recovered rapidly without accident or drawback. CASE XX. February 26,1803. I was called to the same woman in labour with her third child; the same circumstances attended, and the same remedy was employed with a similar effect. This case was witnessed by Mr. Bond, an ingenious young gentleman of Baltimore. 135 CASE XXI. 1792, Aug. 17. Mrs. T. S—, aged 28 years, in labour with her first child; the pains com- menced regularly and pretty severely for some time; they then became more desultory both in recurrence and in force—she took from the midwife stimulating drinks, which rather in- creased her unpleasant feelings, such as a sense of suffocation, heat and pain all over the abdo- men, sickness at stomach, ^c. without aug- menting the force or frequency of her pains; —when I was called to her she was labouring under all the distressing sensations just men- tioned, together with a depressed pulse, fre- quent sighing, great uneasiness, and apprehen- sion—the mouth of the uterus was not much dilated, though quite unresisting when attempt- ed to be stretched; its edges were thickened, but not tense; when pain came on very little impression was made on the child, and the mouth of the uterus rather contracted than opened. As much oppression about the prse- cordia attended, and great heat in the abdo- 136 men, I determined on bleeding her; I took from her arm about twenty ounces before the op- pression and heat were much diminished; but as these were relieved, though not removed, and the .pulse acquired vigour by the opera- tion, I was induced to go on until these un- pleasant symptoms were subdued; this hap- pened by the loss of about ten or twelve ounces more—I tied up the arm quickly, as the pains had now very much increased, and sat by the patient; and in about twenty mi- nutes she was safely delivered. CASE XXII. Mrs. W-----, June 10th, 1805, was taken in labour with her tenth child; her pains began smartly, but soon ceased almost entirely—she continued in this situation from ten in the evening until six the next morning, at which time I was called; I found her with nearly all the symptoms related in case xxi. I bled her about twenty ounces, pain immediately came on, and she was quickly delivered. 137 I had very little prospect of relieving case xxi. in the manner I did, as at that time I was not so well acquainted with this particular kind of case, or of the remedy proper for it; but since this time, many cases of the kind have occurred, and all have been speedily re- lieved in the manner just related. CASE XXIII. 1798, Dec. 18th. I was called to Mrs. Z—, in labour with her third child ; she had been in labour eight and forty hours; waters dis- charged, thirty-six ; the uterus well dilated ; pains severe, but no advancement of the la- bour ; during the pain the child's head, which was well situated, would be forced down, but as soon as it ceased it would again be retract- ed ; this had been the case for many hours be- fore I saw her. In order to ascertain the cause of this delay, I introduced my hand into the uterus,' and presently found the cause of the child not advancing; a circle, as it were, of 133 the uterus had closed between the shoulders of the child and the head, which prevented their passing. I bled her to fainting; pains soon came on, and she was quickly delivered. Cases of this kind have frequently occurred to me; but in some cases I have been obliged to turn, after the bleeding, (which before was impossible) and in one or two others I have been obliged to use the forceps. These cases resemble each other so much in almost every respect, that I do not think it necessary to de- tail but one. Having given an account of a variety of cases in which blood-letting has been useful, and some others, where the labour could not, with- out the most serious evils resulting, be termi- nated without it, I shall close my remarks with observing, that we must not consider the use of this remedy confined to the immediate state of the patient, but extended to her future health and happiness. I look upon it as a pre- 139 ventive to fever, scirrhus, abscess, and con- gestions of Various kinds, to which the viscera are but too much exposed, from badly treated labours.—Where is the woman who is married, had children, and is in bad health, that does not date her illness from one of her lyings-in? I can with confidence assert, I have never seen puerperal fever, milk abscess, or the swelled leg, take place, in any one patient who had suffered large or repeated bleedings during their labour; it seems to ward off every blow aimed at the puerperal state. Difficulty arising from want of force in the Uterus, &c. Besides the causes of difficulty We have al- ready enumerated, we frequently meet with cases in which the uterine efforts are entirely unavailing, although every thing, as regards 140 position and relaxation, are favourable; the labour te, of consequence, much delayed. This situation of the uterus may arise from an original want of power, or it