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Xntrotrttttfon
TO THE
PRACTICE OF MIDWIFERY.
Samuel L. GrlswolOl 

    Printed by C. S. Van Winkle,
Printer to the University of New-York. 
V
               Samuel  L. GrisvroM




AN
asrvR<D3>wBVtt<i>sr
TO THE
PRACTICE   OF  MIDWIFERY.
     BY  THOJWS DEJYMAN, M. D.



CENTIATE IN MIDWIFERY OF THE COLLEGE OF PHYSICIANS, LONDON J

      AND HONORARY MEMBER OF THE ROYAL MEDICAL

             SOCIETY AT EDINBURGH.
                FROM THE LAST LONDON EDITION,


                     Revised by the Author.





       WHU)  Kotis  emir fSnunttattions,





             BY JOHN W.  FRANCIS, M. D.


Professor of Obstetrics and the Diseases of Women and Children in the University of the State of
 New-York; Member of the Medical and Chirurgical Society of London ; Member of the Aca-
 demy of Natural Sciences of Philadelphia; one of the Consulting Physicians of the New-York
 Dispensary; President of the Medico-Chjnfrgical Society qf the University of New-York, fcc.
                       t'
%VV3*
NEW-YORK:
PUBLISHED BY E. BLISS AND E. WHITE,


          No. 128 Broadway.
)                           1821,

 U 
Cv6'0
./-'ZW   mo. £,/ fr   m.   ^
Southern District of New-York, ss :
        BE IT REMEMBERED, that on the eighth day of October, in the forty-sixth
year of the Independence  of the United States of America, E. Bliss and E. White, of
the said district, nave deposited in this office the title of a book, the right whereof they
claim as proprietors, in the words following, to wit:
  " An Introduction to the Practice of Midwifery.  By Thomas Denman, M. D. LicetP"
tiate in Midwifery of the College of Physicians, "London; and Honorary Member of the
Royal Medical Society at Edinburgh.  From  the last London  edition, revised by the
author.  With Notes and Emendations, by John W. Francis, M. D. Professor of Obste-
trics and the Diseases of Women and Children in the University of the State of New-
York ; Member of the Medical  and Chirurgical Society of London; Member of  the
Academy of Natural Sciences of Philadelphia; one of the Consulting Physicians of the
New-York Dispensary ; President of the Medico-Chirurgical Society of the University of
New-York, &c."
  In conformitt to  the act of the Congress  of the  United States, 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  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 histori-
cal and other prints."
                                              JAMES  DILL,

                                      Clerk of the Southern District of New-York. 
NOTICE
TO THIS AMERICAN EDITION.
   I have ventured, with due  deference, to offer  to the
 American public a new edition of Dr. Denman's Intro-
 duction to the  Practice of Midwifery, with  Notes and
 Emendations, the result of some attention to  this branch
 of medical  science.   The high practical merit of the
 original work is universally acknowledged; but in it the
 careful  reader  will  occasionally  have  observed  errors
 which demand correction, and deficiencies which recent
 improvements may supply.
   I was induced  to assume  the  responsibility of this
 undertaking  by a desire  to  render  this introduction
 still more  generally useful as a  manual of the present
 state of obstetrical knowledge.  With all the care I have
 exercised, I cannot pretend to have  noticed  every defi-
 ciency ; yet I have animadverted upon the different parts
of the work with freedom and impartiality, aware that
in all  practical subjects errors, apparently minute,  some-
times  exercise an influence extensively pernicious.   The
 Additions I have made are considerable in number, and I 
vi            NOTICE TO THIS EDITION.
trust will prove of some service.   But independently of
any thing I have  done,  this performance recommends
itself  to all studious  of  improvement in an  important
and responsible department of the profession, by merits
which enlightened  criticism has pronounced hitherto be-
yond successful competition.
  I have advised, that the Aphorisms of Doctor  Den-
man be added to this edition, and  the enterprising pub-
lishers have consented to enrich  the whole  with  the
Series of valuable Engravings which the venerable author
caused to be affixed to the last London  impression of
his work.
                              JOHN W. FRANCIS.
  New-York, October 1,1821. 
               ADVERTISEMENT.

  Contrary to the expectations of the Author, another
edition of this work has been called for, and it has been
thought expedient to compress it into one volume.  Some
corrections have of course  been made, but  not  many
additions, very few practical improvements having come
to the knowledge of the Author since the publication of
the  former editions.   It may be doubted whether any
part of medicine has been more improved within the last
sixty or seventy years than the practice of midwifery, by
returning as it were from too much artifice to the sim-
plicity of nature,  and by relying on the general efficacy
of  the  powers of the constitution  in overcoming the
difficulties which occur in child-birth.   I must, how7ever,
allow, that some improvements have  been  made  in the
treatment of women in child-birth after delivery,  and
perhaps in fixing with more precision  the time when the
interposition or assistance of art was required.
  I hope that at a  future time  some  gentleman compe-
tent to the task, by his  knowledge and experience,  will
undertake to conduct this work, and preserve the labours
of the Author.
                                 THO. DENMAN.
  November 1, 1815. 
 
CONTENTS.
 P  r                                                   Pagft
 Preface,.......               17

                       CHAPTER I.
                       ON THE PELVIS.
 Sect. I. On the bones of the pelvis,      ...      65
      II. On the connexion of the bones of the pelvis,    .    70
     III. On the separation of the bones of the pelvis,     .    71
     IV. On the reunion of the bones of the pelvis,     .     78
      V. On the position and structure of the pelvis,    .     82
     VI. On the formation of matter between the loosened
            bones of the pelvis,.....84
    VII. On the form and dimensions of the  pelvis,     •      85
   VIII. On the dimensions and structure of the head of the
           foetus,......           q<7
    IX. On the application of mechanical principles to mid-
           wifery,     .......88
      X. On distortion of the pelvis,         ...     91

                       CHAP. II.

         ON THE EXTERNAL PARTS OP GENERATION.
Sect. I. Description of the external parts,     ...     98
     II.  On tumours and excrescences of the external parts,   99
    III. On edematose swellings of the external parts,   .     100
    IV. On the cohesion of the labia.....101
    V. On abscesses of the labia,    .     .    .     .      log
    VI. On laceration of the perinaeum,     .    .    .     102
                            2 
10
CONTENTS.
Sect. VII.  On a peculiar laceration of the perinaeum,
     VIII.  On the enlargement of the clitoris,      .     •     10°
       IX. On diseases of the bladder and urethra,     .     107
        X. On the pruritus or itching of the external parts of
                                                          108
             generation,    .
       XI. On the hymen,......109
                       CHAP. III.
          ON THE INTERNAL PARTS OF GENERATION.
Sect. I. Description of the internal parts,
     II. On the contraction of the vagina,
    HI. On the cohesion of the vagina,
    IV. On cicatrices in the vagina,
      V. On polypi,   ....
    VI. On fluor albus,
    VII.  On prolapsus uteri,
   VIII. On hydatids  of the uterus,
     IX. On the dropsy  of the  uterus,
      X. On the tympany of the uterus,
      XI. Of moles,   ....
     XII. On the dropsy of the ovaries,
    XIII. On inflammation, scirrhus, and cancer of the ova-
           ries,     .          .....
112
120
121
122
123
136
140
146
147
148
149
150

155
                       CHAP. IV.

   ON THE PARTS CONTAINED IN THE CAVITY OF THE PELVIS.
Sect. I. On the retroverted uterus,   .    .    .    .     159
     II. On the retroflected uterus,   ....     167
    III. On the dropsy of the  perinaeum,   .    .    .     167
    IV. On the elytrocele,.....170
                       CHAP.  V.

                    ON MENSTRUATION.
Sect. I. On the menstrual discharge,   .
     II. On the efficient causes of menstruation,
171
176 
CONTENTS.
11
Sect. III. On  the final causes of menstruation,     .     .     179
       IV.  On the formation of a deciduous membrane,   .     180
       V.  On obstruction of the menses,      .     .     .     183
       VI.  On excessive menstruation,   ....     187
      VII.  On painful menstruation,     .     .     .     .     188
     VIII.  On the treatment which may be proper at the time
             of the final cessation of the menses.   .     .     189


                          CHAP. VI.

                        ON CONCEPTION.
  Sect. I.  On the different  theories of conception,   .     .     194
       II. On the growth of minerals, vegetables, and animals,  198
      III. On the ova of animals,.....201
      IV. On the difference of the structure of the uterus in
             different animals,.....203
       V. On the first stage of conception,     .     .     .     204
      VI. On  the formation and structure of the foetus,   .     209
     VII. On the funis umbilicalis,     .     .               213
     VIII. On  the placenta,......214
      IX. On the membranes,.....217
       X. On the liquor amnii,.....218
      XI. On the changes which the uterus undergoes in con-
             sequence of impregnation,     .    .     .     220

                         CHAP. VII.

  ON THE SIGNS OF CONCEPTION, AND THE DISEASES OF PREGNANCY.
  Sect. I. On the signs of conception,       .       .        225
       II. On quickening,......229
      III. On  the suppression of the menses during pregnancy,  230
      IV. On the febrile disposition attending pregnancy,      231
       V. On  the use and abuse of exercise during pregnancy,  233
      VI. On  vomiting,......234
      VII. On indigestion, and depravity or loss of appetite,     236
     VIII. On heartburn,......237
      IX. On  costiveness,......238 
]£                     CONTENTS.

 Sect. X. On collections of indurated faeces in the intestines,  239
       XI.  On the hemorrhoids       ....
      XII.  On blotches of the bkin and jaundice,              241
     XIII.  On tenesmus, diarrhoea, and dysenteric complaints, 241
     XIV.  On the strangury and incontinence of urine,  .     242
       XV. On fluor albus,......243
      XVI. On erratic pains, cramp, and numbness of the
             inferior extremities,      ....
     XVII. On varices of the legs, thighs, and abdomen,       244
    XVIII. On inquietude and want of sleep,      •     •      245
      XIX. On the solicitude and anxiety attending a state of
                                                          246
             pregnancy,    ...•••     A™
       XX. On headachs, drowsiness, vertiginous complaints,
             and hemiplegia,     .      .     •     •     •     246
      XXI. On anasarcous swellings of the inferior extremities, 247
     XXII. On ascites,......248
    XXIII. On partial distention of the abdomen and umbilical
             herniae,   ....•••     *48
    XXIV. On the excessively distended and pendulous abdo-
             mens.       •                                 249
     XXV. On the venereal disease,     ....     250
    XXVI. On the small pox-*General remark on diseases
             occurring  during pregnancy,     .     .     •     252
                      CHAP. VIII.

                   ON UTEROGESTATION.
Sect. I. On the situation of the foetus in utero,     .     .   254
     II. On the term of uterogestation,       .     .     .   255
    III. On the causes of 'abour,       ....   259
     IV. On the predisposing signs of labour,      .     .   260
      V. On examination,    ......   263


                       CHAP. IX.

                       ON LABOUR.
%ct. I. Classification of labours,       ....   267
      II. On natural labour,            .     .     .    ■.   268 
                         CONTENTS.                       13

Sect. III. On the symptoms accompanying labour,        .    269
      IV. On false pains,......275
      V. Cautions against endeavouring to promote the power
            and effects of pain,     .....    276
      VI. First stage of labour,     .....    277
     VII. Second stage of labour,   .....    281
     VIII. Third stage of labour,.....283
      IX. On tying and cutting the navel-string,     ,     .    290
       X. On the exclusion of the placenta,   ,     .     .    293

                         CHAP. X.

                   ON DIFFICULT LABOURS.
 Sect. I. General reflections,.....306
      II. Equivocal signs of difficult labours,   .     .     .    314
     III. On the definition and distinction of difficult labours,   316
     IV. On the first order  of difficult labours,     .     .    318
      V. On the second order of difficult labours,    .     .   332
     VI. On the third order of difficult labours,     .     .   339
     VII. On the fourth  order of difficult labours,   .     .   347
    VIII. General observations on difficult labours,   .     .    360

                         CHAP. XI.

 Sect. I. On the fillet, forceps, and vectis,     .    .     .   364
     II. On fillets,     .     .    .    .-•    .    .     .367
     III. On the forceps,......368
     IV. General observations on the use of instruments,     370
     V. On the application  of the forceps,    .    .    .   373
     VI. On the action with the forceps  when applied,    .   375
    VII. On the application of the  forceps under various
           circumstances,    ......   377
    VIII. On the vectis,......379
     IX. On the different kinds of vectes,     .     .     .381
      X. On the comparison of the vectis with the forceps,    383
     XI. On the manner of  using the vectis,       .     .   385 
14
CONTENTS.
                       CHAP. XII.

Sect. I.  On lessening the head of the child,   .     .     .   38t
     II.  On the signs  of a dead child,    . .    .     .     .391
    III.  On the causes of the death of the child,    .     .   397
    IV.  On the instruments used in the operation,       .   399
     V.  On the manner of performing the operation,     .   400
    VI.  On the perforation of the head,     .     .     .   400
    VII.  On the evacuation  of the contents of the head,   402
   VIII.  On the extraction of the head,     .     .     .   402
    IX.  On the subsequent  treatment,      .     .     .   407
     X.  On the propriety  of bringing  on premature  la-
            bour,     .......   407
    XI. On the section of the symphysis of the ossa pubis,   413

                      CHAP. XIII.

Sect.  I.  On the Cesarean operation,-    .     .    .     .417
     II.  On the general reasons for performing the  opera-
            lion........418
    III.  On the supposed reasons for performing the ope-
            ration,    .     .     .    .     .    .     .419
    IV.  On the actual reasons  for performing the opera-
           tion,     .     .     .     .     .     .     .421
     V.  On the causes of death after the operation,    .   424
    VI.  On the manner of performing the operation,     .   425
                      CHAP.  XIV.

Sect. I. On the  distinction of preternatural labours,
     II. On the signs of preternatural labours,
    III. On the first order of preternatural labours,
    IV. On the  distinctions  of the second order of pre
           ternatural labours,     ....
     V. On the first distinction.....
    VI. On the  second distinction,
432
433
434

440
442
445
VII. On the third distinction,     ....     446 
CONTENTS.
15
469

471
Sect. VIII. On the evolution of the child,     ...     450
       IX.  On the distortion of the pelvis,   .     .     ;     455
       X.  On the separation of the head,     .               431


                        CHAP. XV.

                      COMPLEX labours.
  Sect. I. On abortion, and labours attended with hemor-
             r-haSe........463
       II. On the frequency of abortion in women,      .     466
      III. On the treatment of abortion,
      IV. On the symptoms preceding and accompanying
              abortion,     ....
       V. On hemorrhages in the three  last months of
            pregnancy,......478
      VI. On hemorrhages  in which the placenta was at-
             tached  over  the os uteri,     .    .          4g0
     VII. On hemorrhages occasioned by the separation of
             the placenta  attached to  any part of the
             uterus>.....•     .      485
    VIII. On hemorrhages which come on after the birth
             of the child,.....           4«8
      IX. On the exclusion  of the  placenta,     .           492
      X. On the extraction of the placenta,     .           497
     XI.  On  hemorrhages which follow the exclusion of
             the placenta,  .                               ,.««
    XII. On the inversion of the uterus,    .     .           cqo


                       CHAP.  XVI.

           LABOURS ATTENDED WITH CONVULSIONS.'
 Sect. I.  General observations on labours attended with
            convulsions,    .    .                         r,„
                                                        ol 4
      II.  On the  reputed causes of convulsions,  .    .      519
    III.  On the  means of preventing convulsions.    .      523
     IV.  On the  treatment of convulsions,   .    .    ,      524
     V. On the  delivery by art,     ....      528 
16
CONTENTS.
                      CHAP. XVII.

           LABOURS WITH TWO OR MORE CHILDREN.
Sect. I. General observations,   ,                         534
     II. On the signs of twins,   .                         535
    III. On the  management of twin cases,    .    •     538
    IV. On the management of the placentae,   .    •     541


                      CHAP.  XVIII.

LABOURS IN WHICH THERE IS  A DESCENT OF THE FUNIS UMBILICALIS
               BEFORE ANY PART OF THE CHILD.
Sect- I. General observations,   .....     543
    II. On the descent of the funis when the os uteri is
           but little dilated,.....544
    III. When the os uteri is fully dilated,   .     .     •     545
    IV. Farther observations,   .....     546
     V. On monsters,     ......     548
    VI. On the extra-uterine foetus,  .     .     .     .     551
    VII. On superfetation,.....554

                      CHAP. XIX.

Sect. I. On the management of women in childbed,    .     557
     II. On mania,  .......     591
     III. On the swelled leg,.....579
    Denman's   Aphorisms,       .     .     .     .     .     617
    Series of Engravings, with Illustrations,       .     655
    Index,........675 
PREFACE.
   Before the first appearance of these papers in two volumes,
 the greater part  of  them had been separately printed, and of
 many of them there had been several impressions.  By this mode
 of publication I have had an opportunity of correcting many er-
 rors,  though, with all that I have been able to do for the amend-
 ment of the work in general, I am yet very sensible of its defi-
 ciences and imperfections.   But the reader will discover,  that
 pains have been taken to render it less unworthy of his regard;
 and  the hope of  being useful to  those who are engaged in the
 study or practice of Midwifery,  has converted the trouble into
 pleasure.   Very much  still remains to be done for the perfection
 of this branch of the profession, not by the speculative and pre-
 suming, who are ever misleading us—but by men of industrious
 attention and research, capable of reducing into order the obser-
 vations they will  have many opportunities of making, and of
 converting  them to practical  use  and advantage.  In medical
 writings, strict veracity is above all other things  required ;  and
 to this I have constantly adhered, to the best of my knowledge
 and judgment.
   Of the medical treatment of the diseases peculiar to women,
 and of  the  practice  of midwifery in  particular, we have no ac-
 counts from the earliest writers, but such as are very imperfect,
 and involved in works  which the life of one man would scarcely
 be sufficient to glean; while, after  all Ais labour, though his cu-
 riosity might be gratified, he prob'arffy would not, at this period
of time, gain for  himself, or afford to others, much  satisfaction.
The cultivation of medicine at large, especially of that branch of
 which we are about to treat, is of a recent date in our own coun-
try.   This, to one glance of the eye, exhibits a  view of the steps
by which human beings, in  a course of comparatively a few
                             3 
XV1U                     PREFACE.
yenrs, emerge from a state of absolute ignorance and barbarism,
become civilized, and arrive at eminence in every art and science.
  In v hat country medical knowledge was first cultivated, and
reduced into  scientific order, cannot now be  traced;  for, be-
yond a certain period, the records we have are  crowded with fa-
ble, and being chiefly supported  by conjecture, are by no means
entitled to unreserved confidence.  But long before the establish-
ment of systems, there must have been  a time, when means were
used for the cure of diseases,  and the relief of accidents.   There
must h so  have  been a time,   when the rude but well-meant  en-
deavours of one friend  to relieve another in distress ceased, and
application was made to those who were  supposed to have more
information or greater skill.   This would properly be the origin
of the art. By what steps or means  the Greeks became sooner
and better informed, in all arts and sciences, than many other na-
tions, we cannot now decide; whether  it depended upon the
force  of  their  own native genius,  to which something must be
granted ;  (see  Stuwfs  Antiquities  of Miens)  or whether this
knowledge were communicated  by some preceding or  neigh-
bor: ing people.  But  it is  probable,  that the Greeks  were in-
struc ed by the Egyptians; and these, as many contend, by the
natives of India:  yet, by whatever means they  acquired their in-
formation, to the  Greeks the distinguished glory is due of having
conveyed, in their own language, the rudiments not only  of me-
dicine, but of  almost  every  art and science, to  all the western
world.  Though  the moderns have availed themselves  of every
advantage they could obtain  by the study of the ancient writers,
it may be truly said, that they have not  always been too liberal
innheir acknowledgments.   But of this posthumous reputation
Hippocrates has had his  full share,  for  his very  name seems to
have  inspired  with enthusiasm  every succeeding writer; as all
those, of  whom we have  been accustomed to think with venera-
tion, or to speak with respect, have mentioned  him with admira-
tion, and  held him up to our view as  an  example  to be  imitated,
or as a pattern to be  exactly copied,  as  if he  had exhausted all
the fountains of medical knowledge and truth.  Whether we con- 
PREFACE.
XIX
  sider  his writings with regard to the  strict morality which they
  inculcate, the liberal conduct which they recommend, the strong
  and extensive observations with which they abound, or the order
  and method in  which  these  are conveyed,  it is not possible to
  withhold our esteem.*   He  had  likewise the good fortune of
  writing in a language,  which was not  only known,  but spoken
  with classical purity for a longer time  than any other;  for Hip-
 pocrates lived near five hundred years before the Christian era,
  yet the Grecian was the  popular  language at  Constantinople)
  even at  the time when  this city  was taken by Mahomet the Se-
  cond,  in the fifteenth century.   The Greeks also maintained an
  acknowledged superiority in literature and arts, for a long time
 after their political  sovereignty was lost.  But if there be any
  progressive power in the human mind, if any advantage be ob-
 tained in the practice of medicine by the knowledge of the circu-
 lation of the blood,  or of  an infinitely more correct anatomy and
 physiology at large;  by the vast discoveries, improvements, and
 application of chemistry ;  by a more copious and more efficacious
 materia medica ;  by the recorded experience of so many ages; or
 by the several collateral arts, which medicine calls in to its aid;
 we may surely he permitted to say, that  Hippocrates ought not to
 be considered as the guide of physicians at the present time,  or
 as having in any degree limited either the perfection or extent of
 the art, but as an illustrious specimen of ancient medical know-
 ledge and practice.   If this observation hold good with respect
 to Hippocrates, it will have more force  when  applied to all his
 transcribers and commentators, many of whom seem to have lost,
 in their attachment to  him, the use of their own reason and judg-
 ment ; constantly praising  learning at the expense of knowledge,
 and rejecting every improvement,  which could not be explained
 or justified by his writings.  To the Greeks we are indebted for
 the works of Aristotle in the time of Alexander the Great;  and
 it was the first object of the Romans, who subdued them, to ac-
 quire a knowledge of their  sciences, and to possess  themselves of

  * See a short but elegant abstract of the medicar observations and
practice of Hippocrates, in  the Hippocrates Contractus of Dr. Burnet. ^ 
XX                     PREFACE.
 examples of their arts.  With information of almost every other
 kind, the Greeks are to  be considered as the instructors of the
 Romans in  medicine; and allowing for  some change in the ar-
 rangement,  a strong intelligence in his selections, the addition of
 what he had collected from other writers, a few improvements in
 surgery, and the  local application of principles before known,
 Celsus, who lived at Rome in the early part  of the first century,
 may be considered as an  instructive and elegant abridger of the
 writings of Hippocrates.
   The  flourishing state  of the Romans was comparatively of
 short duration.  In the fourth  century the  empire  was divided
 into the eastern and western.  Rome,  which  was the capital of
 the latter, was taken by Odoacer, king of the Heruli, under whose
 subjection it remained ; and  the Romans ceased to speak the La-
 tin language in the beginning of the seventh century.   But nei-
 ther the conquest of Rome by Odoacer, that of Alexandria, under
 the Caliph Omar, nor the  permanent subjection of Constantinople
 by Mahomet the Second in the fifteenth century, extinguished that
 knowledge,  and those arts, which had been so long and so stren-
 uously cultivated and exercised.  From the  destruction of the
 library at Alexandria, which had many bad and  probably  some
 good consequences,  were produced the schools  of Antioch and
 Haran, or what may be called the Arabian schools, the principal
 medical writers of which  were Rhazes, Avicenna, Avenzoar, and
 Albucasis.   The sentiments and manners of no people could be
 less favourable to learning than those  of the Arabians ;  and we
 accordingly  find in every history, that when they spoiled Alex-
 andria, the intention of their chiefs was  to  destroy all kinds of
 science,  by  burning the   magnificent  libraries  which had been
 there collected; and every book which escaped the general ha-
 voc was preserved by the care or partiality of private men.  The
 writings  of  the Arabian physicians were chiefly,  though imper-
fectly, transcribed from the Greeks; yet they prove that the de-
testation of  learning might be more justly attributed to the bi-
gotry of individuals  than to the people at large.  These it will
be allowed are scarcely ever read; but they are  said to contain 
PREFACE.
XXI
 little of importance, except that the first account of the small pox,
 and of a few other diseases of less consequence, was given by
 the Arabians ;  and that Avicenna was the first who  described
 the forceps, or an instrument contrived for the  purpose of de-
 livering women in cases of difficult parturition, preserving at the
 same time the life  of the child.
    After the destruction of the library at Alexandria,  the Grecian
 manuscripts, which were preserved,  were translated into the  Sy-
 riac, Persian, a id Indian languages ; and the learned were  dis-
 persed   in  different countries.   For  it  appears,  that, in the
 year 767, Almanzar, the founder and Caliph of Bagdat, sent for
 a skilful and learned physician from India ; which I mention, as
 it seems to explain an observation made by the Raja of Kishina-
 gur, and reported by the learned Mr. Halhead in  the preface to
 his Persian Grammar,  without any  violence to  other chronolo-
 gies.   Thus  wars  and  apparent  devastation  became, in the
 hands of Providence, the means of diffusing learning over many
 countries, which might otherwise have remained in ignorance.
   But the first schools, from which the western  part  of Europe
 immediately derived knowledge,  were established in  Italy in the
 eighth century ; and the most famous of  those in which the art
 of medicine was taught, were at Padua  /  whither all who aimed
 at excellence resorted, with the view of pursuing their studies, and
 of.qualifying themselves for practice.   From the contiguity of
 the two countries, from the  frequent wars  carried on between
 France  and Italy, or from other  causes, the French had many
 and early opportunities  of acquiring knowledge.  Schools were
 established among them, encouragement was given  to learning,
 many able men arose, and France, by its more convenient situa-
 tion to Britain and the northern nations, succeeded Italy in  lite-
 rary reputation; Paris  and Montpellier being  the  places, to
 which students in medicine, as well as other arts, resorted  for in-
 struction even down to  the beginning of the 18th century.   But
 it will now be necessary to direct  our attention to a  more early
 period, in order  to gain some notion of tlhe  progress  of learning
in this country. 
XX11
PREFACE.
   About fifty years before the birth of Christ, Julius Ccesar
made a descent from Gaul into Britain, a country then but little
known, the inhabitants of which were in a very uncivilized state ;
if we except those who lived on the southern coast of the island,
perhaps not one degree more enlightened than the Indians, whom
their posterity afterwards discovered in America. The Romans con-
tinued long enough in Britain, to humble and render more tract-
able the ferocious spirit of the natives, to prepare them  for civi-
lization,  and to teach some of those arts, by which the evils of
their slate might be lessened, and a portion of the comforts of
life acquired.  On the retreat of the Romans  from  the island,
about the year 426, such of the natives, as, after an impotent op-
position  to their arms, and a rejection of their government,  had
been driven to the distant parts, poured  with irresistible fury on
those, who had submitted  to  the  dominion of Rome.  These
called in the Saxons, to assist and  to  protect  them,  about  the
middle of the fifth century.   Subjection is  usually  the lot of
those, who claim to receive political protection ;  and the Saxons
assumed  the government of Britain.   Being  but little more civi-
lized than those  they  came  to  defend,  they could furnish few
means of improvement ; and  the Danes,  in  their  subsequent
invasions,  checked  and   reduced  the  small  advancement
which the Britons  had  made  towards  learning, notwithstand-
ing  the  encouragement  afforded  by  Alfred,  about  the year
900.   The  Norman  conquest took place in  1066,  and  the
change,  with  all  its  disadvantages,  was productive  of some
general good to the nation : but the great prospect of literary
improvement arose towards the conclusion of the twelfth centu-
ry, when Richard the First undertook  his crusade to the Holy
Land.   It appears, however, that there was not a single  man  in
his whole army,  who understood the Grecian  or  Syrian  lan-
guage ;  so that without any advantage to balance the loss of his
subjects, or the expenditure of his wealth, in all likelihood he and
his people returned to England almost as ignorant as  they de-
parted,  there being no school for the Greek language before the
year 1490.   During all this barren and dreary time, that is, for 
PREFACE.
XX1U
the space of nearly thirteen hundred years, the excellence of the
Britons seems to have been in the strength of their arms,  for they
were constantly engaged in  wars foreign or domestic, and men-
tion  is scarcely made of any  man, who had a  claim to  be  con-
sidered as  learned  in  any  science, before Roger Bacon, who
lived in the thirteenth century.  He was a  man  endowed with a
very superior and excelling genius,  who, among  other branches
of philosophy, applied himself to chemistry,  which he carried to
afar higher degree of perfection than his predecessors of any age
or nation, as  well  as  laid the foundation of many modern  im-
provements.  A few other names of medical men, indeed, are re-
corded, as Richardus .'lnzlicus, Nicholas de Ferneham, Johannes
de Sancto JEgidio  or Giles, Hugh of Evesham, and  Gilbertus
Anglicus;  (see Aikin's  Biographical Memoirs;) but John a
Gaddesden- was the first  Englishman, according to Dr. Freind,
 who acquired sufficient reputation  to  be appointed Physician to
the Court, which Gaddesden  was,  in  the reign of Edward the
Second.  His  work, which he called the  " Rosa Anglicana,"
was  never printed in England: a:vl if it be compared with those
of the Greeks, and perhaps of some other physicians of  his time,
 he may deserve the severity  of that censure, which has been un-
sparingly passed upon him.   But  surely  much allowance is to
be made, and  some honour  must  be  given, to  the first man in
any country, who, by distinguishing himself, was preferred to a
place of such high Irust and  importance.   About the  same time
lived John Ardern, a Surgeon of great reputation at Newarke in
Nottinghamshire, who is  said  to  have composed many works,
none of which have been  printed  except his treatise on the " Fis-
tula in Ano."
   In every country knowledge must be acquired by the mere in-
dustry and genius of the  natives  ;  or  by communication  with
other countries,  in  which it  already exists ;  or the rudiments,
derived from some other nation, may be carried  to greater per-
fection by the industry and genius of those, who originally re-
ceived their instruction from foreigners.   If knowledge were con-
veyed from the Babylonians  or  Indians to the Egyptians, those 
xxiv                     PREFACE.
would probably afford an example of the first;  the Greeks of the
second ; and all Europe of the third.  But the progress of know-
ledge would in the beginning  be exceedingly  slow in every  na-
tion ; and even supposing the powers of the mind were not  di-
verted from the pursuit by more  favourite objects,  it would be
long before men thus circumstanced could be  put into  competi-
tion  with a peopleal ready informed and possessed of knowledge.
The abilities of particular men would very often be lost by their
death; and,  if they were  disposed  to convey their knowledge
by writing, the number of copies would be comparatively small,
full of the errors  of transcribers,  and difficult  to be understood,
from unavoidable changes in the meaning of words,  and the con-
struction of the language in which they might be written.   Nor
would a people deserve the name  of skilful and learned,  because
there were a few men of distinguished  abilities among them,  but
because the  generality were so well informed, as to be able to
execute with aptitude and intelligence what was required of them
 for the good of society.
   All or the greater part of the impediments to the acquisition or
 diffusion of knowledge in general were happily removed in the fif-
 teenth century, by the discovery of the art of printing by JohnFaust,
 or Fust, a German, about the year 1432. This art was introduced
 into Britain in the year 1470, by William Caxton, who is reported
 to have hired himself as a servant at Cologn, for the purpose of
 qualifying himself as a working printer.   There are two books,
 which, it is  said, were printed by him before his return, of one of
 which we shall have occasion to  take notice.   Another event ex-
 tremely favourable to the improvement of medicine took place ear-
 ly in the next century, that is, in the year 1518.   This was the es-
 tablishment of the College of Physicians in London, by the char-
 ter of King Henry the Eighth.   The words of the charter of the
 college denote its view : lmproborum hbminum qui medicinam,
 fyc. avdaciam compescere ; the kind  of institution, institutarum
 civitatum irn Italia exempium imitata ;  and the persons to whom
  it was granted, gravium tirorum doclorum, 8rc. precibus inclinati. 
                         PREFACE.                       XXV

 For certain purposes, intending or promoting the good of society,
 these men were directed to  form a College, with powers for  their
 internal regulation, as forcible as those ever granted to any other
 university or college ; provided such regulations, and such only*
 were made and  executed, as preserved and promoted those inter-
 ests of society, which were  committed to their trust.  I mention
 these circumstances, because the selecting power of the  Fellows
 of this College, though  allowed to all others,  has  been disputed
 by some very able and worthy men,  who, perhaps, did  not re-
 flect, that before its establishment, no school, or even lectureship
 for medicine, had been founded in this country, nor had a single
 book of any estimation been written by a native of it; but that
 the art was then practised  without restraint,  by  men as bold as
 they were ignorant : nor foresee, that, if the College  were to be
 suppressed, or the exercise of its powers perpetually checked and
 contested, the art would, in  all probability, decline  into its primi-
 tive state of ignorance and  confusion.   It would, moreover, be
 easily proved, that since the  year 1518, there have been, at every
 period of time, physicians uf distinguished abilities and eminence,
 and that the general literature of this  country has been in  many
 instances very effectually assisted by the members of this college,
 of which notice is taken  by  Lord Bacon.    There  can scarcely
 be a doubt, but that very important benefits have accrued to so-
 ciety from the establishment of the College of Physicians, and that
 the rank and dignity of the  profession have been raised and sup-
 ported by it.  As early proofs of the first, I may mention the dis-
 covery of the circulation  of the blood,  by  Harvey ; the doctrine
 of irritability, first cultivated by Glisson; the reduction into or-
 der, and more accurate anatomical knowledge  of the  brain and
 nervous system,  by  Willis ; the discovery, or  at least the great
 improvement of our knowledge of the glandular and lymphatic
 system, by Joliffe, Wharton,  Needham,  Willis,  and many  other
 very  able men of  their time;  and  the  discoveries of Mayow,
whom I am  proud of having contributed to rescue from  oblivion.
The second position  is self-evident.   Even those  who are  not
members, eventually partaking of its  advantages, and  profiting
                              4  * 
XXVI
PREFACE.
by its eminence, are interested in its support.    In the  course of
time, the rules of this,  like those of many other  foundations of a
similar kind, may require alterations according  to the general
progress and improvement of science;  but the  powers already
granted might be effectually exerted, to prevent the frauds,  hin-
der the  impositions, and curb  the audaciousness of ignorant and
unprincipled men;  and the exercise of this authority was  never
more necessary, than at the present time.   It  is  probable, that
this important purpose would be  answered if no  patent  for  any
medicine were to be granted, or any nostrum allowed to be sold,
without a testimonial of its efficacy and safety from the  College
of Physicians;  and by  compelling  every  person practising
medicine in any form, to become a member of the  College of Phy-
sicians,  of the college  of Surgeons, or  the Company of Apothe*
caries ;  all  of which might be  intrusted with a  power  of expel-
ling  any member who should act unworthily.  Nor does it seem
difficult, to  make regulations, so  strict that  they should resist
any  claims to the privileges of the  College by the presumptuous,
yet so liberal as not to withhold ihciu  from  the  deserving,  and
thus improve both its public and professional benefits.
   As a  matter of curiosity,  the  following papers,  which  relate
to the delivery of Lady Jane Seymour, Queen  to  Henry  VIII.
were  extracted from  the Cotton Manuscripts  in the British
Museum, by my learned friend Dr.  Combe,  who kindly gave
them to me.

                    BY  THE QUEEN.

   " Right trustie and right well beloued, wegrete you well, and
for as muche as  by th'inestimable goodnes & grace of Almighty
god we be deliuered and brought in child bed of a Prince con-
ceiud in most lawfull  matrimony  betwene my lord the Kings
Majestie and us, doubting not  but  that for the loue and affection
which yebeare unto us, and to the comyn wealth of this Realme
the knoweledge thereof shulde be joyous  & glad tydinge unto 
                         PREFACE.                   XXVU

 youe We haue thought good to certifie youe of the same to th'in-
 tent ye might render unto god condigne thanke and praise for so
 grete a benefit but also continually pray for the  long  continu-
 ance of the same here in this  life  to  th'onr.  of  god joye and
 pleasure of my lord the King and us and th'universall weale quiet
 and tranquillitie of this hole Realme gevyn under  our Signet at
 my Lord's manour  of Hampton cote  the  xij day of  Octobre
 (1537.)"

    Report of the Physicians respecting the State of the Queen.
    ' These shall be to aduertize yor. lordship of the Queene's es-
tate yesterdaie afternoone she  had a  naturall laxe by  reason
 whereof she beganne somewhat to lyghten and (as it appeared)
 to  amende and soo  contynued  till towarde nyghte all this nyght
 shee hath beene very sicke and doth rather appare then amend
 her confessour hath bene  with her grace this morninge and hath
 done that to his office apperteyneth, and now is preparing to mi-
 nisterr to her  Grace the sacrament of unction       at hampton
 court this Wednesday morninge at viij  of the clocke.
       Your Lordships atte commandment
                                    Thomas Rutland.
                                    Robert Karhole.
                                    Edward Bayntun.
                                    John Chambre.
                                    William Butt.
                                    George Owen."