may be owing to its being much exhausted by previous ex- ertion; but both these cases, as far as my ob- servations have extended, are relieved by the same remedy, viz. the ergot or the secale cor- nutum. This remedy has been introduced into prac- tice under very strong evidences in its favour; for few substances of the Materia Medica have supported an equal character under such frequent and varied application. It would appear, from all I have been able to collect, and from all I have observed, that it rarely fails or disappoints, when properly prescribed; or where too extravagant or im- proper expectations were not entertained. That it is not competent to every case of dif- 141 ficult labour must be admitted, for who could expect to find a remedy in any one article for the various contingencies affecting this process? We gain much whenever we become possess- ed of a sure remedy for any one disease; and could we be uniformly progressive in such acquisitions, we should soon be left without opprobria medicorum. The ergot was introduced to our notice principally by Drs. Stearns and Akerly. The former appears to have had very ample expe- rience in its use; and from the latest accounts which I have seen, from that gentleman, on this subject, it would appear that it had not forfeited its character in his hands. The ergot, as an article of the Materia Me- dica, is by no means a new remedy; but its virtues appear to have been very much ne- glected, as no authority which I have in my possession, among the English writers, men- tion it. But in the Diet. Rais. Univers. d'Hist. 142 Natur. by Bomare, we find the following nor tice of this substance, under the article " Sei- gle." " On lit dans le Journal de Physique, Aout, 1774, que ma- dame Dupille pres Chaumont en Vixen, et dont la principale occupation semble 6tre le soulegement des malheureux qui manquent de secours et qui en ont besoin, a fait prendre d'apr^s les experiences de madame sa mere, a des femmes qui avoient de la peine a accouche?, plein un d€ a coudre d'ergot pulverise et delaye soit dans du vin ou de l'eau, ou du bouillon: le travail de I'accouchement, lorsque Penfant se presente bien, se terminoit dans le quart d'heure, et ces femmes n'ont point ete incommodees du l'usage d'un tel re- mede." From this it would appear that this sub- stance was in familiar use prior to the year 1774, and was prescribed for the very cases for which it is at this moment given. And that the effects, noticed after its exhibition, were as prompt as they are now found to be. The mode of exhibiting this drug does not appear to be very material; I have given it both in substance and by infusion, without experiencing any difference in effect. 143 The quantity to be given appears to be pretty well decided; namely, one scruple at a dose, and repeated in fifteen or twenty mi- nutes, until a drachm be given, should neces- sity demand it; it is given in this quick suc- cession, as it would seem that, if it produce no effect in this time, it will not be more successful if a greater interval be allowed to elapse. The quantity here spoken of would seem to entirely comport with the dose exhi- bited by madame Dupille. I have ventured on the use of the ergot in a case for which I never knew it to be pre- scribed, namely, to bring away the placenta after abortion; and from its entire success in this instance, am disposed to regard it as a valuable addition to our present means. It will be confessed by all who have experience in midwifery, that the retention of the placenta, in the earlier months of pregnancy, is some- times productive of great inconvenience; and that we are almost exclusively obliged to rely 144 on the efforts of nature to achieve its delive- rance; and that before this is effected, the wo- man is subjected to serious evils, particularly in hot weather. It is no unfrequent occurrence for the uterus to cease to act for several days after the expulsion of the foetus; and the pa- tient, during this time, suffers from anxiety as well as from the extent and fcetor of the dis- charge, I have seen fever induced, which has not been relieved until after the casting off of the placenta. This remedy is regarded as a stimulant of no mean power; but I must confess I have never witnessed any direct operation upon the sanguiferous system. I have carefully watched the pulse in a number of instances, but could never detect any influence upon it; I have therefore, of late, paid little attention to the state of the system, when about to ex- hibit it. Its operation appears to be very eva- nescent, and to be exclusively confined to the muscular fibres of the uterus. Indeed, it ap- 145 pears to be one of those rare substances, which is justly intitled to the name of speci- fic ; and seems completely to confirm the con- jecture, hazarded many years ago, that we should be able to prescribe internal remedies with as much certainty for a too feeble con- traction of the uterus, as we do for an inter- mittent fever. See page 