  One of the first books printed by  Caxton was " Bartholomew
de Proprietatibus  Rerum."   The name of the author was Bar-
tholomew Glanville.   He was a Franciscan Friar,  and lived in
the  time of Edward the 3d.   He also wrote a history de Sanctis.  X
The first translation was made under the protection of one of the/
earls of Berkeley; but the title  of the copy of this  book which I
have,  (probably Caxton's) is this—" Incipit prohemium de pro-
prietatibus rerum Fratris Bartholomei,  Anglici, de Ordine Fra- 
xxviii
PREFACE.
trum Minorum."   This is in the nature of a Cyclopedia ; and
being a book not much  known, I allow myself the liberty of mak-
ing an extract from it,  which will show  the nature of the work.
His observations on  fire,  which will exhibit his philosophy, are
in this order—De forma-~De elemento—De igne—Deflamma—
Defumo—De carbone—De scintilla -De favilla—De  cinere.—
That following from his chapter de infirmitatibus will show his
medicine.—De febre—De febre effymera—De elhica—De febre
putrida—De signis putridaz febris—De febre cotidiana—De febre
terciani et ejus signis et cura—De quartana et ejus  signis et reme-
diis—De febre simpiici et composita.   He has a  chapter de 6b-
stetrice,  and another  de  umbilico,  but  they both relate almost
wholly to the  management of the child.  A book like  this  pro-
mised to be of great service : but, though the circle was compre-
hensive and regular, it  was filled,  not  with the observations of a
man of real knowledge or experience,  but with popular opinions ;
and these  collected, without much discrimination, from other
writers.  A translation of this work, by John Trevisa, wa? print-
ed by Wynkin de  Worde, in 1507, another edition by Berthelet,
in 1535, and I believe several  others.   Very lew  medical books
seem to  have been printed about this time; and from the exam-
 ples,  their  loss is not  to  be regretted.   The  " Judycyall of
 Vryns"  was printed in  1512; " A litel boke for the infirmities
 and grete Sicknesse called  Pestilence," which passed through
 many editions; and  " A little treatyse called the Gouernail of
 Helthe."   But in the  year J 522,  Lnnacre, who was the first or
 second president of the College, published, when sixty-two years
 of age,  a translation of different  parts of  Galen, which he
 thought most  useful to  be known.   The  ability  and elegance
 with which this translation  was made,  are universally acknow-
 ledged,  and great honour was justly given to Linacre on this and
 many other  occasions.   But  the  English practitioner  did not
 reap  much advantage from the work; for, though there might
 not have been six men in the nation  at that time able to  read or
 translate Greek,  and  probably some hundreds who understood 
PREFACE.
XXXI
Latin, yet the bulk of the people were strangers to both the lan-
guages ; and of this lAnacre himself seems to have been sensible,
for he immediately afterwards published his " Rudimenta  Gram-
matica languce  Latince."  Nor can 1 here help lamenting two
defects even in Linacre's plan;  one when the  College was esta-
blished, that he  did not encourage the publication of papers on
medicine,  under the auspices of the College ; a defect seen by the
establishes of the Royal Society, who published such papers in
their transactions,  a place  not the most proper for them; the
other, that he did not print his works in English ; in which they
would have  been  generally read,  have afforded  immediate in-
struction,  stood as good examples, and taught a proper method
of writing.  It  is  amongst  the most remarkable things  I have
met with,  that no writer in any  other language, than that of the
country in which he lives, ever seems to  be generally understood
by the people of that country,  of which I could adduce  several
proofs.   But this not being  done by Linacre, the English me-
dical writers returned to their former style; and for many years
little real progress in knowledge was made,  or any titles heard
of but  those of Urynals,  Judgment  of Urynes, Anatomies  of
Urynes,  Tresuries of Helth, Mirrours of Helth,  Anthidotaries,
Breuiaries of Helth,  the Tresures of poore Men, Herbals, and
the like, by medycyners and astronomers.  But about the year
1540 some  attempts were made to translate books of reputation
into the English language; as Sir Elrich Hutten on the wood
called Guaiacum that  healeth the French  Pockes, by Paynellt
Canon of Marten  Abbey, who had also translated many other
books about 1533; the  Castell of Helthe, by Sir Thomas Elyot,
who  was  not a  physician;  Albertus Magnus; Prognosticacions
out of the books  of Ypocras, Auicen, Sic.  and the Questionarie of
Cyrurgyens, with the formularie of lytell Guy do in Cyrurgie.  In
the  year  1540 was also published the first book on  the  subject
of midwifery in  England,* called  " The Byrth of Mankynde,"

  *  Dr. Combe has in hi3 possession the identical manuscript  copy of
this work, which  was presented to Catharine, Queen of Henry the 
XXX                     PREFACE.

otherwise named " The Woman's Booke," by Thomas Raynold,
Physition; the  second edition of which was imprinted at Lon-
don, by Thomas Ray, whose  name is not mentioned either by
Ames or Herbert, in their history of printers.   This was also the
first medical  book which has prints reasonably well executed
from neat drawings.  As  every one of these books went  through
several editions, we may  conclude they were in high estimation.
Then (1545) came  forth  also an abridgment of Vesalius, of
which the  copies are not scarce, under the title of  " Compendi-
um totius Anatomise delineatio sere exarata, per Thomam Gemi-
num Londini."   Geminie  was an  engraver.   The knowledge of
Pesalius was  more extensively spread from his book being stu-
died by painters and artists.  In the original work of Vesalius,
a great part  of the engravings,  it is  said,  were  designed by
Rubens
  But  one of the first English medical books, of any value,
properly speaking, I take to be " a short and profitable treatyse
touching the  cure of the  disease called Morbus Gallicus ;  withe
ann account of the nature of Quicksilver, by G. Baker, Maister
of  Chirurgerie,  1579;"  and  the first book  in surgery, called,
" An excellent Treatyse of wounds made with Gunshot,  &cc.; by
Thomas Gale, Maister in Chirurgerie, (1563.)"   The dedication
to Ambrose Pare's work is dated Feb. 8,  1579, and  it was trans-
lated into English in 1634  by Thomas  Johnson ; so that it may
be doubted whether  Gale  did  not precede Pare in the recom-
mendation of a  more simple method of treating gunshot  wounds.
The same Thomas Gale,  who  was a very meritorious and inde-
fatigable man,  also printed " An Enchiridion  of Chirurgerie,"
and many other works relating both to surgery and medicine,
together with the " Institution  of a Chirurgeon." Near the  same
time John Halle published what he calls the " Chirurgia Parva
Lanfranci;"  and John Bannister " a Treatise of Chirurgerie;"

Vlllth.  This copy is  signed with the name of ----Jonas,  but it
does not appear  why the book was afterwards published in the  nam«
©f Raynold. 
PREFACE.
XXXI
 and soon afterwards William  Clowes " A briefe and necessarie
 treatyse touchynge the cure of the disease called Morbus Galli-
 cus, or Lues Venerea, by unctions and other approved waies of
 curing."  There had been published  in the  year 1577, a profit-
 able treatyse of the anatomie of man's bodie, compyled by that
 excellent Chirurgeon,  M. Thomas Vicary,  Esq.  Sarjaunt Chi-
 rurgeon to Edward the Sixth, Queen Mary, and Queen Elizabeth,
 and also chiefe Surgeon of St. Bartholomew''s Hospitall. In this
 book was published the first account  of the  benefits of the juice
 of lemons in the sea  scurvy.   There was also printed in 1597,
 " The whole course of Chirurgerie," by Peter Lowe, a Scotch-
 man, Aurelian Doctour in the facultie  of chirurgerie at  Paris,
 which is quoted in the Critical  Enquiry  published  about one
 hundred years ago by Samuel Sharp, one of the most expert and
 able surgeons this country ever produced.  I find  a  few  books
 published by physicians about this time—" A short discourse of
 the most rare and excellent Virtue of  Nitre"—" A Greene  For-
 est, or a Natural Historie," by John Mapler, M. A. and student
 at  Cambridge—" The  Hammer for  the  Stone,"  by Walter
 Carie;—and  a brief  treatyse  called  " Carie^s Farewell to
 Phisicke"—Stirpium  Adversaria Nova perfacilis investigatio
 luculentaque accessio ad priscorum Materiam Medicam"—" The
 Benefit of the auncient Bathes  of Buckstone, and the  Bathes of
 Bathes ayde ;   by John Jones,  Physician"—" Hygeina,  he.
 authore  Timothe Brighto, Cantabrigiensi Medicinse Doctore:"
 and a Treatyse of Melancholie, by  the same  author;  " Praxis
Medicinae Universalis," (1598,)  and many others in number,
but not of much value, though they show very satisfactorily the
pains taken by  the English  to acquire knowledge by their own
industry, and by translating many of the works, which were then
held in particular esteem.  But it appears also, that the progress
made by the English physicians and  surgeons, for the improve-
ment of the respective branches of the profession, had not been
very rapid, and that much remained to be done at the commence-
ment of the sixteenth century; and particularly that the practice 
xxxu
PREFACE.
of midwifery had been yet little attended to, unless  as a part of
surgery.
  It is necessary to observe, that this  order,  in  which we  are
speaking of different writers, is not meant as recommending an
order of study ; because it seems to be universally agreed, that it
is best for learners to begin  with acquiring a knowledge of those
auttiors, who  have written on the principles  and practice of the
present  time,  and thence to proceed to the study of former writers
and of the ancients ; by which method of proceeding much criti-
cal, and some practical knowledge may be obtained.
  In the year 1560, Francis Bacon,  afterwards  Lord Vertdam,
was born, a man whose fame will receive no  addition from  any
applause which it is in my power  to give.   He  was a  meteor,
from whose lustre all nature received  some light.   Though he
did  not  apply  himself  particularly to the  study of  medi-
cine, he  has  left  some useful  observations relating to it;  and
promoted this, and almost  every  other branch of knowledge, by
teaching and practising the only effectual method of acquiring it.
The more  profound works of this  writer  are  perhaps to  be
studied  with advantage only by men who  have a greater share of
genius than common, or by those who have been  blessed  with a
learned education;  but  his  tractate de  Augmentis Scientiarum
may be of use to all, as, if read with care, it is not difficult to un-
derstand, and  abounds with  the most  acute  observation  and
profitable instruction, though he himself speaks  of it in lowly
terms.
  In the year 1578 William Harvey was  born  at  Folkston, in
Kent; and, having completed  his  studies  at Cambridge, he went
to Padua, where he was admitted  to the degree of Doctor in un-
usually flattering terms of approbation, in 1602.   In the year
1615 he was  appointed by the College of Physicians, to read the
lectures on anatomy and surgery ; and in these he first promul-
gated his discovery of the circulation of the blood, a discovery so
complete, that no person has ever  controverted one  position, or
imended his explanation.  With all the  sagacity and  perseve-
rance of a truly great man, he applied himself to  form  an  entire 
PREFACE.
XXXU1
 history of the generation of animals,  with that of the preceding
 and accompanying  changes;  but his studies were interrupted,
 and many of his papers lost,  in  the time of the civil war.  It
 does not appear,  that  he  had determined  to publish the rest,
 though finished with admirable correctness, till he was prevail-
 ed upon by the  solicitations of his intimate friend Sir George
 Ent, who supervised the printing  of them in English, in the year
 1653;  but  I have no other authority for this fact than the pre-
 face to that edition written by  Sir George.   By inclination,  or
 the necessity of his affairs, Harvey was engaged in the practice
 of Midwifery, by which means he got that information,  which
 enabled him to write his  " Exercitatio de partu,v and the many
 excellent observations upon that subject, with  which  his  works
 abound.  He clearly entertained an opinion, that the  knowledge
 of the circulation, the constituent  parts,  and  properties of the
 blood, would enable physicians to cure all diseases ;  but experi-
 ence has not confirmed its truth.   The discoveries  which  Har-
 vey made, the many subjects which he illustrated, and the deli-
 cacy and patience which he exercised in his investigations,  then
 unknown in this  country, entitle him to the highest honour  as an
 anatomist, and as a man of science.  He died at, or more than,
 eighty years of age,  honoured  and beloved for the  greatness  of
 his abilities, the  ingenuousness of his disposition, and the mild-
 ness of his manners.  His character is strongly marked in a fine
 picture of him, taken in his old age, now in the  museum of the
 late Dr. Hunter.
   From the gradual  progress of science, from  the encourage-
 ment it received, and from the  example of the two illustrious men
just mentioned, Bacon and Harvey, a  happier prospect dawned
 upon Britain, to which I must beg  leave to call your  particular
 attention.*
   Thomas Sydenham was born in  the year 1624,  and graduated
 at Oxford.   He applied himself to  the practice of medicine, and

   * The greater part of this preface  was given  as an introductory
 Lecture.
                              5 
XXXIV
PREFACE.
first wrote his account of the continued fever of  1661, and the
three following years ; which fever he probably  then   supposed
to be the only one in nature.  But farther  experience  convinced
him, that there were many kinds of fever; and of these he has
given an account to the year 1683,   together  with  dissertations
on  the small-pox,  dropsy,  gout,  hysteric, and  many sporadic
diseases.  Some notice is also taken of the diseases incident to
women in childbed, and of many of the complaints  of  children.
His works, originally  written in English,  afterwards  translated
into Latin by bis friend Dr. Mapletoft, were published in distinct
parts, and at different times, as the  occasions occurred to him.
The writings of Sydenham, whether we consider the sagacity and
order with which the observations are made, or the  fidelity with
which they are recorded, have b een held  by all succeeding phy-
sicians in the highest esteem ; and, from the time of Hippocrates
to the present, he has been  deservedly  considered  as  the  best
example of a  faithful   observer of diseases,  and of a  practical
physician.   Though it must be acknowledged, that  he was often
wrong in his theory, and in some  instances in his practice, his
description of diseases is allowed to be excellent ;   but his  omit-
ting to specify the precise times  or stages  of  disease,  when his
method  of treatment  was to be applied, very much lessens  the
value of his work.   He died in  the year 1689.
  Francis Glisson was educated  at  Cambridge, where  he  be-
came  Regius Professor.   He  was  one  of  the physicians to
Queen  Elizabeth,  and  to  James the first.   In  1654  he pub-
lished  his   " Anatome Hepatis,"   on the internal  structure of
which viscus he  made several new  observations ;  in 1659, his
" Tractatus de Rachitide,"  which disease he was the  first who
described ; and after some years (in 1676) his book  "  De Ven-
triculo  et intestinis,"  in which he first took notice of the  irrita-
bility of the simple  fibre ; so  that he has an undoubted right to the
credit of being the  father of  all the doctrine of irritability, since
unjustly attributed to  Holler, and on which  so  many  volumes
have been written  without the mention of  Glissoii's name.  This
could not have happened, if his works had been printed in the 
PREFACE.
XXXV
English language.  He  also  published a treatise  " De Natura
Vita, vel substantias energeticce,"  which he calls the prodromus
of his Treatise de ventriculo et intestinis,  but of this I have never
seen a  copy.  Glisson lived to be upwards of one hundred years
of age,* and died at Streatham, to which place he had retired.
  Thomas Willis, Sedleian Professor at Oxford, was born in the
year 1621,  and  published, as the foundation of a large design,
his  " Cerebri Anatome,  cui accessit Nervorum Descriptio  et
Usus," in 1663.  In this work  he was  much assisted  by Dr.
Lower, who was in fact his dissector and demonstrator, and  the
drawings were taken by the famous Sir Christopher Wren.  The
terms in which Willis  speaks of Lower seem descriptive of both
their characters—cujus cultelli  et ingenii aciem, lubens agnosco—t
emicuit viri  solertia plane  admiranda,  nee non indefatigabilis
industria, nulloque  obice sistendus labor.
  In 1762   he  published  his  work  " De Anima  Brutorum,"
which is to be considered as a sequel to the former.   It is a work
of infinite labour, reflection, and ingenuity, in which he describes
the immediate causes and  effects of the diseases arising from ner-
vous influence.   There are in this book four plates,  three ex-
tremely fine, representing a dissected oyster, a lobster, and an
earth-worm.—In  1673  he published  the  first  part  of his
li Pharmaceutice Rationalis, sive Diatriba de Medicamentorum
Operationibus in Humano Corpore," a work composed of anato-
mical, physiological, and practical observations, with many curi-
ous plates of the lymphatics, vasa vasorum, and other finer parts
of anatomy.  He  died before the second part of this work was
printed, in the preface to which there is a short  account of his
life  and writings.  The works of Willis are very numerous and
useful,  and  bear indubitable marks  of great learning,  genius,
and industry, but they are seldom studied.  Perhaps  his  medi-
cal works may be  too  philosophical for practical physicians,
and his philosophical  works too much blended with medicine, to

  * See the  general Biographical Dictionary ;  or the Annual Regis-
ter for  the year  1767. 
 XXXVI                    PREFACE.

 please philosophers ; and it does seem  possible,  by the study of
 arrangement and subtilities of science to lose sight of practice, as
 by the present systems  of botany, its relation  to  medicine is al-
 most forgotten; though  so much of botany must be allowed to
 be of great use, as enables us to  distinguish such plants as  con-
 tribute to health either  in diet  or medicine from such as are un-
 wholesome.   But there is scarcely a subject connected with the
 science or practice of  medicine which has not been cultivated by
 Willis.  His chapter on the puerperal fever, when simply inflam-
 matory,  is  judicious  and good.   He died  in  the year  1675,
 having founded  a lectureship in the church of St. Martin in the
 Fields, where prayers are read at an early hour chiefly for the
 convenience of medical men.  His practical works  were badly
 translated into English in 1685, and afterwards all his   writings,
 but in a language never very good, and now become obsolete.
   Nathaniel Highmore  wrote his  " Disquisitiones Anatomicae,"
 in 1651,  and "A History  of the Generation of Plants and Ani-
 mals," in which  it appears, that he made many discoveries, par-
 ticularly  of  the antrum  in the upper  jaw,  to which his name has
 ever since been given.
   Contemporary with these was  Walter Needham,  educated at
 Cambridge, then appointed physician  to  the  Charter-house in
 London,  but who afterwards resided at Shrewsbury.   He  wrote
 "Disquisitio  Anatomica  de Fonnato  Faetu," a work  of de-
 servedly  high estimation, in which he  takes the  opportunity of
 treating not  only upon  the contents and economy of the gravid
 uterus, but upon the lacteals and lymphatic system, and  many
 other anatomical subjects.
   In the  year 1656 Thomas Wharton  published his  " Adeno-
 graphia," a work of  established reputation,  in  which, among
 other things,  he has observed some  which relate to the gravid
 uterus.  This work  is quoted in the first edition of NucVs
 Adenographia et Uteri Anatomia, which is dated  in  1679.  On
the claims of the first discovery of the lymphatics there seem to
have been early  debates,  and from  the curious verses   prefixed 
PREFACE.
XXXVU
         to Ruysch, who first described their  valves, the disputes upon
         the discovery of the lymphatics,  appear to have been national.
         But if we consider ihe labours  of Dr. William Hunter on this
         subject, and above all the perspicuous  and connected  arrange-
         ment he has  made of the glandular  and lymphatic system, we
         must be convinced that the  principal  merit in this part  of the
         anatomy is now due to him.
           Nathaniel  Henshaw published his  " Aero-Chalinos"  in the
         year 1677. This contains the five following tracts :—On Fermen-
         tation—Chylification—Respiration—Sanguification—The good
         effects of changing Air."
           About the  same time lived Walter Charlton, who published
         "Onomasticon Zoicum" in the year  1668,  and in the following
         year his "Economia Animalis," of which Sir  George Ent  gave
         this character—opus  maturo consilio inchoatum,  magna  cura
         elaboratum, ingenio denique  et  doctrina  singulari  perfectum.
         Charlton wrote   several  other works, particularly  " De Causis
         Catameniorum et Uteri Rheumatismo."
           He also published the  works of Theodore Mayerne,  to whom
         a vain monument was erected and still remains  in  the church of
         St. Martin in the Fields.
           In 1668 Dr. Mayow of Oxford published his works, entitled
         " Opera omnia Medico-Physica" in  the German edition,  which
         is the only one 1 have seen.
           These consist of the following essays :—1. De Sal-Nitro et
         Spiritu Nitro-aereo.—2. De Respiratione.—3.  De  Respiratione
         faetus  in  utero  et ovo.—4.  De  Motu Musculari et Spiritibus
         Animalibus.—5.  De Rachitide.   In  these  he  treats of  many
         other interesting and curious  subjects, which have been  lately
         brought into public notice, and much approved, though Mayow
         seems to have been greatly neglected  ;  but this  may be account-
         ed for by his  dying at the age of thirty-five.
           Dr. Richard Lower, before mentioned in the account of Wil-
         lis, in  1676 published his  " Tractatus de Corde, item de motu
         et colore Sanguinis, et chvli in eum transitu,"
\ 
xxxviii                     PREFACE.

  This celebrated work has many observations  on the  lympha-
tics, and  the receptaculum  chyli, which he considered as  their
general centre, as early as Pecquet.   He also made many  curi-
ous anatomical  and physiological experiments,  and in this work
asserts his claim  to the invention of the art of transfusing blood,
to which he seems to have been  very partial.
  The Chirurgical  Treatises of Richard Wiseman were dated in
1676, and allowing  for the time when they were written,  are
acknowledged to have  great  merit.   He may not unjustly,
perhaps,  be esteemed the  first English surgeon.  " The  Comes
Chirurgorum," containing  Dr. Read's Lectures, was printed in
1686.  But the improvements in surgery did not keep pace with
those in physic, for in the last, and even in the  beginning of  the
17th  century, it was not unusual for foreign surgeons to  come
into this country, to perform the nicer and more difficult opera-
tions, such as those for lithotomy, all diseases of the  eyes, and
every thing which related to the teeth.  But Cheselden acquired
so much fame by his dexterity in cutting for the stone, that  the
King of Siocden sent his secretary of state into England,  for  the
express purpose of having that  operation performed  by Chesel-
den, who (very much promoted the improvement both of anatomy
and practical surgery) successfully extracted from him a stone of
an unusually large size.   Every  operation appertaining  to the
eyes is now performed with the most consummate skill and dex-
terity, and with corresponding  success, by Wathen, Ware,  and
Phipps ; and  those  for  the teeth  by the Spences,  and  many
 others.  It  is at the  present  time  universally acknowledged,
 that the English surgeons equal, in every branch and respect, if
 they do  not exceed, those of any other nation.
   Dr. Nehemiah Grew published separately, though  they were
 afterwards collected into one volume, his  " Anatomy of Plants "
 in which there are many observations respecting the  solution of
 salts ; his  " Anatomy of Roots"—" Comparative Anatomy of
 Trunks,"  between  the  years  1670  and  1630—" Cosmologia
 Sacra," and several other  works. 
PREFACE.
XXXIX
   At the same"time lived  John Ray, the  celebrated Physician
and  Botanist.   In  1685 Dr. Samuel  Collins,  Physician to
Charles the 2d, published  " A System of Anatomy  treating of
the body of Man, Beasts, Birds, Fish, Insects, and  Plants."
An elaborate work, and of considerable merit for the time when
it was  written.  Mayjield printed his Exercitationes Anatomical
in 1678;  Molins  his  work  on  the muscles  in  1680;  and
Blanchard his Anatomia in 1688.
   Clopston Havers' published his  " Osteologia Nova" in 1690.
In this  work he  described the mucous glands of the joints,
which he discovered, and the internal structure and  an account
of many diseases of the bones, cartilages, &c.
  In the year  1695, Ridley  published  his  "Anatomy  of  the
Brain,"  of which he is said  to have  discovered  the lymphatic
vessels ;  and his " Observations," in which he treats on  several
abstruse parts  of anatomy.
  Dr. Richard Morton published his  " Phthisiologia"" in 1689":
his " Pyretologia, seu de Morbis acutis universalibus"  in 1691 ;
and his work " De Febribus inflammatoriis" in 1694.   Syden-
ham's treatment of Fevers was almost universally antiphlogistic;
Morton's, on  the contrary, was cordial  and sudorific ; but  we
have between these two writers most of  the  arguments, which
have been advanced in favour of both methods of practice.
  The first edition of  Cowper's  " Myotomia Reformata"  was
published in 1695 ; and Keifs Anatomy in 1698.
  By the writings of  these very  eminent men,  and of many
others whom I might have named, particularly of the celebrated
Robert Boyle, it appears that the physicians and surgeons of this
country  were, from the beginning  to the end of the seventeeth
century,  indefatigable in the acquisition and  improvement of
science ; that they were not only  acquainted  with the general
knowledge of the Greeks, Romans, Arabians, Italians and French,
but might fairly be put in competition with those  of any other
nation, if they did not  excel  them ;  and  that  all  the  changes
we have  seen were produced in  less  than  two  hundred years, 
xl
PREFACE.
that is, from the time when the College of Physicians was estab-
lished, in the year  1518? to the termination of  the  seventeenth
century.   Early in the eighteenth century the benefits of medi-
cine  to society were rendered conspicuous  by the  introduction
into  England of the practice of inoculating for  the  small-pox ;
for the knowledge of which we are indebted to the sagacity and
judgment of Lady M. W. Montague.  The  mortality attend-
ing that disease in  a natural way was estimated at least as one in
eight; but by inoculation it  scarcely amounts to one in  a hun-
dred.  Many  objections were made to inoculation,  when  first
introduced ; but  the practice being conducted  with much  cau-
tion and  understanding by some able medical men, and protect-
ed by Queen Caroline,  at length became general.   It required,
however, the experience of fifty or sixty years, to bring inocula-
tion to its present  state of perfection, the merit  of  which  is ex-
clusively due to English physicians and surgeons ;  for the prac-
tice was  strongly resisted by many  other  nations.   Inoculation
for the cow pock as a  preventive of  the  small-pox,  has been
 lately discovered and recommended by my  very intelligent and
 acute friend   Dr. Jenner,  a  physician  of great  worth and
 abilities, to whom only we are also indebted for  the  first  account
 of the cow-pock as a part of natural history, and for our know-
 ledge of the treatment  of the disease  when  inoculated.   As far
 as can be judged  at present, Dr.  Jenner's  discovery, when car-
 ried into general  practice, will be  the means  of saving much
 anxiety, and  an infinite  number  of  lives,  and may probably
 lead to ^he complete extirpation of the small-pox.
   Imust  in  this place beg leave to make a digression.   In the
 year 1668 Herman Boerhaave was born near  Leyden.  He was
 originally designed for the church, but was  led by inclination,
 and the ill state of his own  health, to apply himself, when very
 young,  to the study of medicine.  He graduated  in the year 1693,
 was chosen Lecturer on the Institutes of Medicine in 1701,  and
 enjoyed all the honours which the university  could bestow, or
 the city of Leyden confer upon him.   He raised the reputation of 
PREFACE.
Xli
this school of medicine beyond that of any  other  in Europe.
The industry of Boerhaave, in the pursuit of knowledge of every
kind, is almost incredible ;  that of any other man  compared
with his may be called amusement ;  the facility  with which he
communicated this knowledge to others, was  beyond expression
happy ; and his whole conduct,  in every religious,   moral, and
scientific view, to the highest degree laudable.  He  was greatly
honoured in his life, and his memory is universally  respected.
His history, which was  written by  Dr. Samuel  Johnson,  must
ever remain a very useful study to medical men, and an example
of fine composition.  Boerhaave died  in the year 1738, in the
70th year of his age.  He unfortunately paid too little regard to
the nervous system.
  Among the favourite students of Boerhaave was Alexander Mon-
ro,  who in the year 1719 returned from Leyden  to  Edinburgh,
a city at that time not distinguished by any eminence in medi-
cine.   But in the following year, Dr. Monro  being chosen pro-
fessor of Anatomy and Surgery, and Dr. Alston of Botany, they
began to give Lectures, and established a school of medicine,which
they had the very great  satisfaction of soon raising by  their
abilities to  an  equal degree of  honour with any of whatever
period.  Dr. Monro died  in the year 1767, leaving behind him
many valuable works, which were afterwards collected into one
volume, and published by  his son Dr.  Donald Monro, who did
not succeed  his father as professor.    By this establishment, the
further advantage was gained to Britain of having at Edinburgh
a succession of very able and eminent men,  who have  dedicated
the chief part of their time to the  acquisition  and improvement
of medical science, and to the instruction of those who were in-
tended for the profession.    But Dr. Black and  Dr. Cullen ap-
pear to have been the most eminent men in that school.
  Here I shall conclude these general observations, and confine
myself to such only as relate to the  practice of midwifery, pre-
mising a short remark on a subject,  in which  the interests of so-
ciety, and the claims of individuals, are deeply concerned.
  The dfconomy of the  medical profession  has in  this country
                              6 
Xlil
PREFACE.
 undergone many alterations,  according to  those  of society at
 large.   Physicians, who are called to take charge of all cases of
 uncommon difficulty or danger, or of the lives of persons of high
 rank and eminence, have generally  such an education, as leads
 not only to the acquisition of medical knowledge, but to the cul-
 tivation also and highest improvement of all the powers  of  the
 mind.  But the operative,  and all the inferior parts of the pro-
 fession, fall under the conduct of those, who have been educated
 as surgeons, or apothecaries, or jointly. By the former of these are
 performed all the operations in surgery,  many of which require
 an admirable combination of mental  and  personal qualities ; and
 to their skill and care the lives of the greatest part of the lower
 class of people, and of those who serve  in the army and navy,
 are almost constantly submitted in every  branch of medicine.  In
 order  to  their being duly qualified  for  these important duties,
 young men, having received a reasonable share of classical edu-
 cation, are bound, for a certain term of years,  to  some person
 competent to give them proper instruction and information.  To
 such young men it can  only be  necessary to observe, that they
 will at some future time be called  upon to take charge of the
 lives of men, for which they must be responsible,  not only  to the
 laws of God, but to the law of the landn which has the power of
 inflicting such punishment, as any particular instance of ignorance
 or negligence may be proved to deserve; and, which is beyond
 all other punishment, their names may become ignominious.   I
 may therefore be permitted to recommend the profession of any
 part of medicine, as  a very sacred trust to those who engage in
 it; the necessary aud proper qualifications for which demand all
 their attention, and the sober, constant, and most industrious ap-
 plication of all their abilities.   But it is very much to be doubt-
 ed, whether  some  of those, who, both as parents and  masters,
take the  charge of such young men,  are not sometimes selfish,
and negligent in the performance of that share of the duty which
they undertake; and whether, having received  the gratuity usual-
ly paid, they either give due attention to the morals of the young
men, or instruct them properly in the knowledge of their  pro- 
PREFACE.                     Xllii
fession.  Through this negligence of the masters, or the thought-
lessness  and inattention  of the young men, at the end of their
servitude these must of necessity frequently be ignorant of many
things which they ought to know, to their own misfortune and
disgrace, and to the great prejudice of society.  To all students
I must recommend,  among many other  things,  their perfecting
themselves in the art of drawing.
  By the nature of one part of my employment, that of giving
Lectures, I  have  had too many opportunities of knowing the
truth of the foregoing remarks ; which, with the greatest unwil-
lingness to give offence, I feel  called  upon to make, and  in con-
firmation of which  I  beg  leave to add the following quotation
from unexceptionable authority.
  " Clerks and apprentices ought to be employed entirely in the
profession or trade  which they are  intended to learn.  Instruc-
tion is their hire;  and to deprive them of the  opportunities of
instruction, by taking up their time with occupations foreign to
their business, is to defraud them of their wages."*
  The " Byrth  of Mankynd,  or  the  Woman's Book,"  with
sketches not badly intended or engraved, was printed in the year
1540:  and as it went through many editions, and as I  find no
other book of equal value published about that time, I consider
it as having been the popular book for near one hundred years;
that is, till  the year 1634, when all the works of Ambrose Pare
were translated in one volume.  Pare was a man of much expe-
rience, some erudition,  and not a little credulity, but he made
many useful  observations  relative to midwifery.  In the year
1653, Harvey's Exercitations  were published in English, but
whether translated or original I cannot decide.   About the same
time also  lived  Dr. Chamberlen,  a very celebrated physician,
who applied himself to  this branch of the profession.   A very
elegant monument was erected by the Duke of Buckingham, in
Westminster Abbey, to this  Dr. Chamberlen, of whom the Duke
has also in  his Essays given a  very amiable character.   He had
* Paley's Moral and Political Philosophy, Vol. I. 
xliv
PREFACE.
three sons, who, with their father, were supposed to have a better
method of relieving women in cases of difficult parturition than
any other person, by means of an instrument  said to be the for-
ceps, but which I believe to have been a vectis ; or perhaps they
had more than one instrument.   One of the sons went over to
Paris, with a view of selling the secret, or of making a fortune
by  practice; but being  foiled in the first case to which he was
called, yet acting without discretion and suffering more obloquy
than he deserved, he returned to England, and immediately pub-
lished a translation of Mauriceau's work, which remained for ma-
ny  years in very high esteem.  This was in the year 1672.
  Having been favoured by the late Dr. Kirkland with a manu-
script written by Dr. Percival Willughby,  who lived at Derby,
and afterwards  in London, I am able to give the reader some
idea of the practice of that time, many of the cases being dated
from 1640 to 1670.  This work is entirely practical, and was in-
tended to be published for the use of midwives,  there being  a
title page, and two copies with variations.
  His preface is in this manner:
  " I haue read many bookes, with all the late writers in mid-
wifery, and I do perceiue that they all follow one common roade,
taking their seueral scheemes and figures one from another.
  " In  seueral  of these  scheemes  uarious  things may be  per-
ceiued which will be troublesome to the labouring  woman, which
a judicious practitioner will  not followe.  Let midwiues  mark
whatt hath been written  in  my obseruations, let them  consider
diligently the seueral reportesnot faigned,or the surmised thoughts,
nuctors, or man's fantasie,  sitting and meditating in his studye,
but which really haue been performed in  the traualing woman's
chambre.
  " From mine and their directions let midwiues choose the best
and facilest waies of relieving women in affliction, and  to decide
all  disputes, let reason be the judge,  let  experience argue the
dubious points of practice ;  and, after a full debate, let unspotted
truth recorde to succeedinge times what is most fitt to be follow-
ed and used, &c." 
PREFACE.
xlv
   This  is  a specimen  of his illustration.    " Let midwiues
obserue the waies and proceedings of nature for the production
of her fruit on trees, or the ripening of walnutts and almondes,
from theire first knotting to the opening of the huskes and falling
of the nutt; the greene huskes sticking so  close that it is  not pos-
sible  to  separate  the  huske from  the shell, whilst it is  unripe;
but as the fruit ripenneth the huske choppeth and with  a fissure
openeth, and by degrees separateth the  fruit  without  any en-
forcement.
  " An egge representeth the wombe;  now the  henne with keep-
ing the egge warm doth breed the chicken, which when it comes
to maturitie doth chip the shell, and is by degrees hatched with-
out injurie.  These signatures may  teach midwiues patience, and
persuade them to let nature alone to perform her own worke,  and
not to disquiet women by their strugglings, for such enforcements
rather hinder the birthe than any waie promote  it, and often rui-
nate the mother and usually the childe; and  let midwiues know
that they be  nature's seruantes, &c."   Willughby's practice is
not much  different from that of  the present time.   He divides
labours into two kinds only, natural and unnatural.  The parti-
cular rules I cannot pretend to describe  in this  place; but the
following letter, which he  has quoted from a scarce work, corres-
ponds  so nearly with an observation it was my  fortune  to make
some years before  I saw  this manuscript, that I  may be  excused
relating it.
  "  Referam  hoc  casu, quid  beatae  nieae  conjugi acciderit.
Tertio foetu gravidam, nono praegnationis mense, labores partu-
rientium  arripiunt  circa noctem.   Mox rupta aqua (ut  hie mu-
lieres loqui amant)  extra genitale, infantuli manus propendit.
Ubi  obstetrix advenisset,  uxorem meam in  sedili  collocavit, earn-
que ad continuos conatus (me nolente nee  instigante natura) ad-
egit.   Cum vero res eo  modo non  succederet, meamque conju-
gem supra sedem continuo detineret, ac diris cruciatibus illapsum
ex uteri cervice manum brachiumque retrudere niteretur,  quo foe-
tum ad  exitum  commodius disponeret.  Ego prae dolore chara?
meae conjugis impatiens,  ac indesinentur obstetricem admonens, 
xlvi
PREFACE.
ne quidem elapsi membri reductionem in uterum cogitaret possi-
bile, multo minus moliretur, secundam obstetricem accersiri jussi,
praesertim cum uxor mihi  nunciaret,  quod obstetrix earn dilace-
raret per illam praeconeeptam ac  miseram elapsi membri repul-
sionem.  Cum insequenti die, obstetrix altera venisset, ilia ir  «nus
ad opus applicans remque  diligenter explorans, uxorem meani in
ledum deposuit, mandavitque ut se quietam deteneret, nullosque
conatus excitaret, nisi quando natura earn sui admoneret officii.
   " Interim obstetrix ilia  prudens et expertissima praedixit  mihi
araicisque praesentibus,  uxorem  meam non ante parturam, quam
foetus in utero, ex indebito situ, conatibus strangularetur, quod
eventus docuit.  Multiplicati sunt labores parturientis, et foetus
inflexo ad dorsum capite, (salva matre,) prodiit in lucem."*
   By a genealogical manuscript, written by the first Dutchess of
 Chandos, in the  possession  of  Colonel Kearney, it appears  that
this Dr. Willughby was one of  the six sons of Sir Percival Wil-
lughby, and grandson of  Sir Francis,  so famous  in  the time of
Queen  Elizabeth.
   It is probable, that the  fortune and eminence acquired by the
supposed advantages of the method  of the Chamberlens, which
they reserved as a secret, might be the occasion, that many gen-
tlemen, engaged in practice, endeavoured to establish themselves
upon the same principles,  that  is,  of concealing the instruments
they used ;  of which class was Dr. Bamber.   Others might at-
tempt to gain equal reputation  and fortune by the very contrary
means, that is, by decrying the use of instruments of every kind,
 on any occasion ; for about the year  1723,  Dr. John Maubray
 published a volume upon this subject, called " The Female Phy-
 sician, or the whole Art of New improved Midwifery," in which
 he exclaims with great vehemence against  their use;  and  the
 book, though  written in quaint language, has some general  me-
 rit.  In the following year he also published an appendix, under
 the title of  " xMidwifery brought to perfection," in which he de-
 mands great credit for the many  improvements  he had made,

      * Vovus exortus hominis et animalium.  Anton. Ererard.


               m 
PREFACE.
xlvii
 This appendix is, in truth, no more than a Syllabus of his Lec-
 tures, a course of which consisted of twenty, twelve anatomical
 and physiological, and eight practical.   I believe it  would be
 unjust  to deny to  Maubray  the credit of having  been the first
 public  teacher of Midwifery  in Britain.   He gave his Lectures
 at his house in Bond-street.
   In the year 1719  Dionis' Midwifery was  translated into the
 English language; and in the year 1729 Deventer's  work was
 translated  and published: and  though it appears, that rather
 more credit has been  given  to this author than he deserved, yet
 as he enters upon a discussion of  the causes  of many difficulties
 which occur in practice, and  of the means of relieving  them, and
 as he was generally averse to the use of instruments, Deventer's
 work might be esteemed a  considerable addition to  the stock of
 obstetric knowledge in this country.  Deventer was originally a
 watch-maker.
   Dr. Simson, professor at St. Andrew's, published in  1729 his
 " System of the Womb," a work of sufficient ingenuity, but not
 of much use in practice, even if his theory were true.
   About the year  1733 Edmund Chapman published his " Trea-
 tise on  the Improvement of Midwifery," in which there  are se-
 veral useful observations; and  other writings of temporary con-
 sequence  only.   Chapman was  the second public  Teacher of
 Midwifery in London, and  he was the first also who  described
 the Forceps, in the third volume of  the Edinburgh Medical Es-
 says.
   In the year 1734 Dr. Hody published a  " Collection of Cases
 in Midwifery," written by  Mr. William Giffard.  These cases,
 two hundred and  twenty-five  in number, seem to  be written with
 great fidelity; and as they  occurred in  his own  practice,  they
 were lessons of conduct which was to be pursued in similar cases,
 and may now be considered *as examples of the state of practice
 at that time.   Giffard  also gave a plate representing  the For-
 ceps, and was, I believe, among the first who asserted, that the
placenta might be attached over the os uteri.
   " The Midwife rightly instructed" was  published in the year 
xlviii
PREFACE.
1736 by Thomas Dauke;  and the " Midwife's Companion" by
Henry Bracken, in the following, with several other things equal-
ly unimportant.
   About this  time lived Richard Manningham, who quitted the
profession of Pharmacy, and applied himself with great assidui-
ty to the practice of Midwifery.   In  a controversial pamphlet,
published in the year 1730, he  is mentioned as having been
knighted.  In  the year 1739  he established a ward,  or small
hospital, in the  parochial Infirmary of  St. James, Westminster,
for the reception of parturient women only, which was the  first
thing  of the  kind  in the  British  dominions.   At this ward,
which was supported by public subscription,  he gave  lectures,
and the students had  opportunities of being qualified for prac-
tice.   He published  a  "  Compendium  Artis Obstetrica," a
" Treatise on  the Febricula," on the " Use and Abuse of Phy-
sic," " Aphorismata Medica," and many other essays, relating
chiefly to the practice of Midwifery.   Sir Richard Manningham
was a man of  considerable learning and information, eminent
and successful in practice,  and  very humane  in  the  exercise of
his art.  He died about the year 1750.   Before that time there
had also been published a translation of Heister's Surgery, and
this, containing  not only a  general  outline  of  midwifery, but
many excellent practical observations,  must have been a source
of great benefit  in  a country not then overstocked with infor-
mation.
   Sir Fielding Oulde, of Dublin, in the year  1741, published a
" Treatise of Midwifery," the most interesting parts of which are
his observations on the continuance of the thickness of the uterus
during pregnancy, and his description  of the manner in which
the head of a child passes through \he pelvis z.i the time of birth ;
the truth of which observations has since been fully proved and
acknowledged.
   Having taken this short and imperfect view of the progress of
Midwifery in  this country, from 1540 to the  year 1740, it will
be prudent to conclude, or  this preface  would be carried to an
inadmissible length.   The English might then be said not  only 
PREFACE.
xlix
to have pursued, but to have been in full possession of the sub-
ject ; all the books written in the neighbouring countries being
translated, public lectures given, and an hospital established for
the farther improvement of the art, which was taught by men of
ability and eminence  in practice.  As all the books and papers
printed at that time  may be readily procured, every gentleman
has an opportunity of forming  his own opinion of their respec-
tive merits without any laborious research.   But the College of
Physicians having been pleased, in the year 1783, to form a rank,
in which those who dedicate themselves to the practice of Mid-
wifery should  be  placed,  I  trust  that future accounts will be
more apposite  and correct, and  that this measure adopted by the
College will promote  the  public benefit, by confining  the indus-
try and abilities of one class of men to  this branch of the pro-
fession.  It is my earnest wish  to support  their views in  this
wise and benevolent arrangement; as the fruits of which, I en-
treat Dr. Latham, the President of the  College of Physicians,
whom I must  suppose  to be not less dignified by his learning,
and the integrity and liberality of his  principles and conduct,
than by his rank  in  the profession,  to  accept  this work, dedi-
cated, with all respect, by
                            His most obedient
                                   and obliged servant,
                                       THO.  DENMAN.
     London,  1815.
  To  the  above  Preface  of the  author, the American Editor
thinks  proper to make a few additions.