17 of this Essay. The cases in whieh this remedy however is exclusively indicated, are, it must be confess- ed, but few; but in these few it appears invar luable. We consider the following situations as the proper ones for the exhibition of this drug. First. Where the labour has been long pro- tracted from the rigidity of the soft parts; and the uterus had, from the long continuance- of its efforts, become exhausted or weakened be- low the power required to effect delivery; and although the uterus and external parts T 146 were then in a state of relaxation, yet to ena- ble the child to pass through them, required stronger contractions than the uterus could yield. Second. Where the soft parts are in pro- per condition for the passage of the child, but where the uterus lends its aid so feebly that delivery cannot be effected without more vi- gorous efforts from this viscus. Third. Where every thing is in proper train; where the efforts of the uterus though slow, but not very powerful, yet if sufficiently long continued may effect the delivery, and the labour complicated by any accident which would render its speedy termination desira- ble; such as a prolapsus of the cord, moderate flooding, severe cramps, §c. 6jc. Fourth. Where all the circumstances ob- tained that were last mentioned, with the ex- ception of the accidents enumerated. It would 147 in this case be desirable, and I conceive pro- per, to abridge the woman's sufferings by the use of the ergot. Fifth. Where the head of the child has been separated from its body, and left within the uterus, as has been ingeniously suggested by Mr. Beesly of New Jersey, and now a student of medicine in this University. In this case it bids fair to be a valuable medicine. Sixth. Where the placenta has been pre- vented being thrown off, from want of power in the uterus. Seventh. In dysmenorrhcea, as recommend- ed by Dr. Physick. There is no one circum- stance connected with the use of the ergot, that so justly excites our surprise, as the promptitude of its action. In some cases it scarcely has time to arrive in the stomach, before we observe its effects manifested on the uterus; so sudden, and so efficient are its 148 powers sometimes, as to almost make u* challenge its agency. But it must be confessed that the ergot, like every other remedy, will have its defeats; but these occur so rarely, where properly em- ployed, that they scarcely deserve to be men- tioned. I am aware that in advancing this sen- timent, I am not supported by every practi- tioner who has employed the ergot, for some one or two have informed me, they had given it in very large doses without any advantage whatever. I cannot doubt their statement, as they could have no motive to mislead; yet I am confident the failure must have originated from a bad quality of the ergot, or from in- ordinate expectation. It would seem from some late experiments made on this substance in France, that there exists a considerable dif- ference in its quality, and from this circum- stance, should in general be much more dis- posed to attribute failure to a bad sort having been exhibited. 149 At all events, there is sufficient testimony in its favour, to induce a trial of it in the cases and under the circumstances above mention- ed. We shall now relate a few cases from among a number, as confirmatory of its powers. CASE I. I was called on the 21st December, 1817, in consultation, to Mrs. M. who had been in labour sixteen hours; it was a first child, and the lady was pretty far advanced in life, namely 28 years. The waters discharged early in labour; the pains frequent and strong; the uterus dilated after a few hours so that the child's head passed it, and every expectation was entertained that the labour would finish promptly; in this the physician experienced a disappointment; tjie head was at the inferior strait, and the vertex was applied to the arch of the pubes. £ains still frequent, but gradually became weaker. After waiting six hours for the delivery, I was sent for. I found the patient suffering much from a ge^- 150 neral pain over the abdomen, some fever, and great restlessness; pains were frequent but in- efficient; the head was about to emerge from under the arch of the pubes, but the pains were not of sufficient strength to depress the parietal bones below the tubers of the ischia. I waited about twenty minutes to see the ef- fect of the pains, and during each assisted the proper adaptation of the head to the lower strait; that is, I assisted in turning the face exactly into the hollow of the sacrum, so that each limb of the lambdoidal suture was appli- ed to corresponding portions of the legs of the pubes. By this I diminished resistance and aided the efforts of the uterus to this end. But all this was unavailing, the pains flagged more and more, and it was agreed to give a scruple of the ergot, and repeat it should it be neces- sary; the second dose was given in twenty minutes after the first, although there appear- ed an