  In the preceding sketch  the author cannot claim the merit of
either having exhibited the most satisfactory exposition of the pro-
gress of Midwifery, or of lucid arrangement in the disposition of
his facts. Indeed, he seems to have put together, with too little care,
whatever occurred to him illustrative  of the different eras in  rae-
                               7 
1
PREFACE.
 dicine, rather than to have traced the  history of a particular
 branch of it.  The author was,  perhaps, more successful in mak-
 ing improvements than  in detailing those of others; but it must
 be allowed, in extenuation, that  the materials for this purpose are
 scanty and dispersed, and it deserves to be  remembered,  that
 Midwifery has but lately received the honours of a science.
  Rejecting as uncertain or fabulous whatever is recorded of the
 obstetric art,  anterior to the time of Hippocrates,  it may be ob-
 served, that there is to be found in the different treatises of that
 great man, no  mean  extent of information on the  subject.   A-
 mong his numerous writings, we find three distinct treatises, de
 Natura Mulicbri; de Superfcetatione ; and de Mulierum Morbis.
 In this last mentioned essay, he has described many diseases pe-
 culiar to the female sex, and his catalogue of remedies for their
 removal is unusually extensive.   His view of  menstruation, and
 of its suppression, is  replete with valuable principles, and his
 pathological indications wonderfully felicitous for  the time.  His
 theory of conception  and  generation, though now rejected, was
 the prevailing doctrine for many ages.   Conception, according
 to his idea, consists in a fermentation of the  male and female se-
 men : and he considers the sex  of the embryo as  determined by
 the predominant influence of either parent.  Like Democritus,
 Hippocrates maintained  a loco-motive  power in the uterus, yet
in his book, de Natura Pueri, he furnishes us with some interesting
cases concerning the ovum,  and the means  by which it may be
expelled.   The  singular circumstance  that  a child of seven
 months* gestation has greater chance of living than one of eight,
 was noticed by him, and  he attempts an unsatisfactory explana-
 tion of it.  He has treated, at much length, of difficult labours :
 he notices the various presentations of the child, and the differ-
ent attachments of the placenta : his directions recommend them-
 selves to our notice by their precision and minuteness.  In those
cases in which the head of  the  child presented, but was detain-
 ed above the brim of the pelvis, on  account of the straightness of
 the passage,  he  advises  to anoint  the  parts,  and to put the
 patient into a warm bath.  Provided these means failed, the head 
PREFACE.
li
 of the child was to be opened  with  a scalpel, and then to be
 extracted with strong  iron pincers or hooks.   " Caput gladiola
 dissectum : instrumento, quod constringat comminuto, et ossicula
 per ossium volsella extrahito, aut unco attractorio  ad claviculam
 uti  firmiter adhtereat  immisso, non confestim, sed paulatius  re-
 mittendo, et  rursus adurgendo, extrahito."  According to  Le
 Clerc, he was the first, who in cases of great extremity, adopted
 the expedient  of saving the mother at the expense of the child.
 Blood-letting, so highly useful in  many  cases of tedious labour,
 was strongly enforced by him. In a distinct treatise on superfceta-
 tion, which doctrine he endeavours to support by numerous  ar-
 guments, he  advances  many  important principles, which modern
 experience has confirmed.  On the whole, it may be said of Hip-
 pocratic midwifery,  that it was far beyond what might be rea-
 sonably expected from the then state of anatomical  and physiolo-
 gical knowledge;  that the  remedies  in difficult  cases, though
 numerous, were comparatively feeble, and similar in character,
 to  the expectant method of treatment in other diseases, pursued
 at that period.
   The vast and powerful mind  of Aristotle, intent on universal
 science,  regarded the obstetric art but as subservient to his mag-
 nificent views.   Yet his physiological speculations  and theoreti-
 cal reasonings, are not unworthy of his  mighty intellect.  In a
 portion of his writings  on the generation  of animals, he treats of
 the signs of puberty, of menstruation, and its peculiarity to  the
 human species; of the  evidences and symptoms of conception to
 the period of parturition.  The situation of the foetus in utero,
 the birth of the child and of the secundines, are  also  considered by
 him.   The importance of the menstrual  flux  he so highly esti-
 mates, that he ventured to affirm, that with some few exceptions,
 those females are barren in whom this discharge has not appear-
 ed.   He was aware  how much  more laborious was the parturi-
 tion of the human subject than that of other animals, and he was
an  ardent supporter  of the   theory  of Hippocrates,  that  the
embryo is formed from the union of organical particles of both 
Hi
PREFACE.
parents.   He seems to have been the first to propose the distinc*
tion between the natural and unnatural labours.
   It was not until towards the decline of the republic, that phy-
sicians enjoyed  their proper rank in the  Roman  state.   That
illustrious usurper, Julius Caesar, by a wise decree, first confer-
red upon them the rights of citizens;  and they subsequently en-
joyed the highest dignities  in the empire.   It is uncertain whe-
ther the classical Celsus belonged to the medical profession.   He
wrote with  distinguished ability on  agriculture, on war, on  elo-
quence, and on physic.  In the  first four of his eight books, de
Medicina, he treats of such internal diseases as  require for  their
cure diet  and regimen alone; in the fifth and sixth he describes
such  as may be  removed by medicines,  and in the two last of
whatever requires chirurgical assistance.  It is in these two latter
books, and  especially in  the seventh, that he discourses on the
diseases of women, and on  the means to be used for the purpose
of extracting the dead foetus, but which is little else than an ab-
stract  of the opinions of Hippocrates.  Nevertheless,  a very
high judgment  must be formed  of the  condition of medical  sci-
ence in the Augustine age from the admirable compend of Celsus.
   In the Natural History of Pliny,  are  recorded  some curious
physiological speculations  on  superfoetation.  Though not  a
physician himself, this celebrated writer considered  footling cases
as preternatural  labours.
  In Galen,  who appeared nearly one hundred and fifty years after
the Christian era, we find a most  elaborate and able  expounder of
the works of Hippocrates, and to him is justly ascribed the singular
merit of bringing back physicians to the father of medicine, from
whose simple, but sound  principles, they had  been  too much di-
verted by the methodists and other theorists.   Authors ascribe to
bim five hundred distinct treatises on medical subjects, several of
which relate to midwifery. I shall only, here, enumerate de semine,
de formationefatus, de uteri dissectione.  Although his writings be
deemed chiefly paraphrastic, yet he certainly  effected  many  im-
portant improvements ; and in the anatomy of the viscera of the
female pelvis, may lay claim to the title of a discoverer.   The 
PREFACE.
liii
uterine tubes, since termed  Fallopian, are said to have been first
described by Galen.
  The  name of iEtius is little  known to popular reputation in
general medicine, yet he ranks high  in  our particular  depart-
ment.   He is said to have entered more minutely, and at greater
length,  than any  of  his predecessors, upon most of the different
branches of the art.   A part of his surgical practice has been re-
vived by Pott; but  the variety  and value of his obstetrical stu-
dies, will be appreciated from a  mere outline.   His pretensions
as an original writer are  feeble, but he appears to have been a
most diligent collector of the opinions of others, and  his works
are valuable, as being, perhaps, the best record of the time which
intervened  between Galen and himself.   I shall  briefly  recount
a few of them as illustrative of the state of midwifery in that
age.
  iEtius wrote a system of physic, the last book of which treats
of the diseases of women and children.   In  his chapter de  utero,
he divides that organ into  a fundus and neck, and describes the
os tincae.   His views of conception are borrowed from the accu-
rate Soranus.  Under  the  head of pica, he notices the peculiar
derangement of the digestive organs attendant upon pregnancy.
In enumerating the causes of difficult labours, he chiefly follows
Hippocrates ;  and the  undue union of the ossa pubis, by which
they are prevented  from separating  in parturition, he absurdly
considers as among  the foremost of these causes.  The  circum-
stances which give  rise to difficult labours,  as  referable to the
foetus itself, are such as, with a  few exceptions, we may find in
the best systems  of  midwifery.   He  says much  of the different
presentations in labours; head  presentations are most natural;
little trouble is to be apprehended from footling  cases; the worst
position is  when  the child  presents  double, especially if the hip
bones come foremost.  Not a few  of his directions in cases of
difficult labour, are  such  as the  soundest practitioner might ap-
prove ;  yet, one trembles at his  application of instruments, and
the temerity of his obstetrico-chirurgical operations.  In his man- 
liv                      PREFACE.
agement of the sequela? of labour, he  is minute, and, at times,
happy.
  Paulus iEgineta, of whom it is uncertain whether he belongs
to the fourth or seventh  century, is frequently, but erroneously,
represented to have been  the  first man-midwife.  His  skill in
surgery may be inferred from the repeated reference made to his
writings by Fabricius ab Aquapendente.   His book, de  re me-
dica, embraces a description of the diseases of women;  in  his
chapter on difficult births, he denominates all those labours  na-
tural in which the head or  feet present; all  other positions he
called unnatural.  He read  lectures  on  the different branches
of medicine at JEgina, and acquired  so high renown for his in-
structions in midwifery, as to obtain the title obstetricius.
  I do not  find that our art received any considerable improve-
ment from the Arabians.  That singular race of people were for
a long period the repositories of medical knowledge, and they
contributed to its augmentation by  the description and treatment
of several new diseases which their own filthy habits engendered
among them.  Humanity may lament this addition to the cata-
logue of physical evils, though  medical science must admit  her
obligations to this extension of her sphere.  No notice can here
be taken of their additions to the materia medica.   Loathsome as
were the diseases under which they laboured, they attempted to
combat them but by comparatively feeble means,  and their re-
medies were chiefly Galenical.   Cullen, in his notice of the Ara-
bians, has fallen into several errors, and his character of them is
too contemptuous.  Of the Arabians, I  shall only mention Sera-
pion, Rhazes, Avicenna, and Albucasis,  all of whom wrote on
the  diseases of women and children.  Rhazes has been quite par-
ticular in giving us directions how to  rupture the membranes;
and, in the management required, when the waters are prema-
turely discharged.  He, also, treated of the spina ventosa, and is
the author of a work expressly on the diseases of children.
  Avicenna was a most voluminous author on midwifery and its
kindred subjects.  He was no  less remarkable for the premature
development of his genius, and at the early age of sixteen, pub* 
PREFACE.                       lv
licly lectured on various branches of medical knowledge.  What
is most observable of Albucasis is, that he has given us descrip-
tions and figures of  the instruments used at his time in the ob-
stetric art.   Among  the instruments he notices, are two kinds of
forceps, and two kinds of crochets.
  Towards the latter part of the  sixteenth century, a Dr. Ray-
nalde published in England  a book, the first of the  kind that
had  appeared in that country, which he called the Garden of
Lying-in Women and Midwives.  It was subsequently translated
into  the  Latin, and most of the modern languages, and became
the manuel of instruction for females.   The popular prejudice,
at that time, was so great in favour of female practitioners, that
an unfortunate physician of Hamburgh  was  publicly branded,
whom curiosity had induced to be present at a delivery, in female
attire.
  So few and so unimportant were the contributions made to
the obstetric art by the physicians and   surgeons of Great Bri-
tain, from the revival of learning to the  time of Harvey, that I
shall pass over this interval without further notice.  But in France,
contemporaneously,  surgery was illustrated by the  genius  of
Ambrose Pare.  This eminent man is  also worthy of commemo-
ration, for the improvements he introduced into obstetrical  sci-
ence ; and  on him has been  bestowed the high appellation of the
restorer of midwifery.  His writings are  remarkable for the va-
riety and number of facts which they record, and he may be con-
sidered  the first modern author in medicine, who has  refused a
superstitious deference to the opinions  of the ancients.  Pare
adopted the general  division of labours into natural and preter-
natural, classing under the former, those  cases in which the child
presented with the head, and was delivered immediately on the
discharge of the waters. The preternatural, including all  others.
His practical advice in all preternatural cases, is to turn the child,
and deliver by the feet.  On  this  maxim, which  he applies  al-
most universally, he  chiefly  founds his obstetric reputation.  His
pupil Guillimeau afterwards amplified and extended the direc-
tions of  Pare in a  separate  performance.  In cases of profuse 
lvi                      PREFACE.
flooding9, Guillimeau directed the membranes  to  be forthwith
broken, and the patient to be delivered.   He records, from his
own observation, instances of ruptured uteri.
  The illustrious Harvey, in his work  de Generatione, published
detailed accounts of a variety of experiments which he had insti-
tuted, under royal patronage, with a view to the elucidation of
the intricate subject of generation.  It would be  difficult to offer,
at this time, any thing like an analysis of his book, which Boer-
haave so highly extols.   The principal object of Harvey is to de-
tect the nature of conception, and the origin and progress of the
new animal.  He takes for his chief example, the hen and chick.
He treats of the formation and growth  of the egg, and the seve-
ral parts of which it is composed.   He then, from a daily inspec-
tion during the  time of incubation, traces the first appearance of
the chick, and  its  gradual progress.   He was  the first who dis-
covered its origin from the cicatricula of the ovum, and who per-
ceived the punctum saliens to be the heart.  He accurately dis-
plays, as far as the eye  could inform him, the successive forma-
tion of the several parts, and corrects many ancient errors.   He
maintains, throughout, the position omne animal  ex ovo.  Never-
theless, the system of generation  which he deduces from these ob-
servations, is somewhat singular.  He supposes  that the blood is
the primordium of all animals, and even  prior  to the vessels;
that the female  gives  the original material, and  that the male
renders it vital  and animated.  He denies any  mixture of male
and female semen  in coitu,  and that the male semen ever pene-
trates to the ovarium, or  even  to  the uterus ; and imagines the
ovum to become impregnated, not  by seminal contact, but by a
sort of subtle contagion, as he expresses it, affecting the female ra-
ther than the ovum.  He thinks it impossible that a material cause
can occasion impregnation;  but as the mind, by its action, pro-
duces thought  or conception in  the brain, so he supposes some-
thing analogous to  reside in the womb, which he  terms phantasm,
by the virtue  and energy of which the ovum is  generated:  The
experiments of Spallanzani are  familiarly known to be directly
opposite to the theory of Harvey;  but the speculations of the 
PREFACE.
Ivii
 latter have very lately been countenanced to a certain extent, by
 an ingenious member of the Medico-Chirurgical Society of Lon-
 don, and the result of his experiments published in their transac-
 tions.
   On the difficult subjects, abortion,  extra-uterine  conception,
 difficult labours, and  on various diseases of the Uterus, Harvey
 has added many valuable facts.
   An essay on the life  of the fceius in utero, by  Nymmanus, and
 a treatise on the diseases of women and children, in the works of
 Sennertus, were published about the year 1640.   Not long after
 this period, 1666, Mauriceau gave to  the  world his system of
 Midwifery, a work more ample in its details, and richer in prac-
 tical information on the subject to which it  relates, than any that
 had preceded it.  The extensive experience  of the author, as well
 in private practice as in the Hotel Dieu of  Paris, then the great-
 est establishment  in Europe for the  accommodation of lying-in
 women, eminently qualified him  for the undertaking.  The sys-
 tem of Mauriceau was  soon after translated into English,  and
 published by the Chamberlaynes, subsequently noted for the dis-
 covery of certain instruments which  they  secretly employed in
 obstetrical practice,  and which still bear their name.   The con-
 struction of these instruments was for a considerable time kept a
 profound  mystery.  They soon,  however,  became a necessary
 part of the contents of every fashionable accoucheur's green bag,
 but have now  fallen  into disuse.    Ample notice  of them is to be
 found in various books.   It is curious to observe, that the origi-
 nal instruments, as constructed by the inventors, were lately found
 in an old building formerly occupied  by them in the county of
Essex in England.   They have  since  been deposited in the ca-
binet of the Medical and Chirurgical Society of London, and are
 fully described in a  volume of the transactions of that active as-
 sociation, published in 1818.  These instruments appear to be a
 combination of the lever and the forceps.
  To Daventer and Le  Motte, each of whom wrote  a distinct
treatise on Midwifery, we are indebted for some judicious obser-
vations on the relative diameters  and proportions of the  pelvis
                             8 
lvili                     PREFACE.
 and the head of the foetus. To the oblique situation of the uterus,
 which circumstance had  been  previously observed  by the cele-
 brated  De Graaf, Daventer erroneously attributes the most com-
 mon cause of difficult labours.   Many useful prognostics, never-
 theless, are to  be found in his work.
   Pierre Amand practised Midwifery with  much reputation at
 Paris,  where,  in the year 1715, he published a treatise on deli-
 veries.  He relates several cases of extra-uterine conception, and
 gives us a description, with engravings, of a kind of net invented
 by himself, for extracting the head of the foetus when left in the
 uterus  separated from  the body.  This  fanciful  invention has
 long been laid  aside for the crotchet.
   But this period is rendered memorable by the labours of the il-
 lustrious Ruysch  of Holland,  whose unwearied  application to
 every department of anatomy, and especially his minute and ex-
 tensive  injections of the  human subject,  reflected  a  light on
 some of the more intricate and  obscure parts of the  physiology
 of our science,  to which a large share of its subsequent  improve-
 ment may be assigned.  Beside the various pathological remarks
 recorded in his writings,  the number and  excellence of  his in-
jected  preparations  were almost incredible.  But what particu-
 larly claims  our notice, was his cabinet of preserved foetuses, in
 regular gradation.   This extensive collection attracted the atten-
 tion of travellers  from every country ; and we are  told,  that ge-
 nerals, ambassadors, and even princes, were accustomed to examine
 it. Peter the Great, on his visit to Holland, purchased it for twenty
 thousand dollars; on which the indefatigable  anatomist imme-
 mediately began his labour anew,  in order to supply  its place.
 By a singular coincidence, just a century afterwards, this second
 collection was sold by the authority of Holland, to the emperor
 Alexander of Russia, and permitted to be taken from the country.
 We are not to  be surprised  at the melancholy results to Dutch
 literature and science consequent upon such niggardly conduct;
 and to the parsimonious spirit which led to this disgraceful trans-
 fer, are we to look for  the present low  state of  science and the
 arts in that country.  The schools of Holland, once so  celebra- 
                          PREFACE.                     lix

 ted, are now insensible even to their former glory.   The univer-
 sity of Leyden, which once boasted of  more pupils than the city
 itself could  accommodate, has at  present scarcely  more medical
 pupils than  professors.  And when some years ago I visited this
 once celebrated temple of learning, I found that thirty-three pu-
 pils attended instruction from that chair in which Boerhaave once
 lectured to admiring thousands.
   But to  resume our narrative.   In 1723, Mavhray published a
 work,  entitled, " The Female Physician, or the whole Art of
 New Improved Midwifery."  He was the first teacher of the sci-
 ence in England, and was conspicuous for his opposition to the
 use of instruments.   Dionis  also  communicated to  the public
 some  singular cases which  fell  under his  own observation, of
 ruptured uteri.  Shortly after this time, Chapman's work on the
 improvements of Midwifery appeared.  In it we find a descrip-
 tion of Chamberlayne's forceps, which he had advantageously al-
 tered.   He  was long distinguished as an adroit and skilful ac-
 coucheur  in difficult labour.  We ought not  here to  omit to men-
 tion the Elementa Artis Obstetricce of professor Roederer, of Goet-
 tingen.   The cases in  midwifery written by Giffard, and pub-
 lished  at this time, were a valuable addition to the stock of ob-
 stetrical science.   Manningham, who was an active practitioner
 of midwifery, published several books  on  the subjects : it would
 seem of more benefit to himself than to others.  We are indebt-
 ed to Gregoire, an  accoucheur of reputation in Paris, for the
 first correct ideas of the nature of retroversion of  the uterus, a
 subject of so much importance in the practice of obstetrics.
  We now come to a name better known : In the year 1752, Smel-
 lie published his treatise on Midwifery, which work, until lately,
 was the manual of students.  He is  the  undoubted author of
 many valuable principles  in  the modern practice of midwifery,
 and  contributed materially to the mechanical improvement of the
 instruments  used to facilitate labour in difficult cases.   He was
 the first who accurately determined the  shape and size of the pel-
vis and the head of the foetus, and pointed out the whole progress
of parturition.  An opinion  had very generally prevailed from 
lx
PREFACE.
 the time of Hippocrates, that the foetus is placed in the uterus in
 a sitting posture, and that about the eighth month, or as some
 authors taught, at  the  commencement  of labour, the  head is
 forced  down by the contraction of the uterus.  But Smellie  ob-
 serving that at whatever period the foetus was excluded, it gene-
 rally came head first, he was induced to  consider that as the  na-
 tural position of it in utero. We need scarcely add, that  this opi-
 nion has been fully confirmed  by  Dr. Hunter, who had several
 opportunities of dissecting women  who died  undelivered at diffe-
 rent periods of pregnancy.  The work of Smellie formed  at  the
 time a complete system of the obstetric art: it was the result of
 an experience of forty years.
   But I hasten to the time of the celebrated Dr. William Hun-
 ter, whose work on the Gravid Uterus, appeared in 1775, illus-
 trated by  numerous splendid  engravings,  the publication  of
 which constitutes an era in our science.   In it are exhibited  all
 the principal changes that occur during the whole period of ges-
 tation, in a style of execution which had never been equalled.  In
 this performance he  delineates  the retroverted uterus,  and the
 membrana  decidua  and  reflexa which  he  himself discovered.
 This great work has been subsequently extended by Dr. Baillie.
   The late  Dr. William Shippen  of Philadelphia, has  the ho-
 nour of having  been  the first  public teacher of  midwifery  in
 the United  States.   While in Europe, he enjoyed the high ad-
 vantage of the direct instruction of Dr. William Hunter, and  on
 his return to his native country, was chosen professor of anatomy
 in the medical school  of Pennsylvania.  His  lectures on obste-
 trics, like  his course of instruction on anatomy and  surgery,
 evinced  profound knowledge of his subject, consummate ability,
 and unrivalled command over his auditory.  Dr. Shippen's first
 course of midwifery was delivered in 1762.
  In the year 1767, the medical school of New-York was found-
ed under the  direction  of Kings,  now Columbia college, and
among the appointments was that of John V. B. Tennent M. D.
as professor of obstetrics.  After a substantial preliminary educa- 
                          PREFACE.                       lxi

 tion in his native state, New-Jersey, he availed himself of the ad-
 vantages in medicine which Europe then .held out to American
 youth.  I am informed that his course of instruction in obstetrics
 was able and satisfactory.  While in London he was created a
 fellow of the Royal Society.   Since the time  of Shippen and
 Tennent, midwifery  has been  taught  as  a regular branch of
 education in every medical college in the United States.
   Having thus brought down the history of the obstetric art to
 our own time, we  have  only to observe, that  the present age
 boasts many elementary works on midwifery well entitled  to at-
 tention.  I need only  here enumerate  the writings of Osborne,
 Hamilton, Baudeloque, White,  Burns,  Clarke,  Denman, Merri-
 man, Capuron, and Bard, which works ought to be in the hands
 of every student.
   I shall not now  attempt to enter into a consideration of the
 merits  of these several authors, but content myself with observ-
 ing, that they are practical writers, and give us the results of
 their  personal experience.  They  have added  the sanction of
 authority to what had been before discovered, and have enriched
 the stock of existing knowledge with original facts and observa-
 tions.   Of Dr. Denman  in particular, we may further remark,
 that that curious and important fact, the evolution of the child in
 certain circumstances,  by the action of  the uterus itself, was first
 observed by him.   He first proposed the present approved treat-
 ment in cases of retroverted uterus.  The excitement of prema-
 ture labour,  for the preservation of both  mother and child, in
 cases of deformed pelves,  was originally suggested by him.  In
 convulsions, particularly where the pulse was  slow,  he advised
 copious  bleedings  instead of nervines.  He  introduced  great
 improvements in the treatment of flooding cases.  What he has
 related of the use  of  instruments in  difficult labours, and  his
 aphorisms on the use of the forceps and  lever, may be  considered
 as cardinal rules  for the  young accoucheur.  These, and other
 suggestions, the fruits of  tried experience, are justly  considered
 important improvements, which will ever entitle Dr. Denman to
the gratitude of posterity. 
lxii
PREFACE.
  It will be at once perceived from  our hasty sketch, that this
science comes recommended to the consideration  of the physi-
cian, with claims as numerous, and as powerful, as belong to any
other department of the healing art.  Like every other branch
of our profession, it has occupied the intellectual energy of emi-
ment men, and  has arrived at its present lofty elevation  by cau-
tious observation  and diligent experience.  Since  the treatment
of lying-in women has been confided to  male  practitioners, the
advantages of the change, though  comparatively recent, both in
the manner of conducting the labour, and in  the  subsequent
management of the mother and child, have been so obvious, that
the practice will, doubtless, in time, become universal.  Another
beneficial consequence is, that every  part of the art has been in-
vestigated with the greatest care,  and such has been the zeal of
the accoucheurs engaged in the practice, that the works on the
subject of midwifery which were published  during the last cen-
tury, are sufficient in number to form no inconsiderable library.
I shall not here attempt to point out the propriety of that custom
which authorizes the employment  of male practitioners in the
art, nor examine into the reasons why so salutary a practice  is
adopted less generally in this  country than in Europe, but shall
content myself with stating this simple fact, that the bills of mor-
tality in London and Dublin, attest, that  one in seventy of those
women perish in child birth,  who are in  the hands of midwives,
while, from the accounts of the lying-in-hospitals in those  very
cities which are under  the care of male attendants, parturition is
fatal to less than one half that number.   Nor, indeed, is the pro-
cess of parturition so free from difficulties  as  is  by many ima-
gined.  We learn, from the last reports  under the  authority  of
Mr. Hay of the  Leeds Infirmary, that  of eight hundred and
twenty-seven cases of midwifery, one hundred and fifty  were
such as required manual aid, either with  regard to the expulsion
of the placenta, or child.   I hope it  is not irreverent to females
to assert, that the acts of resolution and firmness which such oc-
currences impose, are less fitted to their delicacy than to the har-
dihood of the other sex. 
PREFACE.                     lxiii
   Another circumstance which fortifies the claims of this branch
 of study, arises from the absolute certainty, that every  one en-
 gaged in the practice of medicine,  is liable to be called  upon in
 obstetrical cases.   Although it is permitted, that the practice of
 physic and surgery be exercised by the same individual, it is not
 unusual  for persons to select that particular branch to which their
 genius or feelings  are most partial.  But, it is proper  for us to
 bear in mind, that whether emulous of medical or surgical repu-
 tation, in the course of our duties, calls in midwifery happen to
 all.  To gentlemen who enter upon the practice of medicine in
 this country, a knowledge of the obstetric art is indispensable.
 Cases of labour occur in every well regulated family, and calls
 of this nature can  neither be parried nor delayed.  Our wide-
 spread population is  little favourable to that division of the  pro-
 fession which elsewhere  obtains, and what is regulated by com-
 mon consent, is not to be controled by individual feeling.
   To studious and  ingenuous youth, our science  presents attrac-
 tions in no wise  inferior  to any other branch of knowledge.
 The whole  range of  physiology solicits  his  diligence,  and
 will  amply reward his toil.   Talents of the highest order have
 lately entered into this field  of investigation, and the most san-
 guine anticipations have been realized.
   But, it is not the charms of philosophy, nor an honest ambi-
 tion of fame, which, in this case, are alone to be consulted.  Con-
 siderations of prudence, and the claims of humanity, alike urge
 us to the acquisition of this part of the profession.   In no situ-
 ation in  which the physician  can be placed, does  he encounter
 greater responsibility than in the practice of midwifery. The lives,
 both of the mother and child, are dependent on his skill, and amid
 the most trying  and perplexing difficulties, his character is com-
 mitted to the tribunal of censorious  and often incompetent judges.
 Nothing but conscious ^ibility can  arm his resolution, or  protect
his feelings from insult.   Of that knowledge which lends its aid
to art, it is not only requisite  that it be possessed, but that it be
ready and forthcoming ;  and on the practice of midwifery above
all others, is it incumbent, that his knowledge  be present, and at 
Ixiv                     PREFACE.
command. No where is promptitude and decision more required ;
in no instance is  the man of science more distinguishable from
the mere pretender ;  in no situation is the conduct of the physi-
cian  more the object of present attention,  or of subsequent criti-
cism.  In the lying-in-chamber no  opportunity is afforded  for
qualification or deliberation.  The case demands immediate as-
sistance, and  it is vain to temporise.   Vacillation and delay,
always dangerous, may here prove fatal.   The student's mind
must be thoroughly prepared, else  the  imputation of  ignorance
will attend his hesitation and confusion.   Firmness and decision,
founded on accurate and precise knowledge, will alone secure
to him present confidence and future approbation.
                                                 J. W. F. 
           INTRODUCTION

                  TO the

PRACTICE OF  MIDWIFERY.
                     CHAPTER  I.

                         SECTION I.

                      ON THE PELVIS.

   The anatomical and physiological knowledge of all the parts
concerned  in  parturition, is  indispensably  necessary for those
who mean  to  excel  in the practice  of midwifery; even  that of
the whole body may, on various occasions, be employed with
advantage   In the  investigation of every subject, there  must,
however, be some point of commencement, and, as there is much
use and propriety in the method hitherto pursued by systematic
writers, I shall follow their example, and give, in the first place,
a description of the situation, structure, connexion,  use, and dis-
eases of these parts;  beginning with the pelvis, which is of great
importance, on account of the direct influence which it has upon
labours, and because  it may be esteemed the foundation on which
all the other parts are sustained.  But this is only intended so far
as may be requisite for the study and practice of midwifery.
  The term pelvis has been indiscriminately given to the inferior
part of the  cavity of the abdomen, and to the bones which form
the cavity; but it appears more eligible to  confine the term to
the bones, and to call the space between them the cavity of the
pelvis.
  The pelvis in the adult state is composed of four bones : the
sacrum, the os coccygis, and  the ossa innominata.
  The sacrum is situated at  the posterior and inferior part of the
trunk of the body, and serves as a basis for the support  of the
spine, of which it is an imperfect continuation.   Its figure  is that
of an irregular triangle, with the shortest side placed upwards.
The anterior surface is smooth and flat, and has a considerable
degree of inflection or curvature, called the hollow of the sacrum,
by which the cavity of the pelvis is much enlarged.   The  poste-
rior surface is convex and uneven, and to it some of the muscles
of the spine and thigh are attached. 
66
INTRODUCTION TO MIDWIFERY.
  In the infantile state,  the sacrum is composed of five, and in
some subjects of six bones, called false vertebrae, cemented toge-
ther by intervening cartilages, which in the adult become bone;
leaving little ridges or lines on the anterior surface, indicating
the parts where they  had been separate.  These bones diminish
in their size as they descend, so that the lowest, which makes the
point  of the sacrum,  scarcely maintains the character of one of
the vertebrae.
  The articulation of the upper part of the sacrum,  with the last
of the lumbar vertebras, is similar to  that of the vertebrae with
each other; but by the manner in which the sacrum and verte-
brae are joined, the latter inclining over the former, an obtuse an-
gle is made, called the great  angle  of the sacrum.  In children
educated with more regard to a false idea of beauty than to the
acquisition of strength, this angle is sometimes so great as to re-
quire  mechanical support.
   Through the sacrum there  is a canal for the residence and se-
curity of the lower part of the medulla spinalis ;  but the posterior
part of the canal is incomplete below the third bone, a strong li-
gamentous substance supplying the place of bone.   That part of
the medulla which  is  contained in the sacrum is called the cauda
equina.
   On the anterior part of the sacrum there are four  pair of holes
or perforations, or more, according to the number of bones of
which the sacrum was originally composed, through which large
nerves pass for the use of the parts contained  in the pelvis and of
the inferior extremities.   On the posterior  part of the sacrum
there  is an equal number  of  perforations disposed in  the same
longitudinal order;  but they  are less than those on the anterior
part, and covered by  membraues, which allow small nerves to pass
through them.
   The sacrum is of a very celular texture, and is  said to be light-
er than any other human bone of equal magnitude.
   The lateral parts of the sacrum form  a broad unequal surface,
by which it is connected with  intervening ligament and cartilage
to another uneven surface at the posterior part of the ossa innomi-
nata.   The inequalities of these surfaces  receiving and being re-
ceived by each other, contribute very much to the firmness of
the union of these bones.  An anchylosis  is  not  unfrequently
formed  between the sacrum and ossa innominata ; and sometimes
in consequence of their separation an imperfect joint, which  very
much weakens that part, and impairs the manner of walking for
the remainder of life*
  * .P?° doub* can e"»st of the occasional occurrence of this impaired
condition of the junction of the sacrum and ossa innominata ; instan- 
ON THE  PELVIS.
67
  To the inferior extremity or point of the sacrum, is subjoined
the os coccygis, which has by some writers been considered as a
distinct bone, and by others as an appendage to the sacrum; and
these form, by the manner of their union, an obtuse angle, called
the little angle of the sacrum.  In infancy theos coccygis is car-
tilaginous, but in adult age it is composed of three, or more fre-
quently of four bones, connected  by  intermediate cartilages, the
uppermost of which is somewhat broader than the lowest part of
the sacrum.   In some subjects these bones  coalesce and  form a
single bone; and in others an anchylosis is formed between the
sacrum and os coccygis;  in consequence of which  the latter is
shortened and turned inwards, so as  to obstruct in some degree
the head of the child in its passage through the pelvis.   But the
impediment thereby occasioned at the time of labour maybe, and
usually is,  overcome  by the  force with  which the head of the
child is propelled, and the os coccygis  again separated from the
sacrum with a noise loud enough to be distinctly heard, of which
I have known more than one instance.  In general, however, be-
tween the bones of which theos coccygis is composed, some re-
gressive motion is preserved; and that which is produced between
the sacrum and os coccygis, when the latter is pressed by the head
of a child  passing through the  pelvis, occasions a considerable
temporary enlargement of the inferior aperture of  the pelvis.*
The insertion of the  coccygaei muscles, of a part of the levatores
ani, and of portions or slips of the sacrosciatic  ligaments into the
sides of the os coccygis, keeps it steady, and prevents any lateral
motion.
   The ossa innominata are the broad large bones which form the
fore part  and sides of the pelvis, and the lower part of the sides of
the abdomen.  In children each of these bones is composed of
three; and, though they afterwards become one, the  lines of ori-
ginal distinction  may be observed at the acetabulum, or socket,
which receives the head of the thigh  bone.   While the bones are
distinct they have peculiar names,  the ilium, the ischium,  and pu-
bis, which names it is necessary to retain in the adult state, that
we may be able to describe with more accuracy each individual
bone, or  allude to it in the description of the adjoining parts, and
on many other occasions.
   The ilium  is the  largest  and uppermost of the bones which
form the ossa innominata, constituting what,  in a description of
ces of anchylosis there are more frequent: specimens of this mor-
bid formation are exhibited in the museum of Dr. Post, the professor
of anatomy in the University of New-York.  F.]
   * Os coccygis adeo extrorsum ssepe verlitur, ut integros deinde
annos conquerantur de dolore, in partibus his residuo.
                                     Ruysch, Advers. Dec. 2. 
68
INTRODUCTION TO MIDWIFERY.
the external surface of the body, would be  called the hip.   « »s
flat, broad, unequally convex and concave ;  in some parts round,
and in others of an irregular square figure.  It is  divided by
anatomists into the crista, basis, anterior and posterior edge, and
the two sides external  and internal.
  The upper part, which has a thick arched border, is called the
crista.  The anterior and middle part of it is convex outwardly,
and the  posterior  somewhat  convex inwardly.  The crista has
original!) on its verge  an epiphysis, of which  there are often
marks to an advanced age.
  The basis or inferior part of the ilium is thick  and narrow.
It forms anteriorly a portion of the acetabulum, or socket,
which receives  the head of the  thigh  bone;  and  posteriorly a
large share of the circumference of the  ischiatic sinus, which is
completed by the ischium and sacrosciatic ligaments.
  The anterior edge  of the ilium  has  two  eminences, called
spines, distinguished  as  superior and  inferior,  between which
there is an excavation or notch, and another  below the inferior
spine.
  The posterior edge is shorter  and thicker  than the anterior,
and terminates with two protuberances or spines, between which
there is also an  excavation.
  The external side of the ilium is convex on the fore, and  con-
cave on the back part. The internal side is irregularly concave ;
and upon that surface which is connected with  the sacrum there
are several irregularities.  From the upper part of this surface
there runs a prominent line, which forms  a margin, defining the
upper aperture of the pelvis.
  The ischium forms the lowest portion of the ossa innominata.
Its  parts are described under the names of body, tuberosity, or
obtuse process, and ramus.
  The body  of the ischium forms the lowest and largest part of
the acetabulum, and sends out a small apophysis, which projects
backwards and inwards, and is called the spine or spinous  pro-
cess of the ischium.
  The tuberosity or obtuse process of the ischium  is very thick
and uneven, and is turned downwards. As it is  the part on which
the body rests when we sit, it hath also been called os sedentari-
um.  The convex  portion was originally  an  epiphysis;   and,
from  the remains of the tendons  and ligaments which were af-
fixed  to it, has, in the fresh subject, a cartilaginous appearance.
  T he ramus is  a flat thin process or apophysis, proceeding
from  the curvature of the tuberosity, ascending and joining to a
similar but sho ter process, which springs from the anterior and
inferior part of the ossa pubis.   The ramus of the ischium aided
by  this short process, forms a large part  of the  outline of that
opening called  the foramen  magnum ischii.   This opening, in 
ON THE PELVI9.
69
the recent subject, is filled up by a strong ligamentous membrane,
which gives rise to the external and internal muscles called obtu-
ratores
  The o«sa pubis contribute the smallest share towards  the for-
mation of the ossa innominata.   Each of them has been describ-
ed in three pa«"ts, the body, the angle, and the ramus.
  The body is that part which is placed transversely  before the
anterior part of the ilium, to which it is united, forming by this
union  the oblique eminence, which distinguishes  on the inner
part of the pelvis these two  portions  of the  ossa innominata.
The body of the pubis contributes also to the formation of the
acetabulum.  The upper edge has on  its  inner part an oblique
ridge, which is  called the crista,  and is continuous with that of
the ilium beforementioned, as defining the margin of the  pelvis.
  The anterior part of the pubis is called the angle, and consti-
tutes that surface, which, being joined to the opposite bone, forms
the symphysis of the ossa pubis, and in common language goes
by  the name of the share bone.  This part of the bone is flat
and thin   The ossa pubis connected together form on the ex-
ternal or inferior side  an unequal  concavity; but on the inter-
nal or superior surface they  are  pretty equally convex, and both
the edges have a small degree of flexure outwards.
  The ramus is a flat,  thin, short apophysis, which, running ob-
liquely downwards, unites with that of the ischium.  The two ra-
mi of the ischia and of the ossa pubis form on the anterior and in-
ferior part of the pelvis an arch, which is usually called the arch
of the pubis.   This arch is much larger in women than in men;
which circumstance is  favourable  to the emergence of the head
of the child at  the time of birth, and constitutes the most distin-
guishing mark between the male and female pelvis.*
  * [The distinguishing marks of the male and female skeleton occur
chiefly in the pelvis ;  and, in addition to what is mentioned in the
text, several others are  deserving notice here.  The pelvis of the
female is less strong, less thick, and contains less osseous matter than
that of the male. In the female, the long diameter of the brim of the
pelvis is from side to side ; in the  male it is from before backwards ;
in the female, the brim is more of the oval shape, in the male more
triangular : in the female the ilia are more distant:  the tuberosities
of the ischia are also more remote from each other, and from the os
coccygis ; and  as these thn-e points are further apart, the notches
between them  are consequently  wider, and  there is of necessity a
considerably greater space between  the  os coccygis and pubes than
in the male.   The female sacrum  is broader  and less curved than in
the  otner sex.   The ligamentous cartih.ge at the  symphysis pubis
is broader and shorter.  In conseqence of the cavity of the pelvis 
70
INTRODUCTION  TO MIDWIFERY.
                         SECTION II
  The advantage to be derived  from the knowledge  of the
bones of the pelvis, in a dried or separate state, is not very evi-
dent.  But we may consider the previous intelligence of this and
some other parts of our subject as essentially useful and necessa-
ry,  because it  comprehends the  rudiments of a  more  perfect
knowledge than  can be  otherwise acquired: we shall therefore
proceed to examine the manner in which  these  bones are con-
nected.
  To the two  lateral surfaces of the sacrum are joined the poste-
rior surfaces of the ossa. innominata, and these are covered with
a thin  intervening cartilage, or ligamentous cartilage;  the ine-
qualities, as was before observed, contributing very  much to the
firmness of the junction.   The ossa innominata are also joined
at the anterior part by a thin cartilage, which covers the scabrous
end of each bone, and the space between them is filled up  with a
ligamentous substance.   This connection is called the symphysis
of the  ossa pubis.
  Within the circuit of the pelvis the periosteum is thickened at
the parts where the ossa innominata are joined to the sacrum, and
at the symphysis of the  ossa pubis.   The symphysis has also
been described as connected by a thin transverse ligament, or by
ligaments which form what  may be considered as a capsular liga-
ment,  adhering to the  part which it incloseth, and to which it
giveth the principal  strength.  Greater stability  could  not  be
procured  by  any internal mode of union,  without  a diminution
of the cavity of the pelvis.*
being wider in women, the superior articulations of their thigh-bones
are farther removed from each other, which circumstance occa-
sions their peculiarity in  walking : they seem to require a greater
effort than men to preserve the centre of gravity when the leg is
raised.  The greater distance  between the anterior and  superior
spinous processes of the  ilia  necessarily increases  the  length  of
Poupart's ligament forming the  crural arch :  on which account  less
resistance being  made to  the abdominal viscera, females are more
subject to femoral hernia  than males.  Soemmerring  has remarked
that the angle of union of the  ossa pubis is in the male from 60 to
80 degrees, whereas in the female it is 90 degrees.
   According to the most accurate calculations the mean height of the
male, at the period of maturity, appears to be about five feet eight and
a  half inches : that  of the female  seems to  be  about five feet five
inches ; and the length of the different regions proportionally less than
in  the male.  A  vvell-fornied  pelvis is generally allowed  to have a
circumference equal to one fourth of the height of the female.  F.]
   * See a short but very  precise account of the connection of  the
bones  of the pelvis  by Dr.  William Hunter.
                                     Med. Obs. and Inq. Vol. II. 
ON THE PELVIS.
71
   But on the external parts of the pelvis, where the union of the
 bones could be  more firmly established by a ligament, there is
 no point where one is omitted: even the tendons of the muscles
 inserted into the projecting parts of the bones, though particu-
 larly designed for other  purposes, eventually contribute to the
 strength of the pelvis.
   From the posterior edges of those surfaces of the ossa innomi-
 nata  which are joined  to the sacrum, strong  ligaments  pass,
 which bind these  bones firmly together;  and all  that unequal
 space behind them is  filled up with small muscles, or the small
 parts of large muscles, in such a manner as to give in the fresh
 subject, when covered  by their  tendinous  expansion,  a  surface
 almost  smooth.
   From the obtuse processes of the ischia strong ligaments arise,
 which,  expanding, pass to the posterior edges and  apophyses of
 the sacrum, detaching  in  their passage small portions to the os
 coccygis.  These ligaments are called the broad or external sa-
 crosciatic.  From the spinous processes of the  ischia ligaments
 arise, which, crossing  and adhering to the ligaments before des-
 cribed,  pass to the inferior a^id inner edge of the sacrum and the
 upper part of the os coccygis, sending slips or small portions to the
 edges of this bone throughout its  extent.   These are called  the
 internal sacrosciatic ligaments.

                         SECTION III.
   By the  knowledge of the parts where, and the manner in which,
 the bones of the pelvis are connected  together, we  are enabled
 to explain many uneasy sensations which women have, and many
 infirmities to which they are liable, at the time of pregnancy, and
 after  their delivery.
   It was for many centuries a received opinion, that these  bones,
 though joined together  in  such a  manner  as scarcely to afford
 any suspicion of a separation, were always separated at the time
 of parturition ; or that  there was a disposition to separate, and
 an actual  separation, if the necessity of any  particular case re-
 quired  that enlargement  of the  cavity of  the pelvis, which was
 consequent to it.   The  degree of separation  was also supposed
 to be proportionate  to  such necessity; and  if  it  did not take
 place, or not in such a degree as was required, distending instru-
 ments  were contrived, and  used  to produce or increase it; and
 upon  the same principle, the section of  the symphysis of the ossa
 pubis, of which we shall hereafter speak, hath been lately recom-
 mended.  This opinion ought, probably, to be assigned  as one
reason for the superficial notice taken by  the early  writers  in
midwifery, of those difficulties which are sometimes  found to  oc-
cur at the time of parturition,  from the smallucss or deformity of 
72
INTRODUCTION  TO  MIDWIFERY.
the pelvis.*  To this may also be  referred much of the popular
treatment of women in child-bed, and many popular expressions in
use at the present time.   But this opinion hath been controverted
by many  writers,  who assert, that  there  is neither a  separation
nor a disposition to separate;  but that when  either of  them does
happen, they  are not to be esteemed as common effects attendant
on the  parturient state, but as diseases of  the connecting parts.f
The disputants on each side have appealed to presumptive argu-
ments,  and .to  facts proved by the examination of the bodies of
those who have died in child-bed, in justification of their several
opinions.   But, notwithstanding nil that has been said upon  the
subject, I know not that we are authorized by the  experience of
the present time, to say, that a separation,  or a disposition to
separate, prevails universally at the latter  part of pregnancy, or
at the time of labour; yet. that these effects are  often, if not  ge-
nerally produced,  may be gathered from the pain and weakness
so often  mentioned and complained of, at the  parts  where  the
bones of the  pelvis are joined to each other, before and after  de-
livery.   In some cases, pregnant  women  are also  sensible of a
motion at the junction of the bones, especially at the  symphysis
of the ossa pubis, and  the noise which  occasionally accompanies
this motion, may be frequently heard by an attentive by-stander.
  A strong presumptive argument in favour  of the  separation of
the bones has been drawn from quadrupeds.  In these, the liga-
ments which  pass from the  obtuse  processes of the ischia to  the
sacrum, on which the firmness of the junction of the  bones very
much depends, and which, at all other times, resist any impres-
sion attempted  to be made upon  them, are for several days pre-
vious to  parturition, gradually deprived  of their strength, and
the animal walks  in such a manner as  would incline us to  be-
lieve could only be produced by a separation of the bones of the
pelvis.   Now, it  is  not  reasonable to conclude, that a circum-
stance which  generally takes place in one class of viviparous ani-
  * Edoctus assero, ossa pubis saepe  ab invicem in partu laxari,
emollito eorum  cartilaginoso connexu,  totamque hypogastrii regio-
nem, ad miraculum usque, atnpliari ;   non quidem ab aquosae sub-
stantiae profusione, sed sua  sponte, ut fructus maturi excludendis
suis seminibus solent hiscere.             Harv. Exercitat. lviii.
  In partu difficili et laborioso  ossa ischii aliquantulum a se invicen
dehiscunt.                               Ruysch, Adv. Dec. 2.
  t Les uns et les autres disent, qui ces os que se separent ainsi a
l'heure de l'accouchement, y ont etc disposez peu a peu auparavant,
par des humiditez glaireuses qui  s'ecoulent des environs de la ma-
trice, lesquelles amollissent pour lors  le cartilage qui les joint fer-
mement, en d'autres temps.  Mais  ces deux opinions sont aussi eloig-
ners de la verite' que de la raison.
                             Mauriceau, torn. 1. liv. 2. cap. 1.
jflft. 
ON THE PELVIS.
73
 rnals, should never occur in another, especially in a matter in
 which there is no essential difference.
   We may, however, leave the question to be completely settled
 by future observations.  To insist that either  of the changes oc-
 curs in every case, or that they never occur, seems an attempt to
 support  opinions repugnant to daily experience.  For no person
 who has been conversant in the dissection of women who  have
 died in childbed, can have wanted opportunities of seeing every
 intermediate state of these parts; from a spparatinn in which the
 surfaces of the bones were completely loosened, and at a consi-
 derable distance from each other, to that in which there was not
 the least disposition  to separate.
   It then appears, that the degrees of separation at the junctions
 of the bones of the pelvis, to each other, may be very different;
 and that, when it takes place beyond  a certain degree, it is to be
 considered  as  morbid.   Several cases of this kind,  which have
 occurred in my own practice, and a greater number  for which I
 have been consulted, have laid  me under the  necessity of consi-
 dering this subject with the most serious attention, and I presume
 that it may  be produced  by two causes:  first,  a spontaneous dis-
 position  of  the connecting  parts ;  secondly,  the violence  with
 which the head of the child may be  protruded through the pel-
 vis.*  Of a separation  from each of these causes, it  will not  be
 improper to give an example to  prove the fact, and to show  its
 consequences.

                           CASE I.
   A young  lady of a healthy constitution, and lively disposition,
 who was married in the twenty-first year of her age,  was, in the
 beginning of 1774, delivered of her third child, which was unu-
 sually large, after a very severe and tedious labour.  For several
 days before  her delivery she  was rendered unable to  walk with-
 out assistance, by pain  and  weakness in  her  loins.  Her reco-
 very  was favourable and uninterrupted, except that for several
 succeeding weeks she was incapable of standing upright, or put-
 ting  one  foot before  the other; the attempt to  do either being
 attended  with pain, and  a sense of looseness or jarring, both at
the parts where the ossa innominata  are joined to the sacrum,
and at the symphysis of the  ossa  pubis.   By the use of such
medicines and means as contributed to strengthen her constitu-
  * In the 484th number of the Philosophical Transactions, there
is an account of the separation  of the symphysis pubis to  the dis-
tance of four inches, occasioned by the sudden starting of the  horse
which the gentleman was riding.               m
                             10 
74          INTRODUCTION TO MIDWIFERY.
tion, she soon became able to walk, and, in a few months, was
perfectly well.
   Having before seen a case of the same kind, I suspected  that
these complaints were occasioned  by the weakness  of the con-
nexion of the bones of the pelvis ; and, imputing this  weakness
to too frequent parturition, she was advised to suckle her child a
longer time.  She, accordingly, continued a nurse fifteen months.
   After weaning her child, she soon conceived again; and when
the time of her confinement drew near, the complaints which she
had in her former pregnancy, were increased  to such a degree,
that she could neither walk nor stand ; and, for three weeks be-
fore her delivery, there was reason to suspect, that the bones of
the pelvis were separating.
   July 7, 1777,  she  was delivered of her fourth child.   At  the
time of her labour she  had frequent faintings,  great marks  of
disturbance and irritability, and was wholly unable to move her
inferior extremities.
  A few days after her delivery she had a fever, which terminated
in an abscess in one  of her breasts.  By this, which was very
painful and distressing, she  was confined to  her  bed for near
seven weeks.  At the end of nine  weeks she could walk with
crutches, when she was sent  into the country,  from which she
received much benefit; as she believed she likewise did by drink-
ing half a pint of a strong infusion of malt twice every day.   In
about five months, she was able to walk without assistance, though
she was sometimes sensible  of  the  motion of the bones, which
seem never to have been perfectly united.
   About Christmas she was again pregnant; and in July, 1778,
being indisposed to move, as she imagined, by the sudden and
uncommon heat  of the  weather, the pain and  weakness in her
back returned, and she could  not walk any more without assist-
ance, to the time  of her labour, which came on October the 11th.
On the 13th  she was  delivered of a very fine child.  Her labour,
which was unusually severe and alarming, was  made infinitely
more fatiguing by her inability to move, all power of supporting
herself being wholly lost, and  every necessary  change of posi-
tion, though she was  in bed, being made by her assistants.
   On the fourth  day  after her delivery she was seized with a fe-
ver, which was soon  removed, but her situation remained  really
deplorable.  The pain at the junction of the  bones continued;
she had  no command of her inferior extremities ; and when she
was moved, the pain, which she described as the cramp, became
excruciating, as if she was tearing asunder.  Her stomach  was at
all times  much disturbed, but when she  had the pain in  an in-
creased degree, a vomiting, or oppressive nausea, or hiccough,
was brought (A The pain also produced strange sympathies in
various parts ;TB a very teasing cough, a constant sneezing,  a 
ON THE PELVIS.
75
sense of weight in her eye-lids, which  she could not keep open,
though she was not sleepy, a loud noise in the bowels, and many
other nervous affections.   When, therefore, the pain was violent,
she had recourse  to  opiates, which she took discretionally, and
the pain being quieted, the sympathies soon ceased.
  At the request of my patient, I explained, upon a skeleton, the
opinion entertained of  her complaints; and, when I pointed out
the manner in which the parts were supposed to be affected) she
was fully persuaded of  the truth of the opinion.
   In this situation she had remained for several months, when it
was thought expedient  that she should  be  raised from her bed,
and make an effort to stand or walk, lest her constitution should
be injured, and her complaints rendered worse by the habit of
resting  so long in an  inactive state.   Every position was tried,
and every contrivance  made, which had a chance of being use-
ful ; but the power  of supporting herself was totally  gone; the
motion  of the bones was plainly perceived; and the consequences
of every trial were so painful  and uncomfortable, that it was not
judged proper to repeat them,  but to wait till, by time, the con-
nexion of the bones was more confirmed.
  About six months after her delivery she menstruated, which
she continued to do at  irregular periods; yet, though  much be-
nefit was expected from this circumstance, no alteration was pro-
duced by it with respect to her  complaints.
   In the year 1779,  she  was removed, upon a  couch, in a boat,
to Margate, for the  benefit of the air  and bathing in  the  sea,
from which  she  was  always sensible of receiving advantage.
There she continued to reside;  when  eight years were elapsed
from the  time of her  delivery, she became able to walk without
crutches; and, though now  perfectly recovered, her amendment
has been extremely gradual.   I have lately been informed of two
other cases of the same kind,.in  one of which the process,  by
which the lameness was at length cured, also required eight years
for its completion.

                           CASE II.
   Many years ago I attended a young woman  of a healthy, but
delicate constitution, who was in labour of  her  first child.  The
os uteri was fully dilated, the membranes broken, and the waters
discharged, before I  arrived at her house.
   She  was immediately  put  to bed, and the pains being very
strong, the head  of the child was  soon pressed  upon the peri-
naeum, the laceration of which I endeavoured to prevent by sup-
porting it  in  the usual manner; but the head of the child was
rapidly forced through the external  parts,  in opposition to the
resistance which I was able to make.       ^^
   At the instant when the head of the childJKs expelled, I per- 
76
INTRODUCTION TO MIDWIFERY.
 ceived something to jar under my hand, and  was even sensible
 of a noise, which led me to suspect, that the perinaeum was lace-
 rated by the sudden expulsion of the head, but, on inquiry, this
 was found to be perfectly safe.
   After a short time, the placenta being separated and protruded
 into the  vagina, was extracted without hurry or violence.  The
 uneasiness of which she then complained, being supposed to be
 what are called  after-pains, did  not make  me  solicitous, but a
 few drops of tinctura opii were given to appease it.
   On the following days she complained of more than usual pain
 in the lower part of the abdomen, which she did not accurately
 describe;  but as there was no symptom of fever, and the milk
 was duly  secreted,  no particular inquiry was made, and I pre-
 sumed that she would soon be well.
   On the  fourth day after her delivery she  was taken out of bed,
 but could  not stand or sit in her chair, on  account of the pain
 and weakness in the part  of which she originally complained,
 and which 1 found to be immediately upon  the symphysis of the
 ossa pubis.
   For near three weeks she remained in the same  state, perfect-
 ly well in  her health, and easy in her  bed,  unless when she at-
 tempted to turn on either side; but when she was removed from
 her  bed,  she could neither stand nor make any  effort to walk
 without assistance, though she could sit for  a few minutes, resting
 her elbows upon the arms  of the chair.
   The continuance of a complaint so very  uncommon, rendered
 it necessary to have a consultation, and a gentleman of great ex-
perience and ability was called in.  After a very careful exami-
nation, we found the internal  parts in the  natural situation and
free from  disease;  the perinaeum was not  lacerated,  nor was
there the  least  appearance of injury  about the external parts.
But it was judged  by the  seat of^the  pain, by  herinability to
stand or walk, except in particular attitudes and positions, that
the symphysis of the ossa  pubis had given way, and  was wholly
 separated; and there was scarce a doubt, but that the separation
had taken place when the bulk of the head of the child was pass-
ing between the spinous processes of the ischia, when I was sen-
 sible of the jarring noise.
   The opinion of the separation  was chiefly founded  on the par-
ticular attitudes and positions in which  the patient sought relief;
 it, therefore, seems necessary to describe them more fully, as they
 were very remarkable.
   When  she endeavoured to stand upright, which  she could do
better on one  foot than both, and better with her feet close than
at a distance, together with the pain at  the symphysis, she had a
 sense of extreme ^akness, accompanied with a faintness.  When
 she first sat downiirher chair, resting her elbows upon the arms
 of the chair, the complaints became tolerable.   When she had 
ON THE PELVIS.
77
 remained a little time in this position, they were again importu-
 nate and she supported herself with her hands upon her knees,
 and presently bent forwards, so as to lean her elbows upon her
 knees; this position becoming irksome, she was obliged to  re-
 turn to her bed, where she was immediately easy.  When she
 first attempted to walk, she was compelled to bend forwards  in
 such a manner as to rest her hands  up n  her knees, making a
 straight line from her shoulders to her feet.
   The explanation  of  her  case, and the  comfort  she  received
 from the assurance that was given of her  recovery, encouraged
 her to bear her confinement, and the present inconveniences she
 suffered, with composure;  yet, the knowledge we  had acquired,
 presuming our opinion  to be true, was useful,  radier by teaching
 us how to avoid doing  mischief, than by enabling us to render
 any actual service.
   At the end  of fourteen weeks, whilst she  was in  a coach, into
 which she had often been lifted for the benefit of air and exer-
 cise, she had a discharge, which she  supposed to be menstruous;
 and though it  had ceased before her return, she was sensible  of
 immediate relief.   From that time she mended daily, and in six
 weeks was able to walk, her  complaints  having gradually left
 her.
   She had, afterwards,  three children, with all which I attended
 her.  Her labours  were easy; and  neither before  nor after her
 delivery, had she any tendency to the complaints 1 have been de-
 scribing.
   The discharge which preceded her recovery was thought  to
 be menstruous; but as it had ceased before her return, and gave
 relief to a  part not directly affected  by menstruation, it is more
 rea>onable to  conclude, that it was from the symphysis ; and  of
 whatever kind  it was, that it had acted as  an  extraneous  body,
 preventing the re-union of the bones.
   Instances have occurred, though they are rare, of women who,
 after labours, have suffered much pain in  the region of the sa-
 crum, and have lost all  power of moving their inferior extremi-
 ties ; and the inability has been imputed to some paralytic affec-
 tion.   They are said to be bedridden, which describes the effect,
 though it does  not explain  the cause of their disease.  As these
 patients  have, after  a confinement of several months, or  even
 years, been generally restored  to the  use of their limbs, it is not
 unreasonable to think, that  their infirmity  was occasioned  by a
 separation of the bones, which, at different periods  after the ac-
 cident, according to the degree of separation, had recovered their
former connexion and strength.*
  * The admission  on the  part of the author,rthat, as a general
principle, there is a separation of the bones of the pelvis, or a dis- 
78
INTRODUCTION TO MIDWIFERY*
                         SECTION IV.
  An inquiry into the manner  in which the bones of the pelvis
may re-unite  when  they have been  separated seems necessary,
position in them to separate at the latter period of pregnancy, or at
the time of labour ;  and that this change is often, if not generally,
produced, is somewhat extraordinary.  True, we have the authority
of the most eminent names, for believing, that a separation of the ossa
ilia from the os sacrum, and of the ossa pubis from each other, have
repeatedly taken place  during parturition.  Hippocrates, Avicenna,
Diemerbroeck, and even Hunter, have given us  facts of this import.
Yet, that such separation does but very rarely occur, and then  only
under very particular circumstances, cannot reasonably be  doubted.
I am not aware, that either rickets, or mollifies ossium, at all predis-
pose to  it.  On the other hand,  there seems  to  be good reason to
conclude, that the majority of instances of this calamity which have
taken place, occurred in individuals of robust and healthy constitu-
tions, rather than in those of  the reverse.   The cases recorded by
our author, are in corroboration of this belief.
  The  most  common cause to  wnich this change may  be attribu-
ted, seems to  be some injury or  external violence, which, in its  con-
sequences, predisposes  to a separation of the bones.  Such was the
well known case of Dr. Greene, in which  the symphysis pubis  was
separated, as  stated in Philosophical Transactions of the Royal Soci-
ety of London, and of the instance recorded by M. Louis, in the Me-
moirs de l'Acad. de Chirug. torn. 4. in which the sacro-iliac junc-
tion separated.   In the  Memoirs of the Academy of Dijon, for 1784,
a case is given of the os  innominatum being luxated in consequence
of a fall   The patient ever after remained lame. A high authority,
Baudelocque, asserts, that the separation of the bones of the pelvis
is very rarely met with ; that it is not more usual after a laborious,
than after an easy labour ; and that it does not occur more frequently
in the distorted, than in the well formed pelvis.
  A case occurred in the  practice  of Dr. Post, in this city, about
seven years  ago,  in which the patient,  a robust woman, aet. 25.
during her pregnancy with her second child, experienced a  consider-
able weakness at the junction of the pubes, which increased so much
a9 to render it difficult for her to walk or turn in bed ; according to
her  representation,  the bones at  the pubes  felt as though  they
moved on each other.   After an ordinary labour, her strength  im-
proved so far, that within about  six weeks, she  was able to take ex-
ercise on foot with comparatively very little difficulty or  pain.  She
has, since that period,  had three other  children, and  towards the
termination  of each  pregnancy, suffers the same inconvenience in
walking, or in endeavouring to turn herself when  in an horizontal
situation.  Her own  sensations,  and her peculiar gait, are  evidence
sufficient of the nature  of her complaint: at the present time  she 
ON THE PELVIS.
79
as the treatment to be enjoined, and the prospect of success, will
be regulated by the idea we  entertain of the state of the parts
when separated.
 is far advanced in her sixth  pregnancy, and she seldom ventures to
 take any exercise.
   An instance of the separation of the ossa ilia from the os sacrum,
 occurred under the observation  of Dr. Hosack, about  twenty-two
 years ago.  The patient, a well formed female of the age of twenty-
 five, during her labour with her first pregnancy, manifested symp-
 toms  of much distress about her loins, and after some considerable
 suffering, was delivered of an  ordinary sized child ; several weeks
 elapsed  before she was able to stand upright.   She said  she felt a
 sense of looseness on both sides, at the junction of the sacrum  and
 innominata, especially on the left side.  It was several months be-
 fore she  had any power of moving one foot before the other, and
 her friends were always apprehensive from her  hobbling  gait,  that
 she would fall.  From that time to the present, she has  remained
 the same unfortunate cripple ; and with each successive child, now
 amounting to eight, her inability to walk has increased.   She, at pre-
 sent, has scarcely any loco-motive power.   There can be no doubt
 of the nature of her  case.  Some short time before her first ac-
 couchment, she received a slight contusion on the left ileum.
   The first of these two cases would strengthen the opinion  of a mor-
 bid predisposition existing at the junction of the pubes during preg-
 nancy, or at the time of childbirth :  the second case shows us that a
 blow or fall may cause a separation of the sacro-iliac junction.  Yet a
 fracture  of some of the bones themselves,  one would think more
 likely to occur  from accidental circumstances of this  sort.  Fortu-
 nately for humanity,  the separation of the bones of the pelvis, either
 by violence, by a scrophulous habit of body, or by any other cause,
 is seldom met with : nature has other resources  than such dread-
 ful means in  order to effect the safe passage of the child.
   The author's presumptive argument in favour of the separation of
 the bones, as drawn from quadrupeds, needs facts for its support. Ne-
 vertheless, on the authority of Le Gallois, there is a separation of the
 bones of  the pelvis of the Guinea-pig, both during pregnancy and
 parturition, for the purpose of facilitating the latter process.
   " When we compare the pelvis of the female of a guinea-pig,"
 says Le Gallois,  " with the  head of a  full grown  foetus, we are con-
 vinced on the first view, that it would be utterly impossible that its
 head should come through the  pelvis, and consequently that the de-
 livery should take place, if the pelvis constantly preserved the state
 and dimensions  observable  at any other time than that of gestation.
 The transverse diameter of the head of a foetus of middling size, full
grown, but dried,  is  nine twelfths of an  inch  (French measure)
whilst that of the pelvis of a female of middling size measured  be-
tween the acetabula on the bare  and dried  bones is not quite five
 twelfths of an inch.  If we  take in the account the soft parts lining 
80
INTRODUCTION TO MIDWIFERY.
   When the connexion of the bones of the pelvis has either been
impaired or destroyed, it is probable, that a confirmation or re-
union takes place by  a restoration of the original mode: by a
callus, as in the case of a fractured bone, or by anchylosis.*
   It is also possible for them to remain in a separated state; and
that an articulation  should be formed by the ends of each bone,
at the symphysis of the ossa pubis, and at the junction of the os-
sa innominata with the sacrum ; of which,  by  the favour of Mr.
Cline,  I have seen an  instance in the dead body, and have had
reason to suspect the same accident in the living.
the cavity of the pelvis, we shall find that when alive, its diameter
is about one half of the head of a foetus ;  and nevertheless guinea-
pigs are delivered with much ease.   It thence necessarily follows,
that nature must have provided some means of removing the difficul-
ty produced by this enormous disproportion.   And this is what does
in fact  take place.  The duration  of gestation in these animals is
sixty-five days.  About three weeks before delivery, the symphysis
pubis is seen to acquire more thickness and a  slight mobility ;  these
are continually increasing.  Eight or  ten days before delivery, the
ossa pubis begin to separate from one another  This separation in-
creases at first  slowly, and only begins to go on rapidly for the three
or four days which precede delivery.   It is such  at  the moment of
parturition that it readily admits the middle finger, and even some-
times both the middle and fore finger together.  The delivery being
at an end, the bones of the  pubes soon close.  Twelve hours  after
the distance of separation  has lessened  more than one half, and
twenty-four hours  after they are in  contact at their anterior extre-
mity ;  and in less than  three days they are perfectly so throughout
the whole extent of their  symphysis,  which then only presents a
slight thickness and mobility.  A few d*iys after  nothing is  to be
seen but a very slight mobility, which disappears sooner or later.  I
have measured  the separation of the pubes in three females killed
at the period of their  delivery.  In two, which were at the sixty-
fourth day of gestation,  this separation was about  five twelfth  parts
of an inch ; and in the  third, which  was in the sixty-fifth day, the
separation was  little  less than six.   In these  three females  the
sacro-iliac  symphysis  possessed great mobility, but without any
remarkable separation.   This mobility of the  sacro iliac symphysis,
without which  the  separation of the ossa  pubis could only be  very
limited, allows besides a posterior motion of the os sacrum."   See
further, Nancrede's Translation.   F.]
  * [When  the connection between the bones of  the pelvis is im-
paired or destroyed,  it  must be either by a  relaxed or diseased
state of the ligaments :  the same change  may also be produced in
the cartilages :  their  re-union can be effected only by restoring the
original formations, and not by callus. An anchylosis can  onlv be bv
callus.   F.]                                            '     y 
ON THE PELVIS.
81
    In all the lower degrees of imperfection in the union of these
  parts, it  is reasonable to conclude,  that the former mode is re-
  stored soon after delivery; for the complaints which women make
  of pain and weakness in  these parts are almost always relieved,
  before their  month  of confinement is concluded.  But, should
  they continue a longer time, it appears,  that the greatest benefit
  will be derived  from rest and a horizontal position, which  will
  lessen the present inconveniences, aud favour that action  of the
  parts by which their infirmity must be repaired.
   But if the complaint  be in an increased degree, and the  health
  of  the patient likewise be affected,  a longer time will be requir-
 ed for the recovery of the  part; which may be forwarded by such
  means as invigorate the constitution, such applications as quick-
  en  the action of the parts, or by mechanical support.
   Should the injury be too great to allow of the  restoration of
 the original mode of  union, of which we are to judge by the
 consequent impotence to move,  a  much longer time will  be re-
 quired for the formation of a callus, if that be ever done but as a
 previous step to an anchylosis, which has been observed by ana-
 tomists to take place at  the junction of the ossa innominata with
 the  sacrum not unfrequently, but never or  very seldom at the
 symphysis of the ossa pubis.   Under  such circumstances, unless
 by an amendment of the general health, little good is to be ex-
 pected from medicine, the  process which  the parts  must  undergo
 being an operation of the constitution which it will not be in  our
 power to control.  In the first case related, a  variety of applica-
 tions were tried,  from the  most emollient to those  which are ac-
 tive and stimulating ; but from cold  bathing only did the patient
 receive any real  advantage.   She was also very much assisted
 by the use of a swath, or broad belt, made of soft leather, quilted,
 and buckled with such  firmness  over the lower part of the  body
 as to lessen, if not prevent,  the  motion  of the  bones;  and this
 was restrained in its situation by a bandage passed between  the
 legs, from the hind to the fore part of the belt.  If this belt  be
 made with a string, it  may be fixed  lower over the ilia,  worn
 tighter, and with  less inconvenience.
  In that unfortunate situation, in which  a joint  is formed  be-
 tween the separated surfaces of the bones, all hopes of the reco-
 very of the patient to her former abilities may be given up. She
 must for the rest of her  life walk imperfectly, and all that  re-
 mains to be done for her relief will be, by the  use of a belt, or a
 similar contrivance, to substitute as much artificial firmness as  we
 can, for the natural which  is lost.  In the case in  which I  sus-
pected this event  to have happened,  the life of the patient was
truly miserable; but I presume that such  very  rarely occur,  hav-
ing been lately informed of another person, who, after a confine-
ment of more than eight years to  her bed, in consequence of the
                              11 
82          INTRODUCTION TO MIDWIFERY.
separation of the bones at the time of labour, was restored to the
full and perfect use of her inferior extremities.   And farther ex-
perience has shown me many varieties, not only in the degrees, but
in the circumstances attending this complaint:  particularly in an
unexpected and total freedom from it, after subsequent labours.

                         SECTION V.
  There is  a wonderful  variety in the position of  the pelvis  of
animals, as it relates to that of the body  in general; and their
powers and p operties very much depend upon this circumstance.
But, with a view to this subject,  they may be  divided into three
kinds; the strong, the swift, and the mixed.
  In those animals, which possess the greatest share of strength,
the position of the pelvis is nearly perpendicular, and  the two
apertures of the  cavity nearly horizontal,  as may be seen in the
elephant.
  In those which are distinguished by their speed or agility, the
position of the pelvis is nearly horizontal, and the two apertures
nearlv perpendicular, as may be seei* in the stag.
  In mixed  animals, or those  in which strength and speed are
united, the position of the pelvs is neither horizontal nor perpen-
dicular, but inclined ;  so as to partake, by  different degrees of in-
clination, of a certain share of the advantages  of either position,
as may  be seen in the horse and  ass.  But these descriptions are
taken from the dried  skeletons.
  In the human  species, when t! e position of the body is erect,
the pelvis, which, bearing the  weight of  the whole body,  is
stronger in proportion to their size  than in any quadruped, is so
placed,  that  a line passing from the third of the lumber vertebrae
will fall nearly upon the superior edge of the symphysis of the
ossa pubis;  the cavity of the pelvis being  projected so far back-
wards, that the ossa pubis become the part on which the enlarg-
ed  uterus  chiefly rests in the advanced  state of pregnancy.*   If,
then, we recollect the smallness  of the ossa pubis, the manner in
which they are connected,  and  advert  at the same time to the
increasing effect, which may be produced by the internal pres-
sure of  the weight supported by them, in addition to  that of the
body, we shall not be surprised at  the frequency of the  com-
plaints of pain and weakness at the symphysis ; especially when
the child was large, or the patient under the necessity of stand-
ing for a long time.   And should there be any degree of weak-
ness, relaxation, or disunion, at the parts where the ossa innomi-
  * This part has been considered as the centre  of gravity in the
human body;  but Desaguliers  thought, that it was in the middle
space between the sacrum and ossa pubis. 
ON THE PELVIS.
03
nata are joined to the sacrum, similar effects will be produced;
and one of these parts can scarcely be affected without an equi-
valent alteration in the other.
  The consequences of the separation of the bones of the pelvis,
or of their disposition to separate, will be more clearly compre-
hended, if we  consider  the  pelvis as  an arch supporting the
weight of the  superincumbent body.   In this view the sacrum
may be called the key-stone; the ossa innominata, as far as the
acetabula, the pendentives ; and the inferior extremities the piers
of the arch.
  If a greater weight be laid upon an arch than it is able to sus-
tain, one of these consequences  will follow :  the key-stone will
fly, the pendentives will give way,  or the piers will yield to the
pressure.
  To prevent the two first accidents, it is usual to lay heavy bo-
dies upon  the  differeut  parts of the  arch,  the weight of which
must bear a relative proportion to each other,  or the contrary ef-
fect will be produced;  for if too great weight be laid upon the
key-stone,  the pendentives will fail;  and, if  there be too much
pressure upon the sides, the key-stone will be forced.
  When the greatest possible strength  is required in an arch, it
is usual to make  what is called a counter arch, which is a conti-
nuation of the arch till  it becomes circular, or of any intended
form.  This contrivance changes the  direction of the weight,
before supported  at the chord ;  and part of it will be conducted
to the centre of the counter-arch, and  borne in what is called the
sine of the arch.
   If the resemblance of the pelvis to an arch can be allowed,  we
may consider all the fore or lower part of it,  between the  acetabu-
la, as a counter-arch, which will explain to us the reason of so
much stress being made upon  the symphysis of the ossa  pubis,
when there is any  increase  of  the superincumbent weight;   or
when that part is in a weakened  or separated state, as in the se-
cond case before described, and particularly by the bending  of
that part in the rickets in children, and in the  mollifies ossium in
adults.
   When the patient before mentioned lay in a horizontal position
she was perfectly easy, there being then no  weight  upon the pel-
vis.
   When she was erect,  the weight borne by the symphysis be-
ing greater than it could support, she could walk before  she
could stand; or, if she stood, she was obliged to move her feet
alternately as if she were walking; or she could stand upon one
leg better than upon  both.   By these various  movements  she
took the superincumbent weight  from  the weakened symphysis,
and conducted it by one leg, in a straight line, to the ground.
   The fatigue  of walking, or of the alternate motion of the feet, 
84            INTRODUCTION TO MIDWIFERY.
being more than she was able to bear,  she was  obliged  to sit.
When she first sat in her chair she was  upright,  resting her el-
bows upon the arms of the chair;  by which means part of her
weight was conducted to the chair; not descending to the  pelvis,
which was also propped.  But there being then more weight up-
on the symphysis than it was able to bear for any long time, and
her arms being weary, by putting her hands upon her knees she
took off more of the superincumbent weight, conducting it by
her arms immediately to her knees.  When she rested her elbows
upon her knees, the same effect was produced in an increased de-
gree ;  but this position becoming painful and tiresome, she had
no other resource, and was obliged to return to her bed.
  It cannot escape observation, that  this patient  instinctively or
experimentally discovered the advantages of the  particular atti-
tudes into which she put herself, and by which she obtained ease,
as exactly as if she had understood her complaint, and the man-
ner in  which I have endeavoured to explain it.
  In the weariness which follows common exercise, when  we of-
ten change our position, apparently without design, the manner
in which ease is procured to any particular part may be readily
understood by a more extensive application of the same kind of
reasoning, and it seems as if the slightest changes were not made
in such conditions without  some advantage.

                        SECTION VI.
  The violence which the  connecting parts of the bones undergo,
when the head  of the child is protruded through the pelvis with
extreme rapidity or difficulty, sometimes  occasions an affection
of the symphysis of the ossa pubis, of more importance than a se-
paration ; because,  together with all  the inconveniences arising
from the separation, the  life of the patient is endangered by it.
This is the formation of matter on the  loosened  surfaces of the
bones, preceded by great pain, and other symptoms of inflamma-
tion ;  though in the beginning of the complaint, it is difficult to
ascertain whether the connecting parts  of the  bones, or some
contiguous part, be the seat of the disease.
   When suppuration has taken place in consequence of the inju-
ry sustained at the junction of the ossa innominata  with  the sa-
crum, the abscess has in some cases been formed near the part af-
fected, and  been cured  by common treatment.   But  in  others,
when  matter has been formed and confined at the symphysis of
the ossa pubis, the symptoms of a  hectic fever have  been  produ-
ced, and the cause has not been discovered till after the death of
the patient.  In others, the matter has burst through the ligaments
of the symphysis at the inferior edge, or perhaps made its way
into the bladder; and in others  it has  insinuated under the pe-
riosteum, continuing its  course along the ossa pubis till it arrived 
ON THE PELVIS.
85
at the  acetabulum.  The mischief being  thus extended, all the
symptoms were aggravated; and the matter making its way to-
wards  the surface, a large abscess has been formed  on the inner
or fore part of the thigh, or near the hip, and the patients, being
exhausted by  the fever  and profuse discharge,  have at length
yielded to  their  fate.  On  the examination of the bodies after
death,  the track of the matter  has  been, in  the few cases which
have been examined,  followed  from the aperture of the  abscess
to the symphysis, the cartilages of which were found to be erod-
ed, the bones  carious, and the adjacent parts very much injured
or destroyed.
   It may, perhaps, be possible to  discover,  by some  particular
symptom, when there is  in this part a disposition  to suppurate ;
or it may be discovered  when suppuration has taken place.   In
all cases of unusual pain, attended with equivocal symptoms, it
will therefore be necessary to examine these parts with great care
and attention.  For when there is a disposition to suppurate,  by
proper means  this might be removed ; and when matter is formed,
if there  be  a  tumefaction at the symphysis, more especially if a
fluctuation could  be  perceived, we might  deliberate  upon the
propriety of making an  incision to evacuate the matter;  and  by
such proceeding further bad consequences might be prevented.*

                         SECTION VII.
   The form of the superior aperture of the pelvis has been  de-
scribed by some as triangular, and  by others as oval,  with the
widest  part  from   one  side to the other.  ,But the inferior aper-
   * [Instances  of this kind are perhaps  less seldom  met with than
those of the separation alone of the bones of the pelvis.   Louis has
given us the particulars of an interesting case.  Oh  examining the
body of the patient after death, there was found a separation of the
bones at the pubis, but the capsule was entire, and so distended as to
contain one and an half ounce of matter.   The disease arose from a
slight accident.   This disorder may  take place in any constitution
from accident;  but those of a  scrophulous habit are most predis-
posed to it.—The  instances must be very rare indeed, in which this
complaint arises from the too  rapid passage of the head of the child
through the pelvis
   Dr. William Moore,  of this city,  whose  extensive obstetri-
cal practice must stamp his opinions on the subject with  the great-
est weight,  has never witnessed a case of the formation of matter at
the symphysis, in  nearly three^housand cases of midwifery which
he has attended.  The experience of several other accoucheurs in
this city goes to the same effect.  Nor has Dr. Moore ever seen an
instance in which  he had reason to believe a separation of the bones
of the pelvis occurred.   F.] 
86            INTRODUCTION TO MIDWIFERY.
ture, independent of the ligaments and soft parts, cannot be said
to resemble any known or general form, on account of its irregu-
larity, though the  widest part is from the inferior edge  of the
symphysis to the point of the os. coccygis, allowing for  the re-
gressive motion of that bone.
  The dimensions of the superior aperture of the pelvis, from the
upper part of the sacrum to the upper edge of the symphysis,
are generally stated to be more than four inches;  and between
the two sides they somewhat exceed five.*
  Of the dimensions of the inferior aperture it is difficult to form
a judgment;  but if the ligaments are preserved, it  may be said
that the proportions are  reversed, the narrowest part  being on
each side.  But in the form and dimensions of  the pelvis, in dif-
ferent women, there is an endless  variety, not depending  upon
any alteration which may be produced by disease.
  The depth of the pelvis from the upper part of the sacrum to
the point of the os coccygis is about five inches ; but thK will be
increased when the latter bone is pressed backwards.    From the
margin of the pelvis to the inferior part of the obtuse processes of
the ischia the depth is about  three  inches, and  at the symphysis
about one and a half.   It appears that the depth of the pelvis, at
the posterior part, is rather more than three times the depth at the
anterior; and that there is a gradual change between the two ex-
tremes, if we admit the ligaments to  make a  part of the outline
of the inferior aperture.   The knowledge of these circumstances
will enable us to judge  in the living subject how far the head of
tlie child has proceeded through the pelvis, and prevent any de-
ception  to which we might be liable, if we were to form our opi-
nion by the readiness with which we can feel the head at the an-
terior part.
  The cavity of the  pelvis is of an irregular, cylindrical form;
but, towards the  inferior aperture, there  is some degree of con-
vergence made by the points of the spinous and obtuse processes
of  the ischia, and the termination of the os coccygis.   This con-
vergence is of great importance in regulating the  passage of the
head of the child, as  it descends towards  the inferior  aperture;
and, being perfected by the soft parts, it gives to  the  vertex, or
presenting  part of the head, the disposition to emerge  under the
arch of the pubis.
   On the concavity or hollow of the sacrum, the ease or  diffi-
culty with which the  head of the child passeth  through the pel-
vis, will very much depend.  A similar curvature  is  continued
by means of the  ischiadic sinus, and  by  the disposition of the
  * Que mensurae, pollice fere integro, similes mensuras capitis fee-
tas superant.  Halter.  Physiolog. lib. xxviii. 
ON  THE PELVIS.                   87
sacrosciatic ligaments, to the obtuse processes of the ischia, where
the sides of the pelvis are perpendicular.  The  upper edge  of
the ossa pubis has a slight reflection  outwards, which prevents
any obstruction to the entrance of the head of the child into the
pelvis;  and at the lower edge there is some degree of divergence,
by  which the departure of the head out of the pelvis is very much
facilitated.

                        SECTION VIII.
  Before we  proceed to the examination  of  the  manner  in
which the head of the child passeth  through the pelvis at the
time of  birth, it is necessary to examine its dimensions and struc-
ture.
  The  largest part of the head of a child, not altered by com-
pression, is from the hind to the  forehead.    The diameter from
one ear to  the other, is less by nearly the same proportion, as the
space between the  sacrum  and  pubis, at the superior aperture,
is less than that between  the sides of the pelvis.
  The  bead of a child, which appears to  be larger according to
the size of the body  than that of other animals, is, at the time of
birth, incompletely  ossified  at  every  part where the  bones  of
which the cranium .s composed, afterwards unite; but chiefly at
the greater fontanelle, or the centre of that part  where the pa-
rietal and frontal bones meet in the adult.  By this  incomplete
ossification, and by the pressure to  which the head  of the child
is sometimes subject in its passage through the pelvis, the form of
the head may be very much altered, and  the  dimensions  lessen-
ed ; for  the edges of the bones will not only accede to each other,
but will lap over in  a very  extraordinary  manner, without any
detriment to the child.  The degree of ossification varies in dif-
ferent subjects; but  the head of a new-born infant is universally
(except in  some  very rare deviations; found  to be incompletely
ossified, and the advantage resulting from it is not only perceived
in those difficulties which may be occasioned by the natural large
size of  the head of the child, but in  those also  which are pro-
duced by all the less considerable  degrees of deformity of the
pelvis.  It is evident beyond all doubt, if this provision had not
been made, that many children must have been destroyed  at the
time of birth, or their parents must have died  undelivered.
  Daily experience very obviously and sufficiently proves, that
there is a  relative proportion between the head of the child and
the pelvis of  the mother;  and, from the excellent order observed
in all the operations of nature, it would be  reasonable to con-
clude, that the largest part of the  head is conformable  to the
widest part of the pelvis.  By the examination of a great num-
ber of women who  have died in various stages of the  act of par-
turition, it  has appeared, contrary to  the general doctrine of the 
88            INTRODUCTION TO MIDWIFERY.
ancient, and of many modern writers, when the position of the
head was perfectly natural, that the ears were placed towards the
sacrum and pubis, or a little obliquely; and that the vertex, or
that part where the hair diverges,  is exactly, or  nearly  opposed
to the centre  of the  superior aperture of the pelvis.*  In  the
course of the descent of the head,  there being some difference in
the form of the pelvis at each particular part of the cavity, the
position of the head is accommodated to each part, not by acci-
dent but compulsion, and at the lower part of the pelvis, in  con-
sequence of that convergence  before mentioned.  With  respect
to the pelvis,  the  lower the head of the  child has descended, the
more diagonal is the position of the ears ;  but they are  not al-
ways placed exactly towards the sides of the pelvis, even when a
portion of  the head has emerged under the arch of the ossa pu-
bis.  But this description  of the changing  position of the head
of the child in its passage through the  pelvis, is founded on the
presumption that it presents naturally, and  is guided by the form
of the internal surface.  If the head should present differently,
there will be corresponding, but  not the same, changes ; or, if it
should be very small,  it will not be influenced by the pelvis, but
may pass in any direction.
  It does not appear,  that any ill consequences  would follow an
erroneous  opinion of the  manner in which the head of the child
is protruded through the cavity of the pelvis in a natural labour,
for, no assistance being wanted, no  principle was required for the
regulation of our conduct.   But in  all cases in  which there was a
necessity of giving assistance, and where a "change  of  what was
deemed the wrong position  of the head, was improperly  com-
prised as a very material part of that assistance, as in the use of
the forceps, great mischief must  often have been unavoidably
done both to the parent and child.

                         SECTION IX.
   From the examination of the form and  dimensions of the ca-
vity of the pelvis, and of the head of a child, attempts have been
made to explain all the circumstances  of a labour upon  mecha-
nical principles, and to establish the practice of  midwifery upon
the foundation of those principles.
   It may  be  supposed, for a moment, that the passage of the
head of a child, through the cavity of the pelvis, should be con-
sidered simply as a body passing through a space ; and we may
try whether it be possible  to apply mechanical principles  with
advantage  for the explanation.
  * This observation was first made by Sir Fielding Oulde, about
the year 1737.  See hit Treatise on Midwifery. 
                      ON THE PELVIS.                    89

   The first circumstance to be considered in  the attempt is  to
 ascertain with precision  the capacity of the space.   Now, it is
 true that we have had many mensurations of the pelvis in all
 its parts, and that we have acquired a competent knowledge of
 the general  dimensions; but we  know, at the same time,  that
 there  is in the pelvis of  every individual woman some variety,
 and that the  exact knowledge of these varieties, on which  the
 explanation of a  mechanical process must depend,  cannot be
 gained in any living  subject.
   It is equally necessary, that we should have an accurate know-
 ledge of the size of the body intended to  be passed through this
 space.   But,  though  we have a good general idea of the figure
 and bulk of the heads of children at  the time of birth,  we are
 not ignorant, that those of any two children  were never found
 to  be exactly alike, and  that the  peculiar difference cannot be
 discovered before a child is born.
   The  head of a child is of a limited size before it enters  the
 cavity of the pelvis;  but, by compression  in its  passage, this is
 likewise altered  in a manner, and to a degree, of which it is im-
 possible to form any previous judgment.
  In the consideration of a body passing through a space, there
 is also a necessity of  knowing whether it be intended to pass by
 its own gravity or force,  or  whether it be passive, und is to be
 propelled by  any adventitious  power.  If by the latter, as in
 the case of a child at the time of birth, the  knowledge  of the
 degree of that power is necessary to enable us to form an esti-
 mate of the  po-sibility or likelihood of its success;  but  of the
 degree of this varying power we can form a very uncertain con-
jecture in any particular case.
  If then we have neither precise ideas of  the  dimensions of the
 space, nor of the magnitude of the  body, nor  of the alterations
 in size or form which the body may undergo,  nor of  the  power
 excited to propel the body, it does not. appear possible to explain,
 upon mechanical principles, the progress  of a labour.
  So much is however to be granted to the introduction  of me-
 chanical principles into the practice of midwifery, that they afford
 the greatest advantage in all  those cases of extreme difficulty,
 in which the assistance of art is ultimately required, because such
 assistance must be given upon these principles; and though they
 will  not  explain, they will illustrate the operations of the  animal
body, and, when applicable, are the surest guides of human ac-
tions.  But, on  the  whole, a fondness for.  an  imperfect  know-
ledge, and some affectation  of mechanical principles, seem  to
have been very detrimental; as to  these, the frequent and unne-
cessary use  of instruments, and sometimes their improper use, 
90           INTRODUCTION TO MIDWIFERY.

in the  practice of midwifery, may in a great  measure be  origi
nally attributed.*
  ♦[Although the last three sections of the text exhibit a sufficiently
accurate view of the pelvis, yet I have thought that a more concise
account of the same, in connection with some notice of the dimensions
of the foetal head, might here be inserted with advantage.  Of the
female  pelvis  three parts  ought especially  to be observed :  the
brim, the cavity,  and  the  outlet.   The brim is  bounded  by the
promontory of the os sacrum on the posterior part, and  by the linea
innominata laterally and anteriorly.  Its shortest diameter is from
the symphysis  pubis to the projection of the os  sacrum, which,
without the soft parts, measures from four to four and a  half inches ;
with the soft parts, from  rather more than three  to three and five
eighths  inches.   The lateral diameter, made by a line  drawn from
one  side of the linea  innominata  to  a point  directly  opposite, is
from  five to five inches and a quarter,  without the soft parts ;  or
from four to four and a quarter with the soft  parts.    The longest
diameter is from either sacro-iliac  symphysis to the opposite  aceta-
bulum, which, with the soft parts, measures from about four   and  a
quarter inches to  four and three quarters ; without the soft parts,
from  five to five and  three quarter inches.  The  cavity  of  the
pelvis is posteriorly about six inches deep,  laterally nearly four,
and anteriorly nearly two.   The outlet of the pelvis, when viewed
with  the sacro-ischiatic ligaments attached to it, appears of a quad-
rangular shape.  Its  shortest diameter is  from one tuberosity of the
ischium to the other, and is about  four or four and  a  half inches,
with the soft parts : its longest diameter is from the apex of  the os
coccygis to the  arch of the pubes, and measures about five  inches
when the bone is pushed back  in labour ; but little more than half
an inch when it is  not.
  When the body is erect, the pelvis  is situated  obliquely ;  the
opening  towards the abdomen looks upwards and forwards  to so
great a degree, that a line drawn  through its axis would approach
much nearer to a horizontial than to a perpendicular direction,  and
strike near to the apex of the os coccygis.  That part of the  pelvis
which is in  front  when the body is seated, becomes the lowest part
in the erect position : and thus the viscera rest on, and are support-
ed by the ossa pubis rather than on the soft parts which bound the
lower aperture :  the advantages arising  from which, in  advanced
pregnancy, are sufficiently evident.
   The  head of the foetus  is to be considered in  connection with
the  admeasurements of the female  pelvis.   At  birth  the head is
nearly one third  of the whole body, and its  passage through  the
pelvis of the mother may be deemed,  with scarcely  an  exception,
as securing the safe  passage of the child.  The bones of the head
are very loosely connected together by membrane, or,  as it is more
commonly expressed, by suture : the sutures are, the sagital,  which 
ON THE PELVIS.
91
                          SECTION X.
  The observations which were made on the form and dimen-
sions of the cavity of the pelvis  relate to its natural state ; but
these are also to be considered when the pelvis is distorted.
  Of the distortion of the pelvis there are two general causes:
the first is that disease incident to children in the very early
part of their lives, known  by the term rachitis, which preventing
the bones from acquiring their due strength, or sufficient  firm-
ness to support  the weight of the superincumbent body, they
bend in different directions and degrees, according to their weak-
ness and the weight imposed upon them, and the distortion there-
by occasioned is often fixed for the remainder of life. The second
is a disease which may occur at any period of  life, and from its
effect is called osteosarcosis, or mollities  ossium.*   It is far less
frequent than the rachitis,  but more dreadful in its consequences,
which no  medicine hitherto tried has had  sufficient efficacy to
prevent or  to  cure.   In  this disease the ossific matter is not
runs from the nose in a straight line  to  the  os occipitis ;  the co-
ronal,  which runs transversely from ear to ear, and connects the
parietal and frontal bones ; and the lambdoidal suture, which unites
the occipital  to  the parietal bones.  The  defective ossification of
the angles of the bones forms, at the front  part of the cranium,
where the frontal and parietal bones meet, the  anterior bregma or
fontanel, an interstice of a quadrangular shape.   The space at the
back part of the head is  of  a triangular form, and is called the
posterior fontanel.  By attention to the fontanels, we are  able  to
ascertain both the presentation  and the position of  the head.
  The foetal  head necessarily undergoes  great changes in its shape
and bulk during parturition, yet its dimensions may be set  down
as follows : its longest diameter, that is from vertex to chin,  is about
five inches : its shortest diameter, or from the protuberance of one
parietal bone to  the other, is about three inches and a half.   The
shape of the foetal head is eliptical,  and  as an  average Calculation
it appears that the size of the cranium of males at birth exceed that
of females by about a thirteenth part.   Dr.  Clarke,  {Philos. Trans.
of the  Royal Society,  1786,) in his  measurement   of  the heads
of sixty male and sixty female children,  at the natural period  of
birth, found that the circumference was on an average fourteen inches
in the males, and only thirteen and five eights in  the females, and the
arch from  ear to ear over the crown seven and a half inches  in
the males and only seven and one-fifth in the  females.  Out of one
hundred and  twenty children,  there were only six in  whom  the
circumference of the head exceeded fourteen and a half inches, and
those six were males.   F.]
  * Molacosteon.  Ossium mollities.   Vogel. Dxxiij, 
92           INTRODUCTION TO  MIDWIFERY.
thought to be dissolved or altered,  but to  be reabsorbed  from
the bones  into the constitution, and carried out of the body by
the common  emunctories, or deposited upon some other part
where  it is useless or  prejudicial.  The bones thus  losing  the
principle of their stability, become soft, according to the degree
and continuance of the disease ; are unable to sustain the weight
of the  body, and  change their natural forms,  in proportion to
their weakness; so that in some instances the most distorted and
frightful appearance of the whole body hath been exhibited.f
  The effect of either of these diseases is  not confined to  the
pelvis : yet it is scarcely possible, that either of them should exist
for any length of time without  producing its influence upon it.
Hitherto much  advantage has not been obtained by the know-
ledge of osteosarcosis,  nor have  the symptoms which precede or
accompany it been  accurately observed, before the effect was
produced.   Yet it is  possible,  by attending to the  secretions,
and  discovering an excess or defect of phosphoric acid  or the
like principles, the deficiencies and exceedings might be supplied
or lessened, and perhaps the disease removed,  together with its
effects.
   The pelvis is  more  commonly distorted  at the superior  aper-
ture  than at any other part, but never laterally.   This is par-
ticularly occasioned by the natural  projection of the upper part
of the sacrum, and the lowest of the lumbar vertebrae, and  the
ossa  pubis,  become distorted  for the  reasons, before assigned.
Should a disease  exist in  the constitution  which is capable of
weakening the bones,  it will  not appear extraordinary that  the
sacrum should be distorted, if  we recollect, that its texture is
originally spongy ; that it supports, both in the erect and seden-
tary position, a great part of the weight of the body ; and that,
by the manner of its junction  with the last of the vertebrae, a
considerable angle is made, which, if  but little  increased,  will-
cause a  very important  change in the form and  dimensions of
the superior aperture of the pelvis.   In some cases an irregular
convexity, and in others  a concavity, are produced by the bend-
ing  o<" the ossa pubis  in different ways and degrees; by which,
together with  the projection of the sacrum and  lumbar vertebrae,
the dimensions of the superior aperture of the pelvis, which in the
narrowest part should e\ceed four inches, have been, in some
instances,  reduced  to less  than  one,  and altered  in  every
possible direction.   It is probable  that, from a mere view  of a
distorted  pelvis,  independently  of the weight  of  the  bone or
Other  circumstances, we  might be able to distinguish, by the
  t See Medical Observations and Inquiries, Vol. V. case 23.   Me-
moirs of the Academy of Sciences, and various Authors. 
ON THE PELVIS.
93
part chiefly distorted, between a distortion occasioned by  the
rachitis in  infancy,  and the mollities ossium happening to an
adult.
  The form and dimensions of the cavity of the  pelvis may be
changed in any part of its space ; but the most frequent altera-
tions  proceed  from  the sacrum, which, besides  the  projection
before mentioned, may become  too straight, when the advan-
tages which should  be derived from its concavity will  be lost.
Or it may have too quick a curvature,  by which the concavity
will be rendered so small as not  admit the head of the child; or
an exostosis may be formed on its internal surface, which will be
the cause of inconveniences  equivalent to those occasioned by
the want of a proper degree of curvature.
   The  os coccygis may be pressed inwards in such  a  manner,
that the  point of it may approach the  centre of the cavity; or
the motions  between the different  portions of  the bone may b£
lost: or an anchylosis may be formed between this bone and tne
sacrum;  by all which changes, according to  their degree, the
head  ol the  child  may be impeded in its passage through the
pelvis.
   The ischia may  be distorted by the unnatural bent  of the
spinous  processes; and the effect of their pressure may be ob-
served for  some  time  after birth, on the temporal and parietal
bones of the head of a child propelled between them  with much
difficulty.  The  dimensions of  the  inferior aperture also may
be lessened by the tuberosities of the ischia bending inwards or
forwards, by  which the arch of the pubis  will be  lessened,  and
rendered unfit  to allow  of  the emergence of the head  of the
child under the  symphysis of the ossa pubis.
   When the stability of the bones of the pelvis is impaired,  it
is not possible to enumerate every kind of distortion which  they
 may  suffer;  but it is  principally in the degree that  we are to
 seek for those great, and sometimes, though rarely, insurmounta-
 ble difficulties  which occur in  the practice of midwifery,  and
 prove dangerous to either, or both  the parent and  child.
   In some cases the distortion of one part of the pelvis produces
 an enlargement of the rest.   Thus, when the  superior aperture
 is contracted, the inferior may be expanded;  and  hence  it is
 often  observed  in  practice, when the head of the  child  hath
 passed the point of obstruction with the most tedious difficulty,
 that a labour will be unexpectedly and speedily completed.
   When women have the appearance of being much deformed,
 it is  reasonable to think  that the pelvis must  be affected.  But
 there  have been many instances of extreme  distortion  of the
 spine,  yet the pelvis has  preserved its  proper  form  and dimen-
 sion ; and some women, who were in other respects straight and
 well proportioned, have had a distorted pelvis. 
94
INTRODUCTION  TO MIDWIFERY.
   If the inferior extremities are crooked, or if any part of the
 body were distorted at a very early period of life, and remained
 in that state,  it is said that we may be assured the pelvis par-
 takes of the disease, and is involved in its  consequences.   But,
 when the spine becomes distorted at a  more advanced period, as
 at twelve or fourteen  years of age, it is not to be esteemed a pre-
 sumptive sign of a distortion of the pelvis, being generally oc-
 casioned  by a local disease of the spine.  These observations
 are, 1 believe, commonly well-founded ;  but, as there are many
 exceptions,  we should not be justified in giving an opinion of a
 case of this  kind, unless we were permitted to make an examina-
 tion per vaginam.   Nor should we by this  examination, or by
 any external  mensuration,  be  able  to  determine  with precision
 the existence of every small distortion,  but such only as was con-
 siderable in  its degree.  If  we  should not be  able to feel any
 projection of the sacrum, or  vertebrae, we should have a right
 to conclude,  that there was no considerable deformity of the
 pelvis;  but if we could  feel the sacrum,  or vertebrae,  we must
judge  by the readiness with which they  can be felt, of the de-
 gree of distortion, and of the impediments which may be thereby
 occasioned.    But, in a matter which   may be  of so much  con-
 cern, it behoveth us to be extremely circumspect before  we give
 an  opinion,  lest, by our  error,  the  peace of families and the
 comfort of individuals should be destroyed.
  In some child-bearing women, having deformity of the pelvis,
 the deformity is found  to increase gradualy in every succeeding
 labour.*
  * [Rickets has been considered as a  species  of mollities ossium,
and similar causes have  been assigned for both diseases.  Of their
agency in  inducing such distortions of the  pelvis as  frequently to
render parturition difficult, if not impracticable, we have too many
proofs.  There are grounds  sufficient for a nosological distinction
of these disorders, and animal chemistry has recently added to our
means  of making a just discrimination.  Rickets is almost peculiar
to young children ; and the  period of its occurrence is generally
before  the end of the  second year.   When it attacks at a later
period, as  about the time of puberty, its effects are more especially
confined to the spine, and an incurvation of the vertebral column
is the result.   Rickets exists independent of scrofula, but is oftener
connected  with a  scrofulous habit than with  any other.    These
diseases,  nevertheless,  attack separately, and are not convertible
into  each  other.   Like  scrofula, rickets prevails most  frequently
in cold, variable, and  humid  climates,  as in Great  Britain and  in
Holland.   That rickets is often indebted for its origin to a deranged
state of the digestive organs cannot  be  questioned.  Among its pre-
disposing causes are to be  enumerated  the impure air of  crowded 
ON THE PELVIS.
95
 apartments, impoverished food, bad  nursing, and other sources of
 debility.   Like scrofula, rickets may  also be induced by the exces-
 sive indulgence which sometimes characterizes the upper  ranks of
 society.   Rickets  and scrofula  are rare  diseases in the  United
 States.
   In rickets there  appears to be a change both  in the physical  and
 chemical constitution  of the bones.   The morbid alteration  which
 is found in  rickety bones appears to  depend almost wholly  upon a
 deficiency in the quantity of the phosphate of lime : the bones, in
 their cancellated  part  more particularly, frequently become so
 soft  that they may be divided by a knife :  the medullary  cavity of
 the long bones contains only a reddish serum.   The teeth  appear
 slowly,  and soon  decay.   Instances  have occurred in which  the
 bony  part  of the  teeth  was soft.   Bichat says the  periosteum is
 thickened, and it is also generally stated that the extremities near the
 joints become enlarged :  but  both these  assertions are still contro-
 verted points.   The bones of the spine are considerably increased
 in thickness, and become spongy and reticular.  Mr. Stanley,  (in  the
 Medico-Chirurg. Trans, of London, vol. vii.) has shown, that in  the
 process by which ricketty bones acquire strength  and solidity, there
 is always  an undeviating regularity  in the  situation, extent,   and
 direction,  in which the  earthy matter  is deposited.   Thus it is
 obvious, says he,  that in  the curved  bone, the part  where there is
 the greatest need of strength, to prevent  its further yielding, is in
 the middle  of its cavity, or,  in other words, in the line of its inte-
 rior curve ; and it is just in this situation that strength and compact-
 ness  will be first  imparted to the bone  by the deposition of phos-
 phate of lime.   It will be further found, that the greatest resistance
 being wanted  at  this part, the walls  are accordingly rendered
 thicker here than elsewhere, and the degree to which this excess in
 thickness is carried, bears an exact ratio to the degree of curvature
 which the bone has undergone.  From some late pathological investi-
 gations, it would seem  that there is no  deticiency of the phosphate of
 lime  in the constitutions of ricketty peVsons so far as can be  ascer-
 tained from the blood : the urine of such persons is often found to be
 freely saturated with the earthy material, and they often suffer from
 bony deposits in parts where nature  never  intended such deposits.
 Hence the opinion  that the bones in rickets only change their shape
 gradually ; that the arteries of the bones of individuals of a  ricketty
 constitution are deficient in the power of separating the phosphate of
 lime from the  blood so as to deposit it in proper  quantity for their
 support, and that there is actually no  deficiency of this material in
 the body itself.
  Mollities ossium is a  very rare disease, and its subjects are  persons
 of middle age, or more commonly in advanced life.  It does not ap-
 pear to be so frequently connected  with  a scrofulous habit  of body
 as rickets ; and, perhaps, upon further inquiry, it may be found to
occur under a greater  variety of circumstances of living and  occupa-
tion.   The natural  solidity of the  bones is destroyed by an inordi-
nate absorption of  their earthy constituent; but more frequently 
96
INTRODUCTION TO MIDWIFERY.
both the animal and earthy matter seem absorbed until mere shells
are formed,  which  too  are also softer th.m natural  bones of  the
same  thickness.   Occasionally large cavities are met with in  the
substance of the bones ;  in which are often contained an oily sub-
stance somewhat similar  to marrow, sometimes masses  of coagulated
blood, or a soft and partially  organized animal  matter.   There is
a  considerable difference in the  degrees of softness  in the bones
in  different  patients.    In  the  Medico-Chirurgical  Transactions
(vol.  4.) Dr. Bosfock  has  given  us  an  analysis  of the bones of the
spine  in  a case of  mollities ossium.   His experiments were made
on a dorsal vertebra of an adult female whose bones were found after
death   to be  universally soft and  flexible.   He ascertained  that in
one part of the vertebra the quantity of earthy matter amounted to
only one fifth of its weight, and  in another only  to an eighth  part
of its weight ; whereas in  healthy bone it  amounts to  more than
one half the weight.
   The causes of this disease are  not known : the life of temper-
ance as well as of  inebriety may be  shortened  by  it;  though we
have  reason to believe  a  scrofulous habit  irregularities in living,
abuse of mercury, &c.  increases the  tendency to it.  In  the famous
case of Madame Supiot, the immoderate use of salt, which  the patient
had been in the habit of eating, was assigned as the  cause of  tne
disease ; yet  we have never been told  that  sailors and others who
have been confined to  salted provisions for a long while have been
afflicted with  mollities ossium.
   The mollities ossium is not only capricious as to the  time of  life
at which it appears, but varies much as to the rapidity of its progress.
Sometimes it takes  years fully to develop itself, and, in other instan-
ces, its celerity is almost incredible.
   1 witnessed a case of this disease  in  the  summer of  1812 :   the
patient  had previously enjoyed good health ;  his habits of living
were temperate, his age fifty-nine years ; the affection first manifested
itself in the tibia of both legs, and after seven years gradual increase,
the inferior extremities were so gibbous that his natural stature was
diminished about eight  inches : he finally lost his ability of  walking,
and died of constitutional irritation three  years ago : no cause could
be assigned for the  production of the disorder: he was  of  a gouty
diathesis.
   An  instance  of mollities ossium occurred in the practice of Dr.
Post,  in May,  1807, remarkable  for the  rapidity with which  the
bone became softened.   The patient was nearly fifty  years of age :
he had been  in an   impaired state of health  for a considerable time,
arising from the abuse  of  remedies  in  the  treatment of  syphilis.
He had  not  recently  taken mercury.   Three  weeks before  the
softening  of  the bone, his thigh became the  seat of  pain, yet he
took much exercise on foot.  On the evening in which  he sent for
medical attendance, he was walking about  his room, when he  was
suddenly seized with excruciating pain  in the right thigh, and went
to bed.  In the course of the night it was discovered that the thigh
was considerably bent, and in the morning it was bent almost to a 
ON THE PELVIS.
97
right angle ; the limb was so flexible that it could be moved in any
direction with the greatest ease : owing to the contractile power of
the  muscles  and the loss of bone, the thigh could not be kept in a
strait position, though the most attentive application of splints and
bandages was made.   Besides the loss of stability in the thigh, the
whole limb became  oedematous, and  its size  greatly increased: he
died  in the  following January.   The other bones were  exempt
from the affection.   On cutting into the thigh after death, says Dr.
Post, it seemed little more than  a dense gelatinous mass, and  there
was scarcely any vestige  of  the  thigh bone  to  be found :  though
small spiculae of bony matter were to be felt, indicating some dis-
position to the reproduction  of bone.   See New-York Medical Ma-
gazine, vol. 1.
  In a subsequent note, other circumstances will be  mentioned, the
effects of  which are sometimes  equally serious,  as diseases or dis-
tortions of the pelvis, in causing difficult or impracticable labours.
  In a specimen of diseased bone now  before  me, there are pecu-
liarities sufficiently  novel and important to be  taken notice  of  in
this place  as an occurrence which might render parturition fatal.
This is a case of morbid change in the form and  cavity of the pelvis.
The patient, an adult subject, fell on the right hip ; the injury done
the  external  parts was comparatively  slight;  but an inffammatory
action took place in  the bottom of the acetabulum, which caused a
total absorption of the bone,  and the protrusion  of the head of the
thigh bone itself into the cavity of the pelvis.  Nor was  the diseas-
ed action limited to these  changes ; large deposits of osseous matter
were made within the pelvis surrounding the  absorbed acetabulum,
and the head of the thigh bone was by  the same  material augmented
to more than double its original size.   The neck of the bone, and
also both  trochanters, are considerably increased in bulk.   The
capacity of the pelvis is diminished about two inches in  its superior
and lateral portion.  This specimen of change from natural struc-
ture may  also be adduced as an instance  of displacement of bone
without fracture or dislocation.   It belongs to the Morbid Collection
of  Dr. Hosack.   F.]
13 
98
INTRODUCTION TO  MIDWIFERY.
                      CHAPTER II.

                         SECTION I.

          ON THE EXTERNAL PARTS OF GENERATION.

  The preceding account of the pelvis appearing sufficient to
serve  all the useful purposes of the practice of midwifery, we
shall in  the next place consider the parts of generation, which
have been properly divided into external and internal.
  The external parts are the mons veneris, the labia,  the peri-
naeum, the clitoris, and the nymphae, to which may be added the
meatus urinarius, and the orifice of the urethra.   The  hymen
may be esteemed the barrier between  the external and internal
parts.
  That soft fatty prominence which is situated upon the ossa pu-
bis, extending towards the groins and abdomen, is called mons
veneris.   Its use seems to be chiefly that of preventing inconve-
nience or injury in the act of coition.   If a line be drawn across
the anterior angle of the pudendum, all that part above it, which
is covered with hair, may be called mons veneris; below it the
labia commence, which  being of a similar though looser texture,
appear like continuations of the mons veneris, expanding in the
middle,  and passing on each side of the pudendum, which  they
chiefly compose.   Proceeding downwards  and backwards, the
labia again unite, and the perinaeum is formed.
   All that space between the posterior angle of the pudendum
and the anus is called the perinaeum,  the  external covering of
which is the skin, as the vagina is the internal; including be-
tween them cellular and adipose membrane, and  the lower part
of the sphincter ani.  The extent of the perinaeum is  generally
about an inch and a half, though in some subjects it is  not more
than  one, and in others is equal to three inches.  The thin ante-
rior edge is called the fraenum labiorum.
   Below the anterior angle of the pudendum the clitoris is placed,
which rises by two crura, or branches,  from the upper part of the
rami of  the ischia.   The external part, or extremity of the clito-
ris is called the glans, which has a prepuce or  thin covering, to
which the nymphae are subjoined.  The clitoris is supposed to be
a principal  seat of pleasure, and to be  capable of some degree of
erection in the act of coition.
   The nymphas are two small  spongy bodies, or doublings of
the skin, rising from the extremities of  the prepuce of the clitoris,
less in  size, and of a more delicate texture,  but resembling in 
EXTERNAL PARTS OF GENERATION.         99
their form the labia.   They pass on each side of the pudendum,
within the labia, to about half its length, when they are gradually
diminished till they disappear.
  Immediately below the inferior edge of the  symphysis of the
ossa pubis, between the nymphae, is the meatus urinarius, or ter-
mination of the urethra, which is about one inch  and a half in
length, and runs to the bladder in a straight direction along the
internal surface of the symphisis,  to which, and to the vagina, it
is connected by cellular membranes.  On each side of the mea-
tus, and on the whole  internal surface of the pudendum, are small
orifices, which discharge a mucus, that, among other purposes,
answers the end of preserving the external parts from any injury,
to which they  might be liable from the acrimony of the urine.
  There is a very  great difference in the appearance and size of
all these parts  in different women, especially in those who have
had many children, and at various periods of life.  In young wo-
men they are firm  and vegete,  but in the old, these, together with
the internal parts,  become flaccid and withered.*

                         SECTION II.
  The external parts of generation are subject to many  diseases
in common with other parts of the body.   They are  also exposed
to some peculiar complaints, and to accidents at the time of par-
turition, of which we  ought to be well informed, that we may by
our care prevent them, or give such relief as  may  be required
when they  have unavoidably happened.
  The labia and nymphae, as might be expected from their fatty
and cellular texture, are liable to elongation, to excrescences, and
to  the production of scirrhous tumours;  which in  some instances
have  grown to an enormous  size,  especially  in  hot climates.f
For preserving all these parts  in a healthy state, nothing is more
beneficial than the daily and liberal use of cold water.
  It is not unusual, and perhaps  not unnatural,  for one of the
labia? or of the nymphae to be somewhat larger and more pen-
dulous than the other; but neither the enlargement,  nor elonga-
tion,  is to  be regarded  as  a disease, till some inconvenience is
produced by it.  The same observation may be made of excres-
cences or scirrhous tumours, which are therefore generally found
to  have acquired a considerable size before they are  divulged by
the patient.
  In all the subordinate degrees of these complaints, when there
  * Partes genitales, cum earum nullus estusus, marcescunt, detar-
huntur, ac veluti obliterantur.   Harv.
  t Nympha? aliquando cnormes sunt4, quare Coptae et Mauri eas
circumcidunt.  Holler. Physiolog 
100         INTRODUCTION  TO  MIDWIFERY.

is reason to think that they arise from some constitutional cause.
relief may be given by such medicines or treatment, as will alter
and amend the general health.  Or if  they  be owing to any
specific cause, as the venereal disease, of which  excrescences in
particular are  a  very frequent consequence,  preparations  of
quicksilver are to be used or given, till  we are certain  that the
constitution  is freed from the infection.   Applications suitable
to the  state  they are in, are at the  same time necessary; and of
these there will be occasion to  use a variety, from the most emol-
lient and  soothing, which may be proper when  the  parts are
in a  very irritable and  inflamed  state,  to  those  which  have
different  degrees of escharotic qualities, when we presume  there
is a chance of removing the excrescences  by such means.  But
when complaints of this kind  have been  of long  continuance,
or when the parts have increased to such a size as to  hinder the
common offices  of life, there is but little reason to  hope for then-
removal by  any application or medicines, and the diseased part
must be extirpated  witbj the  knife;  which  operation  may  be
performed with safety,  and the fairest prospect of success.   As
the  blood-vessels  are  few, and naturally small in proportion to
the size of the parts, there is not much danger of a hemorrhage,
though, in some cases, this is  said to have been  alarming and
extremely difficult to manage.*   But  I  have more than once
seen both  the enlarged nymphae,  and several  excrescences of
considerable size growing upon them, removed  by the knife at
the same time, yet the  surgeon has  not  been  under the necessity
of tying a single blood-vessel.

                         SECTION III.
   Edemafose swellings of the external parts may occur, either
in a general anasarcous state of the'whole body,  or  when any
cause  produces  a temporary pressure upon those vessels which
are intended to  conduct the returning  fluids from  the  inferior
extremities :  particularly the enlarged  uterus,  in  the  advanced
state of pregnancy.  Whatever may be the cause of these swell-
ings, if they should increase so as to become troublesome, the
method of giving relief is obvious and  easy, as it consists only
in making some very slight scarifications in different parts of the
labia, by which  the stagnating fluids will be discharged, and the
 labia reduced to their  natural size.   It is not unusual for  these
 swellings to return two or three times towards the conclusion  of
 pregnancy; in  which case, or even  in the  time of labour, the
 scarifications, if necessary, may be repeated.  A flannel wrung
 out of some emollient  fomentation, and  applied to  the parts when
* See Mauriceau, Vol. ii. Obs. clxxiv. 
EXTERNAL PARTS OF  GENERATION.         101
they have been scarified, will contribute to the easy and perfect
discharge of the fluids, and after delivery the complaint will not
return.
                         SECTION IV.
  The cohesion of the labia to each  other has been  mentioned
as a  disease occurring to  adult women, especially  in  hot cli-
mates, if inflammation, preventing the due secretion  of- the  mu-
cus with which these parts are naturally clothed on their internal
surface,  should  take place; or if they should be excoriated by
any accidental  cause, and neglected  in  that  state.   The labia
will also very frequently cohere  in children,  in such  a  manner
as to  leave no vestige of a passage into the vagina, except at the
anterior  part, for  the  discharge of the urine; and lead us, by
the general appearance, to apprehend a defect in  the  organiza-
tion of the parts.  In such cases, we  have been directed to sepa-
rate them with a knife; and how far such an  operation may be
necessary in the adult, if the parts should cohere, either in con-
sequence of some  new affection, or if a cohesion originating in
infancy should continue  to adult age, must depend upon  the
judgment of the surgeon.   But in infants such  an operation is
neither requisite nor proper; because a  separation may always
be made, by a firm and somewhat distracting pressure upon each
labium at the same time, which  scarcely  makes the child com-
plain; though the small vessels, which had inosculated  from  one
labium to the other, may be perceived to  be dragged out during
the continuance of the pressure.  When  a separation of the co-
hering labia has been  made in the manner before mentioned, a
folded piece of linen, moistened in a very weak  solution of the
zincum vitriolatum, or some lightly astringent liquor, should be
applied every night when the child is put to rest, to prevent the
reunion, to which there  is a great disposition; and which  will
certainly take place, if the labia be suffered to remain in contact
immediately after  the separation.*
   It is extraordinary that so little notice  should have been taken
of a complaint  which  is  very frequent in children ;  but it  is
probable that the  constant and free use of their limbs, when they
begin to walk, causes a separation without any other assistance,
otherwise the cohesion must frequently have occurred in adults,
in whom the case  is very rare.   But on this expected  probable
  * [Notwithstanding the injunction in the text, it will frequently be
necessary to have recourse to the knife in order to divide the cohe-
sion of the labia, even in  infants of the earliest age : with proper
care, no evil can arise from this practice.  The means recommend-
ed by the author to prevent a reunion, must in all cases be  ob-
served.   F.j 
102         INTRODUCTION TO MIDWIFERY.
separation we should be afraid to rely, when we are assured that
the complaint does actually exist.

                         SECTION  v.
  In  consequence  of  violent inflammation from accidental or
other causes, either of the labia may  become tumified, and a large
abscess has  been afterwards  formed.  This  is  attended  with
extreme pain, the desire of relieving which has induced surgeons
to open the  abscess, and  give vent to the matter as soon as it
could be perceived to fluctuate.   But though the pain may, for
the  present,  be abated by  the early  discharge of  the matter, the
part continues indurated, is indisposed to  heal, and not unfre-
quently becomes fistulous.   But if the  abscess  be suffered to
break  of its own accord, the part  will have the kindest tenden-
cy to heal, and, with common care, the cure be soon perfected.*
Should the  pain  be extreme  during   the suppuration, which is
often the case, beside  the use of fomentations and cataplasms,
recourse  must be had  to  opiates for   its abatement   There is
never  any reason to attribute this complaint to  any venereal
affection, though  it is often suspected.   Scirrhous tumours of the
labia may be extirpated with full as much ease as those of any
other part of the  body.

                         SECTION VI.
  Though the perinaeum  is not often  affected with any particu-
lar  disease, it is subject to a laceration  from the distensiou which
it undergoes, when the head of the child is  passing through the
external parts.  This laceration, which is most likely to happen
with first children, though with rude treatment, hurry, or neglect,
either on  the part of the  patient or practitioner, it may occur
with subsequent  ones, especially in those women who have the
perinaeum naturally short, differs  in direction and extent, and
may be in every degree,  from the fraenum, or edge of the peri-
naeum, to the extremity of  the sphincter ani, or  even  higher up
into the rectum.
  That some degree of laceration  should sometimes occur will
not be surprising, if we consider the great chanue  and violence
which  all these parts sustain, at the time when the  head of the
child is passing through them ; or that when a laceration begins,
  * [Abscesses of the labia may be opened with the same propriety
as collections of matter  in  other parts.  The author's arguments
against this practice, however plausible, have no  better foundation
than those of Mr. Ford and other writers, in cases where purulent
formations occur in the  mammae or in the groin.  Our great cau-
tion ought to be not to open them prematurely.   F.] 
EXTERNAL TARTS OF GENERATION.        103
it should extend through a part rendered at that time extremely
thin, and suffering an  equal degree of force.  When the  peri-
naeum is indisposed to distend ; or  if, when distended, it cannot
permit the  head of the child to pass with facility,  the  anterior
part of  the rectum is dragged out, and  gives to the perinaeum a
temporary elongation.   The true perinaeum, and the temporary,
as it may be called, thus forming an equal, uninterrupted space,
if  a laceration should commence at  any part, it  might without
the greatest care extend through the whole.   Of the method  by
which the  laceration  may  be  prevented, and of the treatment
which may be  proper when it  has occurred, we shall speak in
other places.   At  present we shall inquire into the causes of an
accident, the  prevention of which is the principal object of our
attention in natural labours.
  Though no means are used to prevent the laceration of the
perinaeum in quadrupeds at the time of parturition, it is remarka-
ble that they are very rarely or never liable to it, except in  those
cases in which the necessity of their situation is supposed to re-
quire assistance; and this being given with ignorance and violence,
(two very familiar companions,) may not improperly be esteemed
the cause of the accident.  It is therefore reasonable to  presume
that the frequent occurrence of this laceration in the human spe-
cies,  allowing that  it  is  in  some  cases and in some degree
unavoidable, ought to be imputed to some accidental  cause,  or to
error in conduct, rather than to any peculiarity in the construc-
tion of the part, or  in  the  circumstances of their  parturition ;
because when women were delivered without assistance, I  have
not  in any case observed  any very considerable laceration.  I
believe  no observation is more generally true, than that of  the
existence of a  power in the structure and constitution of every
animal, by which evils are prevented or remedied, and by which
the greater part of the difficulties occurring at the  time of  their
parturition are overcome ;  which power, combined with sympa-
thetic  or corresponding  actions of other  parts, is  commonly
exerted  with a degree of energy and effect proportionate to the
difficulty.
  The causes disposing to, and capable of, producing a lacera-
tion of  the perinaeum seem to be these :
  First, the increased tenderness and delicacy of the skin, occa-
sioned  by peculiar habits or modes of living.  That this and
every other part of the  body may, by alteration from its natural
state, become  more susceptible of pain,  and less able to  bear
violence of any kind, is clearly proved by the different degrees
of those properties in parts of the body which are usually clothed
or uncovered.
   Secondly,  the position  of women at the time of delivery.
Women in this country, at the present  time, are placed in bed 
104         INTRODUCTION TO MIDWIFERY.
upon their left side, with their knees drawn up toward the abdo-
men : which position, though convenient to the attendant, seems
to occasion a projection of the part of the child, which presents
in a line unfavourable to  the perinaeum.   But if they were to
be placed  upon their  knees, and leaning  forwards,  which is  a
position at that  time perhaps the  most natural, as it is often in-
stinctively  sought for, and in some countries chosen in cases of
difficulty and distress; then the head or part presenting would,
by its line of gravitation, lessen the pressure upon the perinaeum,
and of course, the hazard of its laceration.
  Thirdly,  the  disturbance  of the order  of a labour.   Every
change which is made in the parts, both   external and internal,
at the time of labour, is  successive,  and   every  pain seems  to
produce two effects ; it dilates one part, and  gives to some other
part a disposition to be dilated.   If,  therefore, by hurry  or im-
prudent management, the head of the child, in its passage through
the pelvis, be brought into contact with  parts which have  not
yet acquired their disposition to dilate; or  if, by artificial dilata-
tion, we  attempt to supply the want of the natural, the parts
will sooner be lacerated than distended.
  Fourthly,  when animals bring forth their  young, the effort to
expel is instinctive, no part  of the force exerted appearing to be
voluntary.   Women,  on  the contrary,  either  from  erroneous
opinions, or from false instructions, exert a considerable degree
of voluntary force,  often indeed  their whole strength, with the
hope and intention of finishing their  labour  speedily.  Now,  if
we suppose that the perinaeum is able to bear all the force in-
stinctively exerted,  without  injury, but  no  greater,  then  the
whole voluntary force will, in proportion to its degree, induce the
danger of a laceration, unless its effect be counteracted by some
adventitious  help.   On this  principle it is usual  to support the
perinaeum, according  to the  exigence of the case, not with the
view  of altering the  direction  of the  head of the child,  but
simply of retarding its passage through the external parts.   For
the perinaeum is not torn because the head of the child is large,
or passes in any particular direction, but  because it passes  too
speedily, or presses too violently upon the parts, before they have
acquired their  proper dilatability; it therefore rarely happens,
that the perinaeum is lacerated in  very slow  or difficult labours,
whatever may be the size or position of the  head  of the child.
Without some precaution, the perinaeum may be lacerated by the
shoulders  or breech of the  child, or by  the rude  hand of an
operator.

                        SECTION VII.
  That kind of laceration of the perinaeum, which commences at
the anterior edge, and runs obliquely or directly backwards, is 
EXTERNAL PARTS OF GENERATION.         105
alluded to in every dissertation  upon  this subject.   But  there
have  been many instances of another kind of laceration, which
may be called a  bursting or perforation of the perinaeum, at that
part which is connected with the circumference of the anus, when
the anterior part is preserved; and through such perforation it
is said children have sometimes been expelled.   There is in some
French writer, whose name I cannot  recollect,* an account of a
case of this  kind, in which the head and body of the child were
excluded  through  an  opening in the perinaeum thus casually
made, in  which the  fraenum of the  perinasum was  preserved
entire.  Nor does the  common  laceration  of the  perinasum
always commence at the  fraenum, even in instrumental delive-
ries, but further  back, and then usually bears down before it all
the anterior  part.
   In  a case which occurred in my own practice, I  was sensible
of this kind of laceration before the expulsion  of the  head,
which I  guided  through the natural passage,  supplying  the
want  of the perinaeum with the  palm of my  hand.  The exter-
nal parts  were  in  this  patient extremely rigid  and contracted;
and,  as I  applied  myself with great assiduity to preserve them,
at the anterior  part of  the perinaeum,  I imputed the accident to
this circumstance rather than to the necessity of the case.  The
patient did  not  make any unusual complaint immediately after
delivery;  but, on  the following  day, there was a violent inflam-
mation of the parts, with a suppression of urine, and the lochia
were  discharged through  the ruptured parts, but no foeces  ever
came through it, or by  the vagina.  By the use of fomentations
and cataplasms,  of cooling laxative medicines, and occasionally
of opiates, the inflammation was soon abated.  The suppuration
being profuse, the  bark was given ; and, at the end  of ten weeks,
the lacerated parts were healed.  No  particular examination
was ever  made during the cure,  and none but superficial dress-
ings  applied.   When I attended  this  patient  with her second
child, I observed a large round  cicatrice  at  the rugous part of
the anus,  but she  then scarcely suffered any  inconvenience from
it; and recovered  as well as if  no sucl|, accident had formerly
happened.  Of  this kind of  accident another case has lately
been  communicated to  me,  which created  much  trouble  for a
considerable time  after  delivery, but  which at length terminated
without any permanent inconvenience.f
  * [Baudelocque and Sedillot have given us cases of this kind.  F.]
  t [An instance of this sort of laceration of the perinaeum hap-
pened in this city iu the practice of a gentleman of much experi-
ence in midwifery.   Means  similar to those adopted by  the author
were pursued, and with the like  result.   The  patient  afterwards
became  pregnant, but suffered no  inconvenience in  labour.  The
                              14 
106         INTRODUCTION TO MIDWIFERY.
                         SECTION VIII.
  The  clitoris is little concerned in the practice  of midwifery,
on account of its size and situation.   But it is said to have been
sometimes elongated and enlarged in such a manner as to equal
the size of the  penis,  when it makes one of those many pecu-
liarities which  have been supposed to constitute an hermaphro-
dite,* or an  animal partaking of the sexual  properties of the
male  and female;  but if there be any examples of true herma-
phrodites,f the term is in this case improperly used.J
  Should the clitoris,  from any cause, increase to  such a size as
to occasion  much  inconvenience, it  may be  extirpated  either
by the knife  or ligature;^ but  if the cause of the enlargement
which is commonly assigned, be true, it is not probable that any
difficulty of cure  in  laceration of the  perineum  is  proportion-
ed to the extent of the wound.  In cases  where the  rent passes
through the sphincter ani into the rectum, the mischief is serious,
and a cure  is scarcely ever accomplished.  F.]
  * Hermaphrodili veri non dantur.—Ruysch. Thes. viii.
  t [To the existence of androgyni   among the mammalia?,  (that
is, of animals capable of performing  the functions of both sexes,)
there is every reason for withholding our assent.  Such  productions
are  at  variance with the analogy of nature ;  and  the  cases  on
record of hermaphrodites  warrant the scepticism of the cautious
physiologist.   What is the determining cause of sex in animals is
beyond  the reach  of philosophy to ascertain ; but that such cause
operates to the evolution of one sex rather than that of the other,
and  that   exclusively,  best  comports   with  our  present  state
of knowledge.  It  is  the  opinion of  Sir Everard Home, that the
development of the sex takes  place subsequently to impregnation,
the  ovum  being originally formed equally fitted to  become either
male or female.
  The  most frequent instances which have been  given us of her-
maphrodites,  or of  those animals whose sexual  organs were so
entire, that they seemed to be capable of performing the generative
functions, have been  females, labouring under either an enlarged or
a defective state of thj^genital organs.   Preternatural enlargements
of the clitoris  have (been the  most common  source of erroneous
conclusions on this  subject.  The latest decisions in juridicial medi-
cine reject the possibility of the existence of both sexes in the
same individual of  the human species.   F.]
  X Clitoris major  in  fcetu  existit.—Ruysch.  Thes. vi. 1. 1. Cercosis.
Clitoris praelonga.  Vogel, cccccxxxv.
  § See  Bruce's Travels ; and Travels in Africa, Egypt, and Syria,
by G. W. Browne, in  which we are told that it is always extirpated
as a religious  ceremony ;  yet  of this there remains some doubt.
See, also, Sonnini,  chap. 23. 
EXTERNAL PARTS OF  GENERATION.
107
motive of delicacy or inconvenience will be a sufficient induce-
ment to suffer the pain of extirpation.*

                         SECTION IX.
  The bladder and urethra in women are naturally liable to fewer
diseases than  the  same parts in men,  the  former being more
short, in a straight direction, and their connexion far more sim-
ple ; their use being wholly confined to the reception and con-
veyance of the  urine.   Women have,  nevertheless,  a stone
sometimes  formed in  the  bladder;  and it has been  thought an
improvement in practice to evade the operation of  lithotomy, by
distending, with bougies  gradually enlarged, the urethra, till  it
is of sufficient dimensions to allow the stone to pass through it.
It is proved by experience, that  the urethra  will distend, or may
be  artificially distended,  sufficiently to allow a stone of a con-
siderable  size to pass, as  I  have known in many instances; but
if the  distention  be carried beyond a certain degree, it is  said
the  tone of the part will  be  destroyed, and the patient ever
remain subject to an involuntary discharge of urine, a greater
evil than any  of the common consequences  of lithotomy, which
is a far less complex and difficult operation in  women than in
men.
  From the cavity of the bladder, in the course of the urethra,
and about the meatus urinarius, excrescences of  various forms
and sizes  sometimes grow, which  produce  symptoms almost
equally troublesome, and  similar to those which are caused by
the  stone or  other diseases in the  bladder, for which  they are
often mistaken.   These may be extirpated by the knife, by liga-
ture, by caustic applications, or by  wearing bougies, according
to  their size,  or  the part where they grow, which  may  render
one method  more convenient or preferable  to the  rest.   But
these excrescences  when they arise in the urethra or bladder, are
sometimes  not to be removed without much difficulty and trou-
ble ; and as little violence as possible is to be used in the opera-
tion, when we attempt to  remove  them by ligature, otherwise
the  bladder might be inverted, or a profuse  hemorrhage occa-
sioned.
  I have lately seen an instance of a person dying in consequence
of  a number of small excrescences with which the  whole internal
surface of  the bladder was beset.
  * Qua? extra venerem, in casta femina,  parva fuerat, suo etiam
modo arrigit et intumescit, ut preposteras veneri servire possit, mul-
toque usu ejus  turpitudinis, denique moles ejus augetur.—Haller,
Physiolog. 
108
INTRODUCTION TO MIDWIFERY.
SECTION X.
   The pruritus,  itching, or stinging of the external  parts, is a
 complaint to which women  are liable at any period of life; but
 it is  most frequently attendant  on the state  of pregnancy, of
 which it is one of the most  troublesome  consequences.   If it
 affect the internal  parts, or be excessive in its degree, it is said
 to  terminate in the furor uterinus.  It is sometimes  occasioned
 by a disease  or affection of the bladder, and is then  equivalent
 to the itching of the glans penis in men ;  but it more  frequently
 proceeds  from some  affection of the uterus, having  been  most
 frequently observed to occur in  pregnancy, especially when the
 child  was dead, or about the time  of the final cessation  of the
 menses,  when  there  was a  disposition  to disease  in the uterus.
 The instances  of this pruritus either proceeding or accompany-
 ing truly  cancerous dispositions of the uterus are very rare.
   The  means  used for  the relief of the  patient must depend
 upon  the seat, the cause, and the degree of the complaint.  When
 it happens during pregnancy, and at all other  times, if attended
 with inflammation, it is necessary to bleed; to  give gentle laxa-
 tive medicines; and  to use sedative applications,  of which per-
 haps the best is a weak solution of cerussa acetata  as a lotion;
 or a decortion  of poppy he ids, with a small quantity  of cerussa
 acetata dissolved in it, as a  fomentation.  But of all the appli-
 cations 1 have seen used, none has more generally afforded relief
 than cold water very frequently or constantly applied with  a
 sponge, and  occasionally made colder  with the addition of ice,
 or a little vinegar and spirit of wine.   More active applications
 are often  prescribed ;  but I have suspected that these, in many
 cases,  rather aggravate  than lessen the complaint, though  such
 benefit is  sometimes derived from washing the parts with water
 moderately acidulated with  the nitric acid : or the application of
 one part of the  unguentum hydrargyri muriati, and three parts of
 the unguenXum cerussae acetatae.  If the patient be pregnant, the
 attempt to' cure it will often be vain, and we must be satisfied with
 moderating it till she is delivered,  when it  will generally cease
spontaneously.*  When  this complaint, independently of preg-
nancy, originates from an affection of the uterus, and  is of  long
continuance,  the applications must be varied, and such medicines
given  as promise relief by changing the state of that part.   Sul-
    [I am inclined to think that furor uterinus, though frequently
connected with  pruritus,  in most  cases  depends  upon  some
other cause for its origin.  In that very troublesome affection, pru-
ritus  the propriety of blood letting cannot be  too  strongly en-
forced.  F.J                                           °J 
EXTERNAL PARTS OF GENERATION.
109
 phur, taken internally, has sometimes been of much service; or
 applied to the part as a powder, liniment, or lotion.  The burnt
 sponge with nitre, and the extractum cicutae have also been given
 with  advantage; together with a  lotion composed of  equal
 parts of the aqua zinci vitriolati cum camphora and rose water;
 or the application of the unguent, hydrargyr. fort.  I have also
 frequently given five  grains  of Plummer's  pill every night at
 bed-time for a month, and  a pint of the decoction of sarsaparilla
 daily; though there was no suspicion of any venereal infection,
 of which the itching is, I believe, a very unusual symptom.  But
 when this complaint has  been occasioned  by an affection of the
 bladder, the constant or daily use of a bougie in the urethra has
 in some cases effectually cured the patient.

                          SECTION  XI.
  The hymen is a thin membrane of a  semi-lunar, or circular
 form,  placed at the entrance of the vagina, which it in great
 part closes.  It has  a very different appearance in different  wo-
 men, but it is generally, if not always.* found in virgins, and is
 very properly esteemed the test  of virginity, being ruptured in
 the first act  of coition; and the remnants of the  hymen are
 called  the carunculae myrtiformes.f   The hymen is also  pecu-
 liar to  the human  species;  from which a moral writer might
 draw  inferences  favourable  to the estimation  of chastity  in
 women.
  There are two circumstances relating to the hymen which
 require medical  assistance.  It is sometimes of such a strong
 ligamentous texture, that  it  cannot  be ruptured, and prevents
 the connexion between the sexes.  It is also sometimes imperfo-
 rated, wholly closing the entrance into  the vagina, and prevent-
 ing any discharge  from the  uterus;  but both  these cases are
 extremely rare.
  If the hymen  be of an  unnaturally firm  texture,  but perfo-
 rated, though  perhaps with a very small  opening, the inconve-
niences thence arising will not be discovered before the time of
marriage,   when  they  may be  removed  by a  crucial  incision
made  through it, taking care  not to  injure the  adjoining parts,
 and to prevent their reunion.
  But the  imperforation of the hymen  will produce  its incon-
  * Membrana hymen, qua? utrum detur, necne sub judice  lis olim
fuit hoc autem tempore in anatomia magis versatis nihil notitus esse
potest.—Ruysch. Thes. iii.  No. xv.
  | Hymenis dissoluti reliqua?, et corruptae adeo pudicitiae indicia.—
Holler, Physiolog. 
no
INTRODUCTION TO MIDWIFERY.
veniences, when  the  person begins to menstruate.*  For, the
menstruous blood being secreted from the uterus at each  period,
and not evacuated, the patient  suffers  much pain  from the dis-
tention of the parts; many strange symptoms and appearances
are occasioned, and suspicions injurious to her reputation  are
often  entertained.  In a case of this kind, for which I was con-
sulted, the young woman,  who was twenty-two  years  of age,
having many uterine complaints, with the abdomen considerably
enlarged,  was suspected to be pregnant, though she persevered
in asserting the contrary, and  had never  menstruated.   Wiien
she was prevailed upon to submit to an  examination, the circum-
scribed tumour  of the uterus, was found to reach as high as the
navel,  and the  external parts  were stretched by a round  soft
substance at the entrance of the vagina, in such a manner as to
resemble that appearance  which they have when  the head of a
child is passing through them;  but there was no  entrance into
the vagina.  On  the following morning an  incision was care-
fully made through the hymen,  which had a fleshy appearance,
and  was  thickened  in  proportion to  its distension.   Not  less
than four pounds  of blood, of the  colour and consistence of tar,
were discharged;  and the  tumefaction  of the  abdomen was im-
mediately  removed.   Several stellated incisions were  afterwards
made through the divided  edges, which is a very necessary part
of the operation; and care  was taken to  prevent  a reunion of
the hymen till the next period  of menstruation, after which she
suffered no inconvenience.   The blood discharged was  not pu-
trid nor coagulated, and  seemed  to have undergone no other
change, after its secretion, but what was occasioned  by  the ab-
sorption of its more fluid parts.  Some caution is required when
the hymen is closed  in those who are in an advanced age, unless
the membrane be distended by the confined  menses, as I once
saw an instance of inflammation of the peritonaeum being im-
mediately  produced  after  the  operation, of which the  patient
died as in the  true  puerperal fever, and no  other reason could
be assigned for the disease.
   The carunculas myrtiformes by  their elongation and enlarge-
ment sometimes become very painful and  troublesome.  Under
such  circumstances   they require  the  same management,  and
admit of extirpation in the same manner as  the  diseased nym-
phae.f
  * Menses a membrana vulvam claudente suppressi, perque hujus
incisionem evacuati.—Ruysch. Obs. xxxii. and all the older writers.
  t [The practical precepts of this section are altogether worthy of
the auUor: his physiological speculations admit of emendation___The
very existence of the hymen has been denied by the highest names 
EXTERNAL PARTS OF GENERATION.
Ill
in science, as Fallopius, Vesalius,  Dionis, De Graaf, and Buffon:
but the current of authority is evidently in favour of its reality, and
the most  distinguished medical  jurists  have  very  generally ap-
pealed to it as a natural production.  It is not certain that the hymen
is peculiar to the  female  of the human  species.  Cuvier,  in his
Comparative Anatomy, has ventured to declare its existence, with
some  reserve, in most of the mammalia.
  As a test of virginity, the presence of the hymen is not decisive.
Gavard  gives  us the case of a girl  aged  thirteen years, who was
affected with the venereal disease,  and yet retained  this supposed
mark  of virginity.   Mauriceau  and Ruysch state many cases of
pregnant women in  whom  this  membrane was entire :  the latter
author thinks that immediately after menstruation, the hymen may,
in some cases,  yield to coition  without rupturing.   He  was in at-
tendance on  a  female  in  whom the  operation of incision of the
hymen was performed  in order to accomplish  the delivery of the
child.  Baudelocque was about to perform  the same operation under
similar circumstances, when the head of the child effected a passage
through without assistance.  Winslow was of opinion that the hymen
existed in children, but disappeared  of itself in after life.  Pare and
Laurens considered  it, when present, as an unnatural  production or
monstrosity   Dr. Hunter found  teeth,  bones, hair, and other une-
quivocal marks of a foetus, in  the ovary of a  woman  who had her
hymen entire.
  Nor does the  want of the  hymen  fix the charge  of criminality
upon  the unmarried female.  Many causes may concur to destroy
the " slight outward curtain to the  nuptial bed."  It  may be com-
pelled to yield by the first  efforts ©f menstruation,  by ulceration,
by the irritation accompanying  leticorrhcea,  by vicious practices,
or by accidental injury.   Tolberg, who found  leisure  to write a vo-
lume on the varieties of the hymen, is quoted as having witnessed
an instance of one resembling in its natural formation  the carunculae
myrtiformes.   The  faculty of Leipsic have declared that the hymen
entire can be deemed only a probable evidence of virginity : it may
be safely asserted that this  membrane is frequently wanting in the
natural and healthy  state of the parts.  F.] 
112         INTRODUCTION TO MIDWIFERY.
                      CHAPTER III.

                         SECTION I.

         ON  THE  INTERNAL PARTS  OF GENERATION.

  The internal parts of generation  are the vagina,  the  uterus,
the  fallopian  tubes, and the  ovaria.  The ligaments  may be es-
teemed appendages to the uterus.
  That canal which leads from the  pudendum or external ori-
fice, to the uterus, is called the vagina.  It is somewhat  of a
conical  form,  with   the narrowest  part downwards,  and   is
described as  being five or six inches in length, and  about two
in diameter.   But it would be more  proper  to say, that it  is
capable of being extended to these or even greater dimensions;
for in its common state, the os uteri is seldom found to be more
than three  inches  from the  external orifice, and  the vagina  is
contracted  as well  as shortened.
  The vagina is composed  of two coats, the first  or innermost
of which is villous, interspersed  with many excretory ducts, and
contracted  into plicae,  or small transverse  folds, particularly at
the  fore and  back  part;  but by frequent child-bearing these are
lessened or obliterated.   The second coat is composed of a firm
membrane, in which muscular fibres are not distinctly observa-
ble, but which  is endowed to a certain degree  with  contractile
powers  like  a muscle.   This is surrounded by cellular mem-
brane, which connects it to the neigbouring parts.   A  portion
of the upper and posterior part of the vagina is also  covered by
the peritonaeum.
  The entrance of the vagina is constricted by muscular fibres,
originating from the rami of the ossa pubis, which run on  each
side of the pudendum, surrounding  the posterior part, and exe-
cuting an equivalent office,  though they cannot be said  to form
a true sphincter.
  The  upper part of the vagina  is connected to  the circumfe-
rence of the  os uteri,  but not in a straight line,  so as to render
the  cavity of the uterus a continuation of that of  the  vagina.
For the latter stretches beyond  the former, and being joined  to
the cervix, is reflected over  the os uteri;  which, by this mode  of
union,  is  suspended  with protuberant lips in  the vagina, and
permitted to change its position in various ways and directions.
When,  therefore,  these parts are distended and  unfolded at the
time of labour, they are continued into each other, and  there is 
INTERNAL PARTS  OF GENERATION.         113
no part which can properly be considered  as the precise begin-
ing of the uterus, or termination of the vagina.
  The  form of the uterus  resembles that  of an  oblong  pear,
flattened, with the depressed  sides placed toward the ossa  pubis
and sacrum ; but in the impregnated state it becomes more oval,
according to the degree of its distension.*
  For  the convenience  of description,  and for some practical
purposes, the uterus is distinguished into three parts; the fundus,
the body, and  the cervix.   The upper part is called the fundus,
the lower the cervix, and the space between them, the extent of
which is undefined, the body.  The uterus  is about three inches
in length, about two in breadth at the fundus and one at the cer-
vix.  Its thickness is different at the fundus  and  cervix, being at
the former usually rather less than half an inch,  and the latter
somewhat more; and this thickness is preserved throughout preg-
nancy, chiefly by the enlargement of the veins and lymphatics,
there being a smaller  change in the size of the arteries f  But
there is so great a variety in the size and dimensions of the
uterus in different women, independently of the states of virginity,
marriage, or pregnancy, as to prevent any very accurate men-
suration.
  The cavity of the uterus corresponds with the external form.
That of the  cervix leads  from the  os uteri,  where it is  very
small, in a straight direction, to the fundus,  where  it is expanded
into a triangular form,  with  two of the angles opposed to the
entrance into the fallopian  tubes;  and at  the place of junction
between the cervix and  the  body of the  uterus, the cavity is
smaller than it is in any other part.  There is a swell, or fulness,
of all the  parts, toward  the  cavity,  which is sometimes  distin-
guished by  a prominent line  running longitudinally through its
middle.
   The villous  coat of the vagina is reflected over the os uteri,
and is  continued into the  membrane which lines  the cavity of
the uterus.J  The internal surface  of the uterus is corrugated in
a beautiful manner,  but the rugae, which are longitudinal,  lessen
as they advance into the uterus, the fundus of which is  smooth.
In the intervals between the rugae  are small orifices, like those
in the vagina, which discharge a mucus, serving,  besides other
  * Facies uteri anterior planior est, convexior posterius ; latera
pene in aciem extenuata.—Roederer.
  | Pars  magna crassitici uteri ad venas pertinet.—Vesalius, and all
the older Writers.
  JPulposum magis quam vaginae velamentum  aliquoties reperi.—
Holler. Physiolog.
                              15  " 
114         INTRODUCTION  TO MIDWIFERY.
purposes, that of closing the os uteri very curiously and perfect-
ly during pregnancy.*
  The substancet of the uterus, which is very firm, is composed
of arteries, veins, lymphatics, nerves, and  muscular fibres, cu-
riously  interwoven  and  connected together by  cellular  mem-
brane.  The muscular  fibres are of a pale colour, and appear
also in their texture  somewhat different from muscular fibres in
other parts of the  body.  These are  seen most perfectly in a
uterus which has been parboiled.
   The arteries of the uterus are the spermatic and  hypogas-
tric.
   The spermatic arteries arise from the anterior part of the aorta,
a little below the emulgents, and sometimes from  the emulgents.
They pass over the psoae muscles, behind the peritonaeum,  enter
between the two laminae,  or duplicatures  of  the peritonaeum,
which form the broad  ligaments of the uterus, proceed to the
uterus,  near the fundus of which  they  insinuate themselves,
giving branches in their passage to  the  ovaria and  fallopian
tubes.
   The hypogastric  arteries  are on each side  a considerable
branch of the internal iliacs.  They pass to the sides of the body
of the uterus, sending oft" a number of smaller  branches, which
dip into its substance.   Some branches  also  are reflected up-
wards to the fundus uteri,  which  anastomose with the spermatic
arteries, and  others are  reflected downwards, supplying the
vagina.
   The veins  which  reconduct the  blood from  the uterus are
very numerous, and their size in the unimpregnated  is propor-
 tioned  to that of the arteries; but the enlargement during preg-
 nancy  is such, that  the orifices of some of them, when divided,
 will admit of the end of a small  finger.  The  veins anastomose
 in the manner of the arteries, which they  accompany out of the
 uterus; and then,  having the  same  names  with  the arteries.
 spermatic, and hypogastric, the former proceeds to  the vena cava
 on the right  side, and  on the  left to the emulgent vein ; and the
 latter to the internal iliacs.
    From   the  substance and  surfaces  of  the  uterus  an infinite
  number  of lymphatics arise, which  follow  the  course of the
  hypogastric and spermatic blood-vessels.  The first pass into the
  glands of the internal iliac plexus;  and the other into the glands
  which are situated near the origin of the spermatic arteries.  Of
  these Nuck first gave a delineation.
  * Adeo abundans ut totam cervicem repleat, et osculum quasi ob-
turet. Holler. Physiolog. and many of the older Writers.
   fin gravida femina in laminas possit dividi, et in morbisin lacinias,
squamasque.—Noortwych. Uter. Gravid} 1. I.e. 
INTERNAL PARTS OF GENERATION.         115
  The uterus is supplied with nerves from the lower mesocolic
plexus, and from  two  small flat circular ganglions, which are
situated  behind the rectum.  These ganglions are joined by a
number  of small  branches  from  the  third  and fourth  sacral
nerves.   The ovaria derive their nerves  from the renal plexus.
By the great number of nerves these parts  are rendered extreme-
ly irritable; but it is by those branches  which the  uterus re-
ceives from  the intercostal,  that the intimate consent between it
and various other  parts is chiefly preserved.
  The muscular fibres of the uterus  have been described in a
very different manner  by anatomists, some of whom have as-
serted, that its substance was chiefly muscular, with fibres run-
ning in transverse, orbicular, or reticulated order; whilst others
have contended, that there were no muscular fibres whatever in
the uterus.   In the unimpregnated uterus, when parboiled for
the purpose of a more  perfect examination, the former seems to
be  a true  representation;  and  when the uterus is distended
toward the latter part of pregnancy, these  fibres are very thinly
scattered ;  but  they may be discovered in a circular direction at
the junction between the body and the cervex of the  uterus, and
surrounding the entrance of each fallopian tube in a similar order.
Yet it does not seem reasonable to attribute  the extraordinary
action of the uterus at  the time of labour  to its muscular fibres
only, if we are to  judge of the power of  a muscle by the num-
ber of fibres of which it is composed,  unless it is presumed, that
those of  the uterus are stronger than in common muscles.*
  * [The muscularity of the uterus is still one  of the vexed ques-
tions in anatomy.  Admitting that the muscular fibres of this organ
are not distinctly visible, yet the offices it is called upon to perform
are so  nearly allied to those which are peculiar to muscles, that this
analogy alone would lead us to concur in opinion with the author in
favour  of its muscular structure.  Blumenbach is the most eminent
of the  writers on  physiology  who  denies the  muscularity of the
uterus  :?He  asserts, that he never yet discovered a true muscular
fibre in any  uterus which he ever dissected,  whether impregnated
or unimpregnated, recent or prepared.  He seems fully convinced
that the uterus  has  no true irritability, but a vita  propria corres-
pondent with its peculiar motions and functions.
  In the Transactions of the  Medical and Chirurgical Society of
London, vol. 4., Mr» Charles Bell  has published  a paper on  the
muscularity of the  uterus, from which  I  shall venture to  make a
few extracts.  Though far from agreeing to many of the conclusions
which  Mr. Bell has seen fit to draw  from his anatomical observa-
tions, yet I cannot but consider his communication as well deserving
particular  attention.  Dr. Dewees of Philadelphia, in his strictures
on Mr.  Bell's paper, has successfully refuted several of his positions. 
116          INTRODUCTION TO MIDWIFERY.
  With respect to the glands of the uterus, none are discoverable
dispersed through  its substance.   Upon  the inner  surface  of
the cervix, between the rugae,  there are lacunae  which  secrete
See Dr.  Dewees' Observations in the eighth volume of the Phila-
delphia Eclectic Repertory.
  " The muscularity of the uterus," says Mr. Bell, " is proved by
direct  occular  demonstration  of the fibres  in  dissection,  by the
thickness of the fibres corresponding with their degree of contrac-
tion, by the visible action of the human  uterus during life, by the
resemblance of the laws of its contraction  (as felt  and as perceived in
its consequences) to those which govern the contraction of the other
hollow viscera, and, lastly, by the vermicular and intestinal motions
of the  uterus, as seen in experiments upon brutes."
  " The most curious  and  obviously useful part of the  muscular
substance of the uterus has been overlooked ; I mean the outermost
layer of fibres  which covers the upper segment ot the gravid ute-
rus.   The fibres  arise from the  round ligaments, and  regularly
diverging,  spread  over  the  fundus, until they unite and  form the
outermost stratum of the muscular substance of the uterus."
  " On the outer surface and lateral part of  the womb, the muscu-
lar fibres run with  an appearance of irregularity among  the larger
blood vessels ; but they  are well calculated to consti inge the vessels
whenever they ahall be  excited to contraction.—The  substance of
the gravid uterus  is powerfully and  distinctly  muscular, hni the
course of the fibres is here  less easily  described than might be ima-
gined.   This  is owing to the intricate  interweaving of the fibres
with each other; an intertexture, however, which greatly increases
the extent of their power, in diminishing the cavity of the uterus.
After  making  sections  of the substance of the  womb in different
directions, I have no hesitation in saying, that toward the fundus the
circular fibres prevail; that  toward the orifice the longitudinal fibres
are most apparent; and that, on the whole, the most general course
of the fibres is from the fundus toward the orifice.   This preva-
lence of longitudinal fibres is undoubtedly a provision for diminishing
the  length of the uterus ;  or for  drawing  the  fundus  toward the
orifice.  At the same time these longitudinal fibres must dilate the
orifice, and draw the lower  part of the womb over the head of the
child.
   " In making sections of the uterus  while it  retained  its natural
muscular contraction, I have  been much struck in observing how
entirely the blood-vessels were closed  and invisible ; and how  open
and  distinct the mouths of the cut  blood vessels  became, when  the
same portions of the substance of the uterus were distended and
relaxed.  This fact of  the natural contraction of the substance of
the uterus closing the smallest pore of the  vessels, so that no ves-
sels are to be seen, where we  nevertheless know that they are
large and numerous, demonstrates that  a very principal effect of the
muscular action of the womb is the constringing of the numerous 
INTERNAL PARTS OF  GENERATION.
117
mucus, and there are small follicles at the edge of the os uteri.
These last are only observable in a slate  of pregnancy or dis-
ease,  when they are much enlarged.
  From the angles  at the fundus of the uterus two  processes of
an  irregularly round form originate, called, from the  name of
the  first describer,  the fallopian  tubes.  They are  about three
inches in length,  and becoming  smaller in their  progress from
the uterus, have an uneven, fringed termination,  called the fim-
briae.   The canal which  passes through these tubes is extremely
small at their origin, but  it is gradually enlarged, and terminates
with a patulous orifice, the diameter of which is about  one third
of an inch,  surrounded  by the fimbria:.   It is  also lined  by a
 vessels which supply the placenta, and  which  must be  ruptured
 when  the placenta is separated from the womb."
   " Upon  inverting the uterus, and brushing off the  decidua, the
 muscular structure is very distinctly seen.  The  inner surface of
 the  fundus  consists  of two  sets  of fibres, running in concentric
 circles round the  orifices of  the  Fallopian  tubes.   These   cir-
 cles at  their circumference unite and  mingle, making  an intri-
 cate tissue.  Ruysch,  I am inclined to believe, saw the circular
 fibres  of one side only,  and not adverting to the circumstance of the
 fallopian tube opening in the centre of these  fibres, which  would
 have proved their lateral position, he described the muscle  as seated
 in the  centre of the fundus uteri.   This structure of the inner sur-
 face of the fundus of the uterus is still adapted to the explanation of
 Ruysch, which was, that they produced contraction and corrugation
 of the surface of the uterus,  which the placenta not partaking of,
 the cohesion of the surface was necessarily broken.
   " Further, I have observed  a set of fibres on the inner surface
 of the uterus which  are not described.   They commence  at  the
 centre of the last described muscle, and having a course  at  first in
 some degree  vortiginous, they descend in a  broad irregular band
 toward the orifice of the uterus.  These fibres co-operating with
 the  external muscle of the uterus, and with  the  general mass of
 fibres  in the substance  of it, must tend to draw down the  fundus
 in the expulsion of the foetus,  and to draw the orifice and  lower
 segment  of the uterus over the child's head.
  "  I  have  not  succeeded in discovering circular fibres  in  the os
Ymcae corresponding  in place and office with the sphincter of other
 hollow viscera, and I am therefore inclined to believe,  that, in  the
 relaxation and opening of the orifice of the uterus, the change does
 not result from a relaxation of muscular fibres  surrounding the ori«
 fice.   Indeed, it is not  reasonable to  conceive, that the  contents
of the uterus are to be retained during the nine months of gestation
by the action of  a sphincter muscle.   The loosening of the orifice
and that  softening and  relaxation which precede labour,  are quite
unlike  the yielding of a  muscular ring." 
118         INTRODUCTION TO MIDWIFERY.
very fine  vascular  membrane  formed  into  serpentine plicae.
Through this canal, the communication between the uterus and
ovaria  is preserved.   The fallopian tubes are  wrapped in duph-
catures of the peritonaeum, which are called the broad ligaments
of the  uterus;  but  a portion of their  extremities thus folded^
hangs  loose on each side of the pelvis, and  fringed,  by which
the impregnated ovum is  supposed to be guided and  conveyed
from the ovarium into the fallopian tube.
   The ovaria are two flat oval bodies, about one inch in length,
and rather more than half in breadth and thickness, suspended
in the broad ligaments  about the distance of one inch from the
uterus, behind, and a little below the  fallopian tubes.*
   To  the ovaria, according to the idea of  their structure enter-
tained  by different anatomists, various uses have been assigned,
or the purpose they answer has been differently explained. Some
have supposed, that their texture was glandular, and that  they
secreted a fluid equivalent, and  similar to the male semen;  but
others, who  have examined them with more accuracy, assert
that  they are ovaria in the literal acceptation of the term, and
include a number of vesicles, or  ova, to the amount  of twenty-
two of  different sizes, joined to the internal surface of the ovaria
by cellular threads or  pedicles; and that  they contain a fluid,
which  has the  appearance of thin lymph.   These vesicles  are
in fact to be seen in the healthy ovaria of every young woman.
They differ very much in their number  in different ovaria,  but
are very seldom so numerous as  has  just been stated.   All have
agreed, that  the ovaria prepare  whatever the female originally
supplies toward the  formation of the foetus  ;  and  this  is proved
by the operation of  spaying, which consists in the extirpation of
the ovaria, after which the animal not  only loses  the power of
conceiving, but desire is for ever extinguished.
   The outer coat of the ovaria,  together with that of the uterus,
is given by the peritonaeum ; and whenever an ovum has passed
into the fallopian tube, a fissure may  be observed at the part
through which it is supposed to have been transferred.  These
fissures healing,  leave small longitudinal cicatrices on the sur-
face, which are said to  enable  us to determine,  whenever the
ovarium is examined, the number of times a woman  has  con-
ceived.
   The corpora lutea are oblong glandular  bodies of a yellowish
colour, found in the ovaria of all animals when pregnant,  and
according  to some, when they are salacious.   They are said to
be calyces from which the  impregnated  ovum  has  dropped;
and their number is always in proportion to the  number of  con-
  * Ovaria in vetulis admodum exilia, ut plurimum visuntur. Ruysch,
Obs. Anatom. xlv. 
INTERNAL PARTS OF GENERATION.
119
ceptions  found in the uterus.   They are largest and most con-
spicious  in  the early  state of  pregnancy,  and remain for some
time after delivery, when they gradually fade and wither till they
disappear.  The  corpora  lutea are  extremely vascular,  except
at their centre, which is whitish; and  in  the middle of the white
part is a  cavity, from which the impregnated ovum is thought to
have immediately proceeded.*
  From  each lateral angle of  the uterus,  a  little before and
below the fallopian tubes, the  round ligaments arise, which are
composed of  arteries, veins, lymphatics, nerves,  and a  fibrous
structure.  These are connected together by cellular membrane,
and  the  whole is  much  enlarged during pregnancy.  They
receive their outward  covering  from  the peritonaeum, and pass
out of the pelvis through the ring of the external oblique  muscle
to the groin,  where the vessels subdivide  into small  branches,
and  terminate at the mons  veneris and contiguous parts.  From
the insertion of these ligaments into the groin, the reason appears
why that part generally suffers in all  the diseases and affections
of the uterus; and why the inguinal glands are in women so
often found in a morbid or enlarged state.  By the favour of
Dr. R. Hooper, I  saw two preparations in which the  fallopian
tubes terminated bluntly, and without any aperture, fimbriae or
ovaria.   All such cases must necessarily occasion sterility.
  The duplicatures of the peritonaeum, in which  the  fallopian
  * [The appearance of corpora lutea is not to be deemed decisive
of previous pregnancy : nor does their number indicate the number
of conceptions.  They are irregular as to  the time of their disap-
pearance after delivery.   The evidence is strong that these marks
sometimes exist in virgins ; and, I think, that  future investigations
will determine that disorders of the  uterus frequently induce what
have  been taken for corpora lutea.  Upon  examining the ovaria of
several  women who had  died virgins, and in whom the hymen was
too perfect to admit of the possibility of  impregnation, according to
Sir Everard Home, he found that there were not only distinct corpo-
ra lutea, but also small cavities round the edge of the ovarium left by
ova that had passed out at some former period.  Philosoph. Trans-
act, of the Royal Society for 1817.
  In the trial which arose from the death of Miss Burns, and which
took place at the Lancaster assizes, in England, in 1808,  the medical
witnesses for the crown  declared the corpus  luteum a  conclusive
evidence of previous conception.  This  celebrated  case has since
called the attention of medical  men to a  fuller investigation of this
point, and  the  opinion that  " nothing can  account for  the corpus
luteum in the ovaria but impregnation," pronounced on that occasion
by eminent physicians, and then the received doctrine, is now invali-
dated.   F.] 
120
INTRODUCTION TO  MIDWIFERY.
tubes and ovaria are involved, are called the broad ligaments
of the  uterus.  These  prevent the entanglement  of the  parts,
and  are  conductors of the vessels and nerves, as the mesentery
is  of those of the intestines.   Both  the round  and broad liga-
ments alter their position during pregnancy;* appearing to rise
lower and more forward than in the unimpregnated state.  Their
use is supposed to be that of preventing the descent of the uterus,
and  to regulate its direction when it  ascends into the cavity of
the abdomen;  but whether they answer these purposes may be
much doubted.

                         SECTION II.
   The  diseases of  the internal parts of generation will be  best
understood  if  they  are described  in  the order observed  in the
description of the parts.
   The diseases of  the  vagina are, first,  such an abbreviation
and  contraction as render it unfit for the uses for  which it  was
designed ;  secondly, a cohesion of  the sides in  consequence of
preceding  ulceiation; thirdly, cicatrices,  after an ulceration of
the parts; fourthly, excrescences; fifthly, fluor albus.
   This  abbreviation and  contraction of the vagina,  which
usually accompany each other, are produced  by original defec-
tive  formation; and they are seldom discovered before  the time
of marriage, the consummation of which they sometimes prevent.
The curative  intentions  are to  relax the parts  by the  use of
emollient applications, and  to dilate them to  their proper size
by  sponge or other tents,  or, which  are  more  effectual, by
bougies gradually  enlarged.    But  the  circumstances  which
attend this disorder are sometimes such as might lead us to  form
 an erroneous opinion of the  disease.  A case of this kind which
was under  my care, from the  strangury, from  the heat  of the
 parts, and the  profuse and inflammatory discharge, was suspect-
ed  to  proceed from venereal infection ; and with  that opinion
 the  patient had soon after her marriage been put  upon a course
 of medicines composed of quicksilver for several  weeks without
 relief.   When she  applied to me, I prevailed upon her  to sub-
 mit to an examination, and found the vagina rigid, so much con-
 tracted as not to exceed  half an inch in diameter, and not  more
 than one inch and a half in length.  The repeated, though fruitless,
 attempts, which had been made to complete the act of coition had
 occasioned a  considerable  inflammation  upon the parts, and all
 the  suspicious appearances before  mentioned.   To remove the
 inflammation, she was bled, took some gentle purgative medicines,
  * Ovariorum eorumque ductuum situs mutatur tempore gestationis
et puerperii.—Ruysch. Thes. ix. No. xv. 
INTERNAL PARTS OF  GENERATION.        121
used  an emollient  fomentation, and afterwards some unctuous
applications; she was also advised to  live separate from her
husband for some time.  The  inflammation being  gone,  tents
and bougies  of various sizes were  introduced  into the vagina,
by which  it was distended, though not very amply.  She then
returned to her husband, and in a few months became pregnant.
Her labour,  though slow, was  not  attended  with any extraor-
dinary difficulty ; she  was delivered of a  full sized child, and
afterwards suffered no inconvenience.
  Another kind of constriction of the external parts sometimes
occurs, and  which  seems  to Jae a  mere spasm.  This is  to be
removed in some cases by sucvapplications as  soothe and allay
irritation, especially by introducing  two  or three grains of opium
formed into a pill, into the vagina or rectum ;  and in others by
such  means  as distend  by resisting the spasm, which is  some-
times so forcible as to require the use of bougies of a proper
size  for a long time, even in women who are  married, or have
borne children.  Perhaps  this complaint may also be occasioned
by an erysipelatose  inflammation of, or  deffuxion of, acrid hu-
mours  on the  parts, and  will then require different modes of
treatment.

                       SECTION III.
  By the violence or long continuance of a labour, by the mor-
bid state of the constitution, by the negligent and improper use.
of instruments, or by injuries, an inflammation of the external
parts, or vagina, is sometimes produced, in  such a degree as to
endanger a mortification.   By careful management, this conse-
quence is usually prevented; but in some cases, when the con-
stitution of the  patient was prone  to  disease, the external parts
have sloughed away, and  in others equal injury has  been done
to the vagina.  But the  effect of the  inflammation is usually
confined to the internal or villous coat, which  is sometimes cast
off wholly or partially.   An  ulcerated surface being thus left,
when the disposition to  heal  has   taken place, cicatrices have
been  formed of different kinds, according  to the depth and ex-
tent  of the ulceration ; and there being no counteraction  to the
contractile state of the parts, the dimensions of the vagina become
much reduced : or, if the ulceration should not be healed, and
the contractibility of the parts  continue to operate, the ulcerated
surfaces being bi ought together may cohere,  and the  canal of
the  vagina  be  perfectly  closed.   The inconveniences and  ill
consequences of this complaint  may in geneml  be prevented,
or very much lessened, by proper attention  at the time of healing ;
but  in many of the  cases  I  have seen,  the first inflammation
being neglected, and the sloughing  from the vagina overlooked,
the  cohesion had  taken  place long before  it  was suspected.
                              16 
122
INTRODUCTION TO MIDWIFERY.
When a slough of considerable size  has  been cast off from the
bladder and vagina, the cohesion of  the parts, by which a  kind
of artificial bladder is made,  is a far less evil than  a constant
involuntary flowing of the urine.

                         SECTION IV.
  Cicatrices in the vagina very seldom  become an  impediment
to the  connexion between the sexes  ; when  they do, the  same
kind of assistance is required as was recommended  in the  natu-
ral  contraction or abbreviation of the part,  and I believe  they
always give way to the pressure^" the head  of the  child in the
time of labour, though  in  maiy cases with great  difficulty.
Sometimes the appearances may mislead the judgment; for I was
lately called to a woman  in labour,  who was thought to   have
become pregnant, the hymen remaining  unbroken.  But on
making very particular inquiry, I  discovered that this  was her
second labour, and that the part which, from  its form and situa-
tion, we supposed to be the hymen, with a small aperture, was a
cicatrice,  or unnatural contraction  of the  entrance  into the
vagina, consequent to an  ulceration of the part after her former
labour.
  When the sides  of the vagina cohere  together, it  may be
requisite to separate them with a  knife; and when  they are in
a healing  state, their  reunion may be prevented  by tents or
bougies, or by a leaden canula of a proper size, introduced into,
and worn  in the vagina.   But if the  cohesion have taken  place
far up in the vagina, the knife must be used with the utmost cir-
cumspection, or irreparable injury may  be done  to  the bladder,
rectum, or the adjoining part, as they all are drawn and knit close-
ly together.  A patient under these circumstances, who applied to
me for relief, and in whom the menstruous blood was secreted,
though it  could not be discharged,  was advised to  defer any
operation,  as I  presumed the  menstruous blood, at  some future
time, would be collected in such a  quantity as either to separate
or protrude the cohering parts  in such a manner as to render the
operation,  if necessary, more secure, effectual, and easy.   Ac-
cordingly, when they were stretched  and protruded  by the re-
tained  menses,  the  point most eligible  for perforation  was
indicated, and  the  operation  was  performed easily and safely.
But in some cases of cohesion it has  not been thought justifiable
to attempt to  separate the united parts by incision, and the
patient has been obliged to submit to the injury for the remainder
of her life, in preference to an involuntary and perpetual flowing
of the urine, which every  person who has seen will  consider as
one of the  greatest evils  to which any  human  being  can be
subject. 
INTERNAL PARTS  OF  GENERATION.         123
                         SECTION V.
   Fungous excrescences arising from any part of the vagina or
uterus have been distinguished, though not very properly, by the
general term  polypus; but as the  term is by long custom gene-
rally understood, it  may  be  retained.   These are  of different
forms, sizes,  and substances,  and may sprout from  any part of
the cavity of the uterus, and  perpend in  the  vagina ;  or from
the os  uteri;  or from  the vagina, generally with one, but not very
unfreqnently  with more  roots.   The texture of the excrescences
is also very  different, being in some cases fleshy and firm, and
in others truly fungous, and almost as soft as coagulated blood.
Some of them hang by a small pedicle, and others have a broad
basis, especially at their commencement.   Such substances have
not been described by anatomists, nor the accompanying symp-
toms marked  by nosologists.   Those who are not very guarJed
in their practice, are often led  into error, in their prognostic and
treatment of  these cases.  Some  of them  are perfectly distinct
substances, probably arising from  the internal membrane of the
uterus; but others are partly composed of the substance of the
uterus, which shoots so as to be  intermingled  with that of the
polypus, or to form a covering over it.  These distinct structures
of the polypus, are  not discoverable before an attempt is made
to extirpate them.
   The cause  of polypi is supposed to be some accidental injury
done to the part at the time of labour or otherwise; but more
commonly it  is  a spontaneous disease, proceeding from  a certain
disposition of the constitution  or of the part itself; as those who
have a polypus  of the uterus, for instance, are apt to  have ex-
crescences from other parts;  and they sometimes exist in those
who have never been pregnant, and even in virgins.
   A polypus may be formed for  several  years before it is per-
ceptible  by any examination,  and during  the whole time may
occasion many untoward and intractable symptoms.  Sometimes it
may be discovered within the os uteri, through which it at length
drops  by its  own gravity, or is excluded by pains similar tf
those of  labour,  and when it has  passed  into the vagina it jf^
at rest.  A polypus has been unexpectedly found in the vagfea,
which  had  passed through the os  uteri  without pain.  Ji has
happened, though very rarely, that  there  is  a polypus,  jough
growing in the cavity of the uterus, which does not always pre-
vent conception, or much impede  or obstruct  parturition ; which
polypus  has  been immediately excluded after the birth of the
child.
   Those which are of a  small size are not impediments either
to conception or parturition  ; at  least if they spring from the 
124          INTRODUCTION TO MIDWIFERY.
vagina  or os uteri.   Sometimes tumours of a similar kind are
formed on the external surface of the uterus.*
  *[Cases of this kind are very rare, compared with those in which
the tumour grows from some part of the internal surface of the ute-
rus ; yet I believe them to be ot much more frequent occurrence than
is generally supposed   Two very  remarkable instances of these
tumours, growing from the external  part of the uterus, came within
my observation during the spring of 1821.
   the first occurred in  a patient  aged thirty-two years, of a deli-
cate  form of  body,  and of temperate  habits  of living.  She had
been married six years, but never proved pregnant.   She suffered
from her complaint about five years, when she died suddenly, and
rather unexpectedly.  During the whole of her illness,  which was
seldom so painful or annoying to her as to  prevent her from attend-
ing to the ordinary duties of her house,  she regularly menstruated,
though the discharge was small in quantity, and thinner than natural.
The greatest inconvenience  she laboured  under was the weight of
the tumour, and its pressure upon the abdominal and pelvic viscera.
She  frequently had a sense of bearing down pain which was but
little relieved  by the  horizontal position.  Her digestive  organs
were often  disturbed ;  though  her  mind was rarely depressed by
her situation.  Upon examining her body after death, the  whole
muscular system was  found  to be  greatly emaciated, particularly
her inferior extremities; her abdomen was prodigiously  distended :
the uterus and its appendages were of the ordinary size : the parie-
tes of the uterus were of their ordinary  thickness, and the os tincae
as natural as  in the most healthy state of the parts.  From the fun-
dus of the  uterus, connected  by a small pedicle  not  more  than an
inch in breadth, grew a tumour of a bulk so extraordinary that the
whole of the abdominal cavity was occupied by it ; it pressed the
regions of the abdomen on each side, though  rather more on the
right than on the left.   The anterior part of the abdomen was put
on the stretch by this mass, which extended to the scrobiculus cor-
dis.  This  tubercle was of the species usually denominated  fleshy,
of a pale reddish colour, and of a  fibrous  vascular structure.  At
different parts of the surface of this  tumour  grew  out six  other
small excrescences of a similar structure and tattered appearance  :
the largest of these was almost two pounds weight, the smallest two
ounces.
   Such was the appearance of the abdomen, arising from the shape,
texture,  and pressure of the tumour, that the patient was supposed
some time  previous to her death to  be suffering under ascites : and
she twice underwent the operation of paracentesis in order to ob-
tain relief: on these occasions one or two ounces of a fluid somewhat
purulent was the only discharge obtained :  Her friends beine satis-
fied  that no relief could be afforded her from surgical aid, she had
recourse to a variety of means  for  her relief when her sufferings 
            INTERNAL  PARTS  OF  GENERATION.         125

  In  the  first stage, a  polypus may be accompanied with all
those  symptoms  which proceed  from uterine irritation; and  in
its progress and advanced state with a serous, mucous, sanious,
were at all severe ; and after an undue exertion of her strength, she
suddenly expired.
  Upon removing the tumour from  the abdomen, it was found to  be
of the character of those which  Dr. Hunter has noticed as fleshy
tubercles of the uterus.   Its fibrous structure was  evident.  Upon
cutting  into  its  substance in  different directions, a sac was  found in
the right portion of it, out of which issued three quarts of a puru-
lent and most offensive matter.  This condition of the tumour may
account for the fluctuation which seemed to  be felt by striking the
abdomen ; a peculiarity which is not to be observed in mere fleshy
tubercles of the uterus.  According  to evidence taken at  the time
of examination, the tumour and its excrescences weighed rather more
than one hundred pounds.   The circumference of the abdomen of
the patient,  before the removal of the tumour, measured four feet
eight inches  and a half.
  The above case occurred in the practice  of  Professor Mott, of
the University of New-York.
  The other instance of fleshy tubercles of the  uterus to which I
have alluded, happened in this city in April last.   The patient was
aged about  forty-four years.  She  had  enjoyed  good health  until
within the last two years of her life : at this time she  was supposed
to be  pregnant, and had  many of the symptoms  which attend that
state ; as the cessation of the menses, and  occasional irritation of the
stomach and bowels. , Toward the end of what was supposed to be
her full time, she was accidentally exposed to cold, to which she at-
tributed the sickness which  took place  shortly after.   At this time
she believed that the slight symptoms which she suffered were those
of approaching labour : but  these  symptoms soon disappeared, and
for more than twelve months subsequently her principal complaints
were an acrid discharge from the uterus, which was irregular both
as to its appearance and quantity, a sense of great fulness and oppres-
sion at and around the region of  the symphysis pubis, and slight
irritation of the bowels  and urinary organs.  She  took little more
than mild aperient  medicines  to mitigate her symptoms, and died
apoplectic.
  Upon  opening the  body,  the  uterus was  found  to  be  en-
larged to the size it  usually attains at the sixth month of pregnancy ;
its  parietes were thickened to  the extent  of an inch and a quarter,
and the substance itself was  in many parts in an  ossified state.   At
its fundus, internally, there was attached by a short pedicle a round
bony tumour about the size of an orange.  The right fallopian tube, at
a short  distance from the part which opens into the uterus, had, also,
a round bony tumour of a firm and granulated osseous appearance :
the ovarium on the same side was larger than  ordinary. There were
other appearances still more extraordinary.  Near the cervix of the 
126         INTRODUCTION  TO  MIDWIFERY.
or sanguineous discharge, increasing in quantity,  frequently
changing  its appearance, and irregular in the times of  its con-
tinuance, according to the growth  of the disease and the  state of
the constitution, or of the part.  By these discharges, and often
by the continual  or  frequently returning  pain, the patient may
at length be  reduced to extreme weakness;  and if relief be  not
given by the extirpation  of the polypus, she may perish from
mere loss of strength,  or  the production  of  other diseases, as I
have  more  than  once known.   But these symptoms  being
common to some other  affections  of the uterus, the cause of
them is frequently  overlooked, the  detail of the symptoms  which
precede,  or which accompany the commencement or progress
of the "uterine  polypus,  having been  hitherto very imperfectly
described.   When, therefore, no advantage is obtained  in cases
of profuse  discharges, by  the use  of  suitable  and efficacious
medicines, it should be made a general rule  to inquire,  whether
there  may not be a polypus, or what is  die  nature  of the local
disease.
   The polypus may be removed by excision, or by ligature,  but
the latter is  by far the preferable method, and the ligature is to
be used in the same manner, and on  the same principle, as  in the
extirpation of nasal polypi.  The  kind of ligature I have gene-
rally used has been either one of the laces made of silk,  used in
the dress of women, or a piece of fine whipcord, but wire and
other materials  have been  used for the purpose.   Perhaps  co-
loured ligatures, when moist, occasion soreness of the parts. The
difficulty of the operation lies in  the  proper application of the
ligature, and this  depends upon  the distance of the part to be
tied  from the external orifice, and upon the size and thickness
of the basis or stem of the polypus, as well  as the size and form
of it.  If the circumstances of the case  will  admit of delay, the
operation will be rendered  more easy  by deferring it, as the tu-
uterus there grew out by small attachments six large tubercles of an
oblong shape, which so branched out that the whole inferior portion of
the abdomen, nearly as high upas the umbilicus, was occupied by them.
They were of a vascular texture, of a pale reddish colour, of a very
firm and resisting nature, and, in many places, had evident marks of
ossification.  Two other smaller excrescences were discovered, one
growing from one of the tubercles, and the other from the fundus of
the uterus, of the size of a walnut.  The tumours and the diseased
uterus  were found to  weigh thirty-two pounds four ounces.  I  am
indebted to Mr. L  Proudfoot for an opportunity of examining this
remarkable specimen of disease.
   I have purposely forborne for the present a more minute account
of these cases.  F.] 
INTERNAL PARTS OF GENERATION.
127
mour will descend lower, and the stem or pedicle become thinner
and longer.
  This is the manner of tying the polypus.  Draw the ligature,
doubled,  through the canula or ligator  commonly used for this
purpose,  and then conduct the bow of the ligature with the fin-
gers, all  round and over the bulk  of the  polypus,  taking care
that it  does  not hitch  on one side when  it is  passed  over the
other,  which it is apt to do if the  polypus be  large or uneven.
In several cases, especially when the polypus was large, 1, have
found it  more convenient to pass the ligature single through the
canula,   which being conducted to the stem  of the  polypus,
becomes  a fixed point whence the ligature may be directed round
the stem  by  either of the forefingers.  But it will then be neces-
sary, without disturbing the ligature already passed, cautiously
to withdraw the canula, to give  an opportunity of repassing the
detached end of the ligature through the canula, and then acting
as will be hereafter mentioned.   Whatever part of the operation
can be done with the fingers, is always done  better  and  more
safely  than  with  any  instrument.   The ligature being passed
over the  polypus and upon its stem,  the  canula is to be again
carried to the stem, and  both the ends of the ligature  carefully
drawn through till it is tightened.  We  are   then to examine
with the  finger, whether the ligature be  fixed upon the most eli-
gible part,  which is usually as high up as we can reach, and
sometimes beyond it; but there is no occasion to fix it upon any
precise part of the root of the stem, because the part beyond the
ligature decays, and comes away with the rest, leaving the uterus
clear.   When the ligature  is drawn to its proper degree of tight-
ness, the ends must be fixed upon the cross bars of the  canula,
which  if too short will press painfully on the external parts.
   I have found it better to draw the ligature slowly to what may
be called its bearing, than  to tighten it  hastily, especially at the
time of fixing  it, lest the stem  should be cut  through  prema-
turely,  if the substance were tender;  and then, perhaps, the
tumour might repullulate ; there  would be an awkward discharge
for sometime  afterwards, and the operation would  be less com-
plete.  I therefore very gradually tighten the ligature every day
till it comes away, which  cannot  happen till  the stem is  sepa-
rated,  which is usually on the fourth or fifth day, earlier or later,
according to the  thickness  or texture of the stem.   In one case
the ligature remained till  the fifteenth day from the time  of its
being fixed.   The first sign of a successful operation is the scent
of something putrefying. When the stem of the polypus is divided
by the operation  of the  ligature, or sloughs away, the ligature
is set at liberty.   There is  seldom  any difficulty in  extracting
the polypus,  unless it is very large;  and it is  sometimes dwin-
dled extremely ; but of that we shall afterwards speak. 
128
INTRODUCTION TO  MIDWIFERY.
  During the operation of the ligature, we must carefully watch
any tendency there may be to pain or inflammation in the abdo-
men, and if either of these should come on in any material de-
gree, we must obviate them, and proceed more circumspectly.
  It has been mentioned  as a general rule, that we ought not to
pass the ligature round a polypus, unless we can feel the stem;
but in cases of extreme danger  this rule must  be disregarded ;
and  when  the  polypus  is very large,  as in case the 5th, the
stem cannot possibly be felt.  We must also distinguish a poly-
pus from  an inverted  uterus, for there is,  in some respects, a
resemblance between the two complaints, and sometimes  they
exist together, even when the polypus is not  large.
  Should  a polypus arise from the substance of the part whence
it originates, with a basis as large, or larger than the excrescence,
the ligature cannot be fixed, for  it will either slide off or take a
partial hold.  In such cases, attempts  to pass the ligature pro-
duce no advantage, for in general such tumours have a cancerous
disposition, but this deserves consideration, whether the stem can-
not be laid hold of, and the whole substance destroyed by means
of a pair of denticulated forceps of a proper length and  curva-
ture, so contrived  as to remain fixed where they may be placed ;
and  perhaps by some  other device.   When the  polypus  has a
small pedicle, the case is  commonly more favourable than where
the pedicle is of a considerable thickness, whatever  may be its
size.
  Before  the ligature  is passed,  we should be informed of the
state of the uterus, for if this be diseased, except as far as may
be  reasonably  attributed to  the  irritation  it has suffered, the
patient will not profit by the  extirpation of the polypus, and we
may ultimately do no good nor  acquire any credit, though  act-
ing with the strictest propriety and greatest skill in the operation.
There is, also, sometimes an apparent enlargement of the  uterus,
because the whole polypus is  not excluded out of  its cavity.
   The polypus has sometimes  terminated  favourably without
assistance, or with assistance of a different kind.  After a long con-
tinuance of the disease, which may not have been suspected, or per-
haps mistaken for some other, the tumour has  pressed through the
vagina and external orifice, and the stem being too weak to sustain
its weight, or to afford nourishment, it  has decayed and dropped
away; or when the polypus has pushed through the external orifice,
a ligature has been fixed round the stem, and the polypus been
easily and perfectly extirpated. But in such cases the uterus is more
frequently inverted by delaying to  remove the polypus at a  pro-
 per time, and the  patient is unnecessarily exposed to a continu-
 ance of suffering and an increase of danger.  There have  also
 been instances of the polypus decaying completely  away, while 
INTERNAL PARTS  OF  GENERATION.    .  129
it  has remained attached in the vagina, one of which I  have
seen after having determined to pass the ligature.
   As little has been said on this subject by any writer in this
country, I presume it may be of use to give a detail of a few
cases attended with rare symptoms ; especially as it will give me
an opportunity of mentioning some circumstances unnbticed in
the foregoing description of the operation.

                           CASE I.
   A single lady, twenty-two years of age, had, for a considera-
ble time, been subject to frequent and profuse returns of uterine
hemorrhage,  which resisted all the means that could  be devised
for her relief, and at length reduced her to a state of great weak-
ness.  Dr. Turton (whose worth and continued friendship to me
I am happy on every occasion to acknowledge) was the  physi-
cian who attended, and he, suspecting some local disease, desired
I might be permitted to make inquiry.  I discovered a polypus,
not of a large size, lying low in the vagina.   When I came to
pass the  ligature, there was  much embarrassment from the state
of the parts,  any injury to which I was solicitous to avoid.  On
the fifth  day from the time  of my passing  the ligature it came
away, but the polypus  could not  be extracted without  much
caution and trouble.  There was no return of the hemorrhage,
she soon recovered her strength,  and in a few months was mar-
ried.   She has since had seven fine children, with sale and easy
labours.   This polypus weighed four ounces.

                           CASE II.
   Another young lady had long suffered from  frequent uterine
hemorrhages, together with  most violent pains, recurring in the
manner of those of labour.   High up in the vagina, just cleared
through the os uteri, I discovered a small polypus, round  which
a ligature was with difficulty passed.  The late Mr. Hunter was
with me at the time.  When I began  to tighten the ligature she
complained of very severe  pain  and presently  vomited.   The
ligature was  immediately slackened, but on every future attempt
to draw it tighter,  the same  symptoms were instantly produced.
After many trials I was obliged  to desist altogether, leaving the
ligature loose round the polypus, merely to keep up  in the mind
of the patient some faint hope of benefit.   The health  of this pa-
tient was very bad  when I first saw her, and in about six weeks
from the  time of the operation, she died.
   Leave being given to open the  body, the uterus was found
inverted, and the ligature to have passed over the inverted pan,
which occasioned all  the  symptoms before-mentioned.   This
polypus could not have weighed  more than one ounce, and had
a very short,  if it  could  be  said to have any stem ;  so that the
                             17 
130          INTRODUCTION  TO  MIDWIFERY.
 uterus cpuld not in this case have been inverted mechanically,
 but  by its own vehement action excited to expel the polypus,
 which, like anv other extraneous and offending body,  was a per-
 petual cause of irritation.

                          CASE III.
   Many  years ago I  visited a lady,  who  had for  a long time
 suffered greatly from various uterine complaints, and was sup-
 posed to have a cancer in the uterus, of which her general aspect
 gave very strong indications, but on examination 1 found  a large
 polypus in the vagina.  The late Dr. Ford, than whom no one
 was  more intelligent or  expert in practice, was in  consultation
 with me.   I passed the ligature and drew it  tight,  confidently
 expecting a  happy termination of the  case.  The stem  of the
 polypus was very thick, and it required eight or nine days action
 of the ligature to divide it.  When I had removed  the polypus,
 I was very much mortified to find a new substance,  nearly of the
 size  of.that which had been taken away, in  the vagina.   Her
 health  being very infirm, it was thought advisable for her  to go
 to a  short distance in the country, for the chance of establishing
 her  health, before another operation.   But a  colliquative  diar-
 rhoea with aphthae came on, she gradually declined, and about
 the end of the month died.
  Of this repullulation, if it were such, I have never seen any
 other instance, so early after the operation, and it  might be at-
 tributed, 1. to the thickness of the stem ; or, 2.  to the slow decay
 of the stem; or, 3. to a cancerous disposition of the uterus ; or, 4.
 to a  large portion of the polypus remaining in the uterus, beside
 what was  discoverable in the vagina.  If a case  similar to this
 were again to occur to me, I should certainly act more speedily
 with  the ligature,  and  however reduced the patient  might be,
 should feel justified in passing the ligature on the  second  excres-
cence,  as  affording  the only chance of  saving the patient; but
 this is perhaps to be considered as an instance of the  great mis-
 chief done  to the  constitution,  by too  long delaying the  ope-
ration.

                          CASE IV.
  A  lady  about sixty years of age, who had had  several chil-
 dren, had, with violent  pain,  frequent hemorrhages from the
 uterus, so profuse as to bring her at each time of  their return
into  the greatest danger.   When she permitted me to  take an
examination, there was no polypus in the vagina, but the uterus
was  much distended, and the os  uteri  being opened  nearly to
one  third  of its circumference, I could discover  within, and
pressing upon it, a tumour of apparently a very large size. In 
INTERNAL PARTS OF GENERATION.
131
the course of a few weeks an immensely large polypus dropped
into the vagina.  Her health was much  reduced, and the extir-
pation of the  polypus appearing the only chance of saving her,
I  made  many and strenuous attempts to pass the  ligature, but
without success.   I then  procured  a longer and different instru-
ment, like that used in tying the tonsils, but with this I was also
foiled.  In my endeavours to pass  this instrument  round the
polvpus, the surface was abraded, a blood vessel of a considera-
ble'size was wounded, and there was a loss of blood,  which ren-
dered  the  patient still more  weak.  After a few days,  without
any instrument, I  gradually introduced my hand into the vagina,
got the ligature over  the polypus, and then  tightened it.  Dr.
Orme and Mr. Croft  were with me at the time.  But many com-
plaints came  on, and  she died in a few days, before the  polypus
could be extirpated.
   The  blood vessels which  convey nourishment to a  polypus,
probably bear a  relation to its size,  and must,  of  course, be
sometimes very large; so that in passiug the ligature, it  behoves
us to be very careful that we do  not wound the polypus ; and,
perhaps, in every case when the polypus is  large, it would be
bettor, if possible, to  introduce  the hand, for  the conveyance of
the ligature, than  to use any instrument.  Much will also depend
on the texture of  the  polypus, which is sometimes so slight as to
resemble an injected and corroded liver or kidney.  I remember
a  case  in  which, though I only took a common  examination,
and with the usual caution, so violent a hemorrhage was  occa-
sioned,  that  I thought  the patient would have died instantly.
Was a case similar to this to occur to me again, I should bj dis-
posed to try the effect  of styptic injections, deferring any attempt
to pass the ligature, till I had  seen the effect which would be pro-
duced by them.
   The  three preceding cases are the only ones among a very
great uumber, in  which I have not been successful; and I have
judged  it right to state them thus  circumstantially, to set  others
upon their guard, and to prepare them for the possibility of dis-
appointment.
   In the museum of the late Dr. Hunter, there  is a large poly-
pus  from which  an engraving  was made, and by the register it
appears that,  after many attempts to pass the ligature, without
success, this patient died.  Perhaps by a knowledge of the causes
of the miscarriages of others, (as in case 4, just recited,) subse-
quent trials, even  in polypi which are of the largest size, may be
more fortunate.   I have very great pleasure in  relating  the fol-
lowing case, which was lately under my care. 
132
INTRODUCTION  TO  MIDWIFERY.
                                CASE  V.
         A foreign lady, who was born,  and had lived the greatest part
       of her time,  in a  hot climate,  applied  to  me.  She had had
       every day, for more than three years, a very considerable dis-
       charge  of blood  from  the  uterus,  together  with others  of a
       different kind  and complexion, by which her strength was very
       much reduced.  She  had been attended by different gentlemen,
       who had  not given  any decided opinion of the nature of her
       disease.  When  I first examined her, I was indeed very much
       surprised, for not only the  whole vagina was filled  up with a
       fleshy substance, but the os uteri was as completely dilated as
       when the head of a child is passing  through it, and the cavity
       of the uterus appeared to be filled and much distended with the
       same substance.   I at first hesitated  whether I  should make an
       attempt to pass the ligature, as  I could not reach the stem  of the
       substance, but after  deliberating  upon  the state of the patient,
       who must  soon  perish, unless  relief could be given, and know-
       ing that if the ligature could be passed,  I should have the power
       either of proceeding, or of stopping 011 the appearance of any
       untoward  symptom, I determined to make a trial.  The first and
       second attempts to pass the ligature were fruitless, but I at length
       conveyed  the ligature beyond the bulk of the tumour, and far
       beyond  my reach, by means of a piece  of thin cane, notched at
       the end.  The ligature  being  daily drawn gradually  tighter,
       was at liberty on the sixth day.  The external parts  were unu-
       sually contracted, and as any endeavours to bring away the po-
       lypus at that time must have failed, it was left in the vagina to
•      soften and decay.  On the ninth day after the ligature was come
       away, she had pains  as regular  as those  of  labour, and when the
       os externum became somewhat  dilated, I laid hold of a portion
       of the tumour, first with my fingers,  and then with a small sharp
       pointed hook, favouring the expulsion  of it as well as  I could,
       during the pains by which it was  at length  propelled with  consi-
       derable force, after a labour of four hours continuance.   From
       that time to the end of five weeks, there was not any discharge
       of any  consequence.  Then she menstruated regularly, and re-
       turned home in perfect health.                                ,
         This  polypus, which was the  largest I ever saw, was put into
       the hands of Dr. Baillie, who saw the patient during the opera-
       tion.  It weighed  two pounds and three ounces, so that allowing
       for its decay, perhaps it could not originally have  weighed  less
       than three pounds.   But the violence of the symptoms does not
       always  depend upon the large or  small size of the polypus.
         When polypi are too large to be extracted without much diffi-
       culty after their separation, no harm  can arise from their remain- 
INTERNAL PARTS OF GENERATION.
133
ing some days in the vagina, as I have found in several instances,
and their bulk hourly lessening by decay, their extraction is ren-
dered more easy.
  In the museum of the late Dr. Hunter,  there is  likewise pre-
served a polypus, which  from  its size appears to have inverted
the uterus, and the ligature when  passed over it, being out of
reach, was found to have  been fixed upon the inverted  part of
the uterus, so that when drawn tight it had produced the same
symptoms as those described in case 2; of this an engraving has
also been made.  It is remarkable that this woman lived till the
inverted portion of the uterus  was  more than half cut through
by the ligature, and I am of opinion with very slow proceeding
she might have survived the operation.  For in a  case in which
I was concerned with Mr. Heaviside and other gentlemen, the
ligature being passed  round a cauliflower excrescence,  as it is
called, of the os uteri, a portion of the os uteri itself was included
aud came away with the excrescence, and the patient lived several
months after the operation.  But the same  causes and degrees
of irritation differ so widely in their effects in different constitu-
tions, that  the event of such cases must be both hazardous  and
doubtful.
  These cases lead to an observation on  the difference between
what is properly meant by the term polypus,  and excrescence.
By the former is to be understood, those excrescences that  arise
distinctly from the uterus or vagina; and by the latter, a morbid
enlargement of those parts. The first of  these generally admits
of extirpation with safety and  advantage; but the  latter, though
they admit of extirpation, and  even  promise success, cannot with
propriety or  advantage  be removed.  If  operations in surgery
are  proposed,  and  only justified  when they are  performed with
the hope of removing present  or preventing future mischief,  no
operation ought in these cases to be  performed, because in several
in  which I have passed a ligature over them, those particularly
of the os uteri, the present sufferings of the patients  have  been
grievously increased, and their lives have been shortened.
   The late Dr. Hamilton  of Glasgow obliged  me  with a draw-
ing of a polypus  which weighed one pound and  four  ounces,
and had dropped  through the os externum, inverting and drag-
ging along with it the fundus  of the uterus.   The patient died.
Had  the nature of this complaint been  understood in due  time,
in would, in all  likelihood, have been possible to have tied and
extirpated  it, before it had occasioned so much mischief.  It is
an example among  many others, of the impropriety of  waiting
till the polypus is excluded through the os  externum before we
attempt to lie it, an opinion which some have entertained.
   A very great part of those on whom I have performed this ope- 
134
INTRODUCTION TO MIDWIFERY.
ration have been foreigners, or persons  who  have lived in hot
climates;  but it remains to be proved whether women in such
climates are more subject to  the polypus than those who live
in cold  ones, or whether  this has been  an accidental circum-
stance.
   I  have  seen several cases of excrescences, not  above the
thickness  of a large  earth-worm, springing  from the cavity  of
the uterus or os uteri,  and growing to  a great length.   These
were easily tied  and removed.  In one  case  the  cervix  of the
uterus was so  much  elongated as to drop through the external
parts, assuming the appearance  of a thickened membrane, but
with this it was not thought prudent to interfere.
   In the course of the  year 1801 I met with two singular cases.
The first was a polypus so large  that 1 could not reach the stem,
but having passed  the ligature, very  violent pain in the abdomen
came on,  which obliged me to slacken the ligature, to use fomen-
tations, and to give opiates.   When the  patient became easier I
gradually  tightened the ligature again,  and on the  eighth day
the polypus came away.   But this patient's general health was
very much affected.  She  went into the country, and died  in
about three months, having before her death a  profuse discharge
of purulent matter from the vagina.  Probably the uterus was
diseased,  or some  other part was affected.-—In the second case
there was a polypus or excrescence, not of  a large size, but
with a \ery thick stem, and when I passed my finger to the ex-
tremity of it, within the os uteri, I found as it were  the bottom
of the cavity of the uterus, with a considerable enlargement and
induration of  the  body of the uterus.   These cases I consider
as of very uncertain event,  however dexterously the ligature
may be  applied : they are often accompanied with  certain proofs
of the existence  of cancer,  or some  incurable disease  of the
uterus.  Yet it may be justifiable in some of them to  try the
consequences of a  removal.   Perhaps case 3 was of  this kind.
   I lately saw another patient whose situation was  very  much
like that described p.  133;  but in this case the elongated os uteri
was enlarged,  and  had  assumed the form of a polypus, occasion-
ally hanging  without  the  os externum.   The  symptoms  in
this  patient (who had never been pregnant)  were such  as
are  common  in  every case  of great  uterine  irritation.   I
proposed  her wearing a flat pessary, and supporting her general
strength;  and  if  by the  discharge and  other circumstances,
there should be  any tokens of imminent danger,  I  thought  it
would be  right to take  the chance of doing some good and pro-
longing her life, by passing a ligature round  the  small  part  of
the excrescence, near the  proper os uteri : she died in  the course
of a few months in consequence of repeated   hemorrhage-; no
attempt having been made to pass a ligature round the part. 
INTERNAL  PARTS  OF  GENERATION.        135
  I am sorry to have known reasons for concluding this account
with  the following observation.   When a polypus  is  discovered
to exist, it does not seem right to proceed to the operation imme-
diately, but to request a consultation; to prove the  nature of the
disease and  the necessity of the operation, that the  honour  of
the profession, and of the person employed,  may  be preserved
inviolate.   (See  a case of polypus described in the  3d volume
of Medical and Chirurgical Transactions, page 308.)*
   *[Married and unmarried women are both  liable to polypus  of
the  uterus:  and though  they sometimes  prove pregnant, while
afflicted  with the  disease, parturition commonly happens prema-
turely.   In some  few  instances,  they  conceive, go  through the
period of utero-gestation without inconvenience, and are delivered
as under ordinary  circumstances.  To the  valuable observations  of
the author little can be here  added.   The discharges from the ute-
rus are of such different appearance, at different times, in different
kinds and state  of polypi,  and are excited  by such slight causes,
that the propriety of examining, per vaginam, in cases of preternatu-
ral evacuations from the uterus, ought always to be insisted upon.
Polypi of the uterus, on  account of their shape and size, have some-
times been  mistaken  for cases of inverted uteri:   difficult labour,
however, has generally preceded  this accident; though  some un-
common  instances have happened where polypi have first  protruded
immediately  after  delivery.   See  a valuable  essay on the symp-
toms, causes, and treatment of inversio uteri, with a history of a
successful extirpation  of that organ, during the chronic stage of the
disease, by W. Newnham.  Lond. 1818.  We must pay great at-
tention to the history  of the  case, and remember  the  msensibility
of polypus ; besides, unless the uterus be only partially inverted, the
tumour will not be encircled by the os tincaj.
   The cauliflower excrescence of the os uteri might be  mistaken
for polypus : the prominent diagnostic marks of the former are its
irregularity of surface, its originating from the substance  of the  os
uteri, with a broad base  and not coming through  it,  and the watery
discharge which attends the disease.  On this subject 1 am induced
to give an  abstract of what  Mr. Clarke of London has  furnished
us, who  seems entitled  to  the credit of having  first described the
cauliflower excrescence  of the os uteri.   Mr. Clarke's paper may
be found entire in  the Transactions of a Society for the  improve-
ment  of Medical and Chirurgical  knowledge, vol. 3.
   The cauliflower excrescence,  according  to Mr. Clarke, arises
always from some part of the os uteri.  As several of  the early symp-
toms are not very distressing to the patient, the tumour in the begin-
ning is  rarely the  subject of medical attention ;  the first changes
of structure have therefore not been  observed.  Mr.  C.  does not 
136          INTRODUCTION  TO  MIDWIFERY.
                         SECTION VI.
  A mucous, ichorous, or sanious discharge from the vagina or
uterus,  is called the fluor albus.  (Leucorrhcea.   Nimia  muci
aut ichoris ex vulva profusio.—Vogel, cxix.  Cachexia uterina,
sive fluor  albus.—Hoffman.)  These discharges are various in
their  degrees as  in  their  kinds, from a simple increase of the
recollect to have ever met with a case,  in  which the size  of the
tumour was less than that of a blackbird's egg.  At  this period it
makes an irregular projection, and has a base as broad as any other
part of it, attached to some part of the os uteri.  The surface has
a granulated  feel; considerable  pressure, or handling  it, does  not
occasion any sense of pain.   The  remainder of the  os uteri  will,
at this period,  be found to have no sensible  alteration of structure.
By degrees, more and more of the circle of the os  uteri, and  the
external part of the  cervix uteri, become affected with  the same
morbid alteration of structure, till  at length the whole is involved
in the disease.
   The growth is, in some cases, slow, but in others rapid, so that,
in the course of nine months, it  will sometimes entirely fill  up  the
cavity of the pelvis, and block up the entrance of the vagina.
   As the  bulk of the tumour increases, the granulated structure
becomes  more evident, and is  found to resemble very  much  the
structure of a cauliflower, when it  begins to run to seed.   In most
cases it is of a brittle consistence, so that small parts of it  will come
away, if it be touched too rudely, and such pieces generally  appear
very white.  Sometimes, though no violence has been  used, small
portions of a white substance come away with the urine of the pa-
tient, and in the discharge from the vagina.
   When the tumour has arrived at a size greater than that of the os
uteri, it spreads very much,  and as the base is the smallest part of
the tumour, persons, not  conversant  with the  disease, have often
mistaken it for polypus.   A little attention, however, to the  feel of
the tumour, and the  breadth of its  base,  will be sufficient to distin-
guish them.
   In the very early state of the cauliflower excrescence, a discharge
from the vagina takes place like fluor albus.   It very soon becomes
thin and watery, and is sometimes tinged with blood.   In most cases,
upon coming away, it is apparently as thin and  transparent as pure
water ; but the linen on which it is  received, when dry, becomes
stiff, as if it had been  starched.  The quantity of the discharge,
when the  excrescence is large,  will sometimes be sufficient  to wet
thoroughly ten or twelve napkins  in a day.  Now and  then a dis-
charge of pure blood occurs.  When this ceases, the discharge of
a thin  transparent fluid  reappears.  An offensive odour  generally
accompanies the discharge, which is greatest, when there  has lately
been an evacuation of pure blood, or of thecatamenia. 
INTERNAL PARTS OF  GENERATION.        137
natural mucus of the part, to that which is purulent, or of the
most  acrimonious  quality; but  the first is not esteemed a dis-
ease,  unless it  be excessive in its  degree.  It is the most frequent
   Through the whole course of the disease, Mr.  Clarke  never
 found, in any instance, any appearance of pus in the fluid discharged
 from the vagina.   Sometimes, however, mucus will be seen in it.
   The  catamenia are  not affected in an early state of this disease.
 This discharge is, however, generally more abundant than in health,
 and the period is apt to last longer.   With the catamenial secretion
 blood is very often  effused.  When the constitution  becomes much
 weakened,  menstruation is less regular, and in the last stages of the
 disease, it observes no  regular period.
   Patients,  labouring  under  this  disorder, are  variously  affected
 with regard to pain   In the commencement none is felt, but during
 its progress  pain is, in  some cases, experienced.  Generally, in the
 advanced stage, the patient feels pain in the back, and in the direc-
 tion of the round ligaments of the uterus.   The pain is not described
 to be  lancinating, as in cancer, and is without any sensible aggra*
 vation by paroxysms ;  but, on the whole,  it  is most felt after the
 patient has been long in a perpendicular attitude.
   The  disease attacks indiscriminately women of all  ages.   The
 patient is destroyed by  the debility occasioned by the profuse dis-
 charge ; and, in the course of the  disease, she always becomes ex-
 tremely emaciated.   Mr. C. never met with  an instance, in which
 the disease did not terminate fatally.
   Respecting the treatment of this disease,  Mr. Clarke says, that he
 can  offer, at present, little satisfactory information.  The  disease
 being described, and distinguished from others, is something gained.
 All stimulating substances, either in diet  or  medicine, seem to ag-
 gravate it, by increasing the discharge, and no astringents internally
 given  appear to lessen  it.
   The only means, from which he  has  seen any benefit derived, is
 the injecting into the vagina, three times  a day, a strong decoction
 of cortex granati, or of cortex  quercus, in  which alum is dissolved,
 in the proportion of eight or ten  grains to every ounce of it.  This
 has the  double effect  of lessening the quantity of the  discharge,
 and rendering it less offensive.
   I-t is scarcely necessary to add,  that the use of anodynes must
 be resorted to for the  mitigation of pain,  and that  the  occasional
 symptoms of suppression of urine, and costiveness, are to be relieved
 by the use of a catheter, and mild laxatives.
   Of the different sort of polypi of the uterus, it may be observed,
 that, with few exceptions, they admit  of cure  only by means of an
operation, and this  consists in the application of a ligature  round
the neck of  the tumour.  Instances have been adverted to of poly-
18 
138          INTRODUCTION TO MIDWIFERY.
complaint to which women are liable, and is by them suspected
to be the  cause of every disease which they may at the  same
time suffer; but it is generally a symptom of some local disease,
or a consequence of great debility of the constitution, though,
when profuse, it becomes a cause of yet greater  weakness.  In
many cases the fluor albus is  an indication of a disposition to
disease in the uterus, or parts connected with it, especially  when
it is  copious  in quantity, offensive  in smell, or acrimonious in
quality, about the time of the final cessation of the menses: and
before the use of such means as are merely calculated for the re-
moval of the discharge, we must first endeavour to restore  the
uterus to a healthy state.
   The  symptoms  attending  the fluor  albus, whether it be an
original disease, or a symptom of other diseases, are very simi-
lar.  The complexion is of a pale, yellowish colour, the appetite is
depraved,  there is invariably a pain and sense of weakness ia
the back, loins, and inferior extremities; the patient has usually
a feverish disposition, with a wasting  of the flesh and reduction
of the strength, and ultimately becomes hectic or leucophlegmatic.
   The method of relieving or curing the fluor albus must depend
upon its  cause, and whether  the discharge proceeds from  the
uterus or vagina.   When it is occasioned by general weakness
of the constitution, any of those medicines which are classed
under the general term  of  corroborants  or tonics, as bark and
preparations of iron, and especially the  zincum  vitriolatum, to
the  quantity of one grain, or  more, two or three times a day,
may be given,  under a variety of forms,  with great  advantage.
But their effect upon the discharge is not immediate ; and, pre-
viously to their use, it will be proper  and  necessary that the
patient  should  take some mild purgatives, and in all cases  wliere
there is any feverish disposition,  that is  to be removed  before
the use of any kind of tonic medicine.   Balsamic and agglutina-
ting medicines of every kind, as the extract of bark with gum oli-
pus tumours being pushed, during the efforts of vomiting, out of the
os externum, and, upon the returning of the  uterus, after the ab-
dominal muscles have ceased to act upon it, the neck of the tumour
has been broken.  But such favourable  method of. cure  is rarely
indeed to be expected, and he would be criminal who would depend
upon it.
  On polypus of the uterus,  consult Baillie's  Morbid Anatomy.
Levret, Observations sur la cure radicale  des polypes de la matrice
et du  nez.  Ruysch is, also, one of the best, as well as one of the
earliest writers  on this  subject.   See  Observationes Anatomic.
Chirurgic.  F.] 
           INTERNAL  PARTS OF GENERATION.         139

banum, mastic, or elemi, and all the class of terebinthinate bal-
sams, of which the best for internal use is that called the balsam
of Gilead, or the  Tinct. Benzoin.  Composit. are also frequently
prescribed, and sometimes with much benefit.  In some obstinate
cases,  preparations  of quicksilver, especially calomel  in  very
small  doses, have been given  with advantage, when there was
no  suspicion  of any venereal infection.  Gentle  emetics  have
also been recommended in some  cases of long continuance, and
they are supposed to be of singular  use, not only by cleansing
the primae vige, or by making a revulsion of the humours  from
the inferior parts,  but by exciting all  the powers of the constitu-
tion  to more vigorous action.  Cold  bathing, partial or general,
particularly in the sea, has  often been of eminent service.  In
this, and  all  similar complaints, good air,  moderate  exercise,
nourishing, but very plain and simple  diet,  and a quiet regular
manner of living, will of course  be advised.
  When there is reason to think  that the  complaint is local, and
arises from the relaxation of those  orifices by which a necessary
mucus is discharged on particular occasions; or if the discharge
should continue after an amendment of the constitution, injections
of various kinds may be used daily.  But the safest and best are
those which are composed from astringent vegetables, as a strong
infusion of green  tea, or the leaves of the red rose;  proceeding
cautiously to  weak solutions of cerussa acetata, zincum vitriola-
tum,  or  alum,  as is the practice in  long continued defluxions
upon the  eyes.   Though  these  applications  cannot  well  be
expected to produce an absolute  cure, they seldom fail  to afford
temporary benefit,  which is  a  great comfort to the patient, and
if cautiously and judiciously directed, they may be continued or
repeated  without  hazard,  and perhaps ultimately cure  the dis-
ease.*
  *[Leucorrhoea or fluor albus may, most properly, be considered a
constitutional disease :  it  arises from different, and even  opposite
states of the system ; occasionally from general plethora, but in a
great majority of instances, from  constitutional weakness  and de-
bility.   Sometimes it  may be  induced by local irritations,  and,  in
other cases, may be deemed as symptomatic of particular affections of
the uterus, as cancer, polypus, &c.: the depressing passions may also
be the cause of it. The discharge of leucorrhcea may proceed from
the uterus itself, or from the vagina, or from both ; it may be mild
or acrid ;  and when it continues for some considerable time, it not
unfrequently acquires the virulence of gonorrhoea.   On this account,
in addition to other reasons, the judicious practitioner will act with
prudence.   The discharge of fluor  albus generally alternates with 
140
INTRODUCTION TO  MIDWIFERY.
                         SECTION VII.
  The uterus is liable to many diseases, and being a part with
which the whole  body  is  readily drawn into consent,  there  is
the menstrual evacuation, even in women who are regular.   Some-
times the discharge of leucorrhoea  is much increased, just  before
the menstrual period.  And, moreover, leucorrhoea is most common
with those  females who  are subject to an immoderate  flow of the
menses.  If by conception the  discharge has  ceased, the secretion
from the vagina  may be greater, and may cause abortion.
   The  serious  results  which  often attend a long  continued fluor
albus, ought  to teach  the physician  the necessity of early and  per-
severing treatment.  Blood-letting  and active cathartics, when the
disorder arises  from  general plethora, may be advantageously em-
ployed,  particularly in  subjects habituated to  free living.   In those
cases, in which the discharge  takes place during  pregnancy, mode-
rate venesection will prove beneficial.   Obstinate cases  of  fluor
albus,  when  the disorder depended on this  general  fulness of the
system, have been cured by the patient giving suck ;  and on the
other hand, the complaint  occurring in a different state of the con-
stitution, has been brought on by  excessive suckling.  When the
complaint depends  upon  general debility, all the means calculated
to invigorate the system ought to be prescribed.   Among  them,  as
the most efficient, are the chalybeate mineral  waters ; cold bathing,
general  and  local  ; exercise in  a  clear  and dry atmosphere, and
nutritious diet.   The bark has been sometimes  given with  advan-
tage, as also the  mineral acids,  muriated tincture  of iron, and
other preparations of that metal.   The  decoction  of the oak  bark
with sulphate of zinc, the cold infusion of green tea, a solution  of
alum with infusion of rose petals, are valuable local remedies.  At-
tention  to the state of the digestive  organs ought to be enforced, and
the mind cheered  by flattering anticipations : By strengthening the
tone of the stomach and bowels, we often accomplish  this object,
and restore the  functions of the uterus.   It need hardly be observed,
that when leucorrhoea  is symptomatic, the primary disorder must
first be removed.—For  a disease of so  frequent occurrence, and
so formidable to the constitution, and  which is so apt to baffle the
skill of the most experienced,  it is not surprising that such various
methods of cure have, at different times,  been recommended.  It
is necessary  to  keep  constantly in  mind, that the disorder  is almost
always  constitutional, and  that, therefore, local  remedies, though
they may afford temporary relief, must prove inefficient in accom-
plishing a cure.   The fluor albus  which takes place in  advanced
life, after the  menstrual evacuation  has ceased, requires for its
cure more frequently,  than in any other condition of the  system,
occasional  blood-letting,  and the free use of cathartic medicines.
Cold lavations and astringent injections, in these cases, may do great
-and sudden mischief,  unless preceded by the antiphlogistic  plan. 
INTERNAL PARTS OF GENERATION.        141
scarce one under which women have at any time laboured, but
what has  been attributed  to  its influence : yet  it is  not  proved,
that there is any essential difference in those diseases of women
to which men  are equally subject, though  there is some variety
in the symptoms.  We shall confine our attention to the  most
obvious diseases of the uterus, and begin with the prolapsus, or
procidentia, which very frequently occurs.
   By the prolapsus is meant a subsidence or descent of the uterus
into the vagina, lower than its natural situation, and it is termed
a procidentia when the uterus is pushed through the external ori-
fice of the pudenda.*  This sometimes happens  to  such  a de-
gree as to  put on the appearance  of an oval  tumour  growing
from the external parts, depending very  low between the thighs,
causing  great  pain and  uneasiness, and rendering  the patient
unable to perform the common offices of life.  A moderate share
of circumspection, especially with  regard  to the state of  the os
uteri, will enable us to distinguish the procidentia of the uterus
from its inversion, and from all resembling diseases.
   There are many causes of the prolapsus or procidentia of the
uterus; as long standing during the time of pregnancy, carrying
heavy burdens, an extreme degree of costiveness, and all sudden
and violent exertions  of the body ; whence they  most frequently
happen to women in the lower ranks of life.  They may be un-
avoidably  occasioned by  the circumstances of a labour,  as the
descent of the  os uteri into the pelvis,  before it is dilated ; by the
preposterous efforts  of the woman in  an erect position,  by an
  The tincture of cantharides  has  been strongly recommended by
Mr.  Roberton, as a specific in  leucorrhoea ;  but  the experience of
American  practitioners seems  not  to have  confirmed its  efficacy.
He  has recommended the tincture to be  taken diluted with water;
beginning with  two drachms, united with six ounces of water, a
table-spoonful  three  times  a day ;  and  gradually  to  increase the
dose, until  the  patient  has taken four drachms of the lytta within
the  twenty-four hours.  It is in this way to  be  persevered in until
the   patient experiences some uneasiness in passing urine,  and a
puriform  discharge from the vagina is induced.   But to accomplish
this end, a perseverance in the use  of the remedy is sometimes re-
quired for months, and even years.  Mr. Roberton was induced to
adopt this  potent  article  of  the  materia  medica in fluor  albus,
from the resemblance of  this disorder to gleet.  I have  prescribed
the  tincture of lytta with the best results in  this  last mentioned dis-
ease, but with very little  apparent  benefit in the former.—Dr. La-
tham  has given some valuable observations on  leucorrhoea in the
Medical Transactions of the  College  of   Physicians  of London,
vol. v.  F.]
  * Hysteroptosis.   Uteri vel vaginae procidentia.   Sauvag.  xlix. 
142
INTRODUCTION TO MIDWIFERY.
uncommonly large child, by the rude and  hasty  extraction  of
the placenta, and  by rising too early after delivery.   Nor are
oviparous  animals free  from  these accidents from  a  difficult
exclusion of the eggs, when these are of an unusual size.  They
may also be produced by mere relaxation  of the  parts, after a
long-continued fluor albus, as unmarried women are sometimes
subject to them, though less frequently than those who have had
children.   By  a knowledge of the causes of these complaints,
we are led  to their prevention and  cure; and it  is worthy  of
observation,  that  when  a  prolapsus  or procidentia  has  been
occasioned  by the  circumstances of one labour, they may often
be relieved,  or sometimes  perfectly cured,  by care  and  long
confinement of the patient  in  a  horizontial position  after the
next.   When women who  have  a prolapsus are pregnant, the
inconveniences are increased in  the early part of pregnancy,
because the uterus being then more weighty and enlarged, sinks
lower than usual into the vagina;  but in the latter part,  they are
lessened, as it  is  then supported  above the brim of the pelvis.
Yet, when  the pelvis is very capacious and the parts much relax-
ed, the lower part  of the uterus, including the head of the child,
has in some cases been pushed through the external orifice,  even
in the time of labour,  before the os uteri was dilated.
   The procidentia is not, properly speaking, a  disease  of the
uterus, but a change of its position, caused  by the  relaxation or
weakness of those parts to which it is connected, and by which
it should be supported.  It accordingly most commonly happens,
that the first tendency to  it  is discovered  by the protrusion  or
fulness of the anterior part of the vagina, and sometimes  also the
posterior part of the vagina first becomes tumid, forming a  kind
of pouch by the partial distention of the rectum ; and this  happens
in some cases where  there  is no descent of the uterus,  perhaps
first caused by inattention to the state of the bowels, and suffering
the lower part of the rectum to be distended mechanically till  it
has lost its contractile power.  Before there is any actual change
in the state of the parts, the patient has usually, on slight exer-
tions,  a  strong sensation of their descent,  but in  the principal
degrees of the procidentia,  the position of the uterus and vagina
is not only very much altered, but likewise that of the bladder
and contiguous parts.*
   The intentions in the cure of the procidentia or prolapsus are,
to restore  the uterus to its proper situation, and to retain or
support it when replaced.
  * Maximam vesicas partem secum trahit—Ruysch. Advers. Dec. 1.
6.—See Medical Observations and  Inquiries, vol. iii. case 1.  By
Dr. Thomas White of Manchester. 
INTERNAL PARTS  OF GENERATION.         143
   The  reduction of the parts to  their situation is  not usually
attended with much difficulty, even in the worst degrees of this
complaint.  In  some cases, however, it is necessary, by  bleed-
ing, confinement in bed, gently purgative medicines, and emol-
lient  fomentations,  to lessen the inflammation and tumefaction,
or to heal the ulceration of the parts if any exist; and when the
procidentia  or prolapsus occurs  soon after delivery, very gentle
means can only be used with propriety, as the parts are often in
too irritable and tender a  state to bear any other without mis-
chief.   When the parts are replaced, it will sometimes be proper
to use local  astringent and aromatic applications, in the form of
a lotion or fomentation applied externally, or conducted into the
vagina by  means of a syringe or sponge.   But  these will  not
often fully answer our intention, and we shall be obliged to have
recourse to  pessaries,  of which many have been  contrived  of
various forms and substances.
   The intention in the use of pessaries is to  support the uterus
in its situation, without injuring it, or  the adjoining parts;  but
certainly many of the kinds now in  common use are ill calculated
for one  or both of these purposes, as they can neither be intro-
duced nor worn without inconvenience, and  often fail to answer
our  intention.   Previously to these I  have  commonly recom-
mended a piece of sponge  of a suitable size  moistened with red
wine, to be  tried; or a small ball of the elastic gum moderately
distended with cotton; and if these  fail,  a  pessary of  a  firmer
kind must be introduced.   Pessaries are generally made of box
or  ebony wood, or of cork covered  with wax.   By some  the
circular form is preferred;  by others the oval; whilst others are
persuaded that globular ones are the most  effectual ;* and if these
are made very thin, they  are certainly easy to wear,  and com-
pletely relieve the complaint; but  they cannot be used by women
who live with their husbands.  Much  dexterity  and judgment
also are required in the introduction of pessaries of any kind, for
if they are  too small,  they will not remain in the vagina; and,
if too large,  they will inflame and ulcerate the parts, mechanical-
ly causing the strangury, obstinate costiveness, and other painful
symptoms.  The size  of those first  used should be sufficiently
large, and they may be gradually diminished, till they are no long-
er  necessary.   VVhen  a  pessary has been introduced, it is
requisite that the patient should for some  time be quiet, and in a
horizontal position, by which the present  inconveniences will  be
lessened, and the good we expect to derive  from it will be increas-
ed ;  yet, there  is  no doubt  but that  we are often disappointed
  * For the first account of the globular pessary, which was invent-
ed by Dr. Sandys, see London Medical Journal, vol. vii. 1786. 
144
INTRODUCTION TO MIDYVIFERY.
in our expectations of the advantage to be gained by the use of
pessaries, from impatience, or the want of attention  in their ap-
plication.  Pessaries, when introduced, are chiefly supported by
the perinaeum ; but if this should have been lacerated,  the com-
mon ones cannot be used.  A sort has for such cases been con-
trived with stems, to  which ligatures are to  be fixed, and then
brought forwards and backwards