evident increase of power from the first; in twenty minutes more she was delivered 151 of a very large healthy boy; nothing worthy of note occurred after the delivery. CASE II. May 30, 1817, at eight o'clock P. M. I was called to Bush-Hill to attend Mrs. M. C. She was the mother of several children; extreme- ly delicate and feeble. Her pains were weak and a long time apart; sometimes would not recur for an hour. On the 31st, at eight o'clock A. M. made an examination, and found the os tincse dilated and very yielding, the pains still very slow; during a pain, I gently stretch- ed the os uteri, with a hope of exciting a stronger action, but failed of success; and as the parts were well disposed, I ruptured the membranes without any advantage. At two o'clock P. M. I gave a scruple of the ergot, and in fifteen minutes more repeated it; the pains came on rapidly and with great force, and in a quarter of an hour more she was safely delivered. 152 This case was one of the most striking in- stances of the influence of the ergot I ever witnessed; and its specific action, if we may so term it, was most prompt and efficacious, for it succeeded in producing contraction, when a very powerful means (rupturing of the mem- branes) had failed. I was in this case induced to rupture the membranes for two reasons: First, that by the evacuation of the waters, the uterus might be stimulated to action, by coming in contact with the child's body; secondly, and by this contraction, to prevent a flooding from atony. CASE III. June 3, 1817, I was called to Mrs. B. in labour with her first child. She had been poorly, as they called it, all night, but towards dav light her pains became very smart, and I was sent for. She was twenty-five years of age, stout made and very firm. Her labour advanc- ed very well, the soft parts yielded without much reluctance after a bleeding of about 153 twenty ounces, the waters escaped by the force of pain, and the head sunk into the lower strait in the sixth position. It for some time advanced as rapidly as such a presentation would permit, but the pains suddenly became weak, though pretty frequently repeated. I waited two hours, in the expectation of their force being recruited, but they seemed weaker and more tardy than before. I sent for a drachm of ergot, and gave one third part of it without any advantage; a second portion was given in twenty minutes, and the pains began to in- crease, when at the expiration of fifteen mi- nutes more, the other portion was given; the pains in a few minutes afterwards became powerful and frequently repeated, and in an hour more she was safely delivered. Had this been a case of the first or second presentation, the child would have been de- livered sooner, as the force of the pains and the disposition of the parts were favourable to a rapid issue. u 154 CASE IV. September 10th, 1818, Mrs. C-----, was delivered of twins at the fifth month, after a few hours endurance of pain; some hsemor- rhagy attended, but it was not threatening; the ova opened, and the foetuses were thrown off; a slight flooding followed. After a few hours more of moderate pain, it ceased, and four days elapsed without it returning; the discharge became offensive, and considerable tenderness of the belly was felt, and some fever was excited; the fever every night ter- minated in profuse sweating. As the action of the uterus did not return to throw off the placenta, and as there was some unpleasant symptoms present, I thought it proper to attempt the renewal of the uterine efforts; for this purpose I ordered a drachm of the powdered ergot to be divided into three parts; one to be given every half hour, until pain should be excited. Two doses were given, 155 and the uterus was immediately roused to brisk action, and the placenta thrown off. The second dose of the ergot was not neces- sary, but the anxiety of the patient induced her to take it, although pain had been excited by the first. After the expulsion of the placenta the con- tractions of the uterus were calmed by lauda- num. My patient, after the lapse of three days, was persuaded that one .of the placenta remained undischarged, and, without consult- ing me, took the remaining portion of the ergot, which had the effect of renewing the painful contractions of the uterus, which were again relieved by opium; nothing untoward followed; my patient recovered rapidly after this period. From all then that we know at present, we are justified in saying, that this drug appears to have a very decided action upon the ute- rine fibre, exciting them to contraction when- 156 ever exliibited for a considerable number of days after the expulsion of the uterine con- tents ; and that the only precaution to be ob- served in the use of it is, that it must not be administered until the mouth of the uterus and external parts are well dilated or very favourably disposed to this state. THE END WZL DflU * ■! ^■SpV^''':■'■■■'•' ■' M, YWiBY'E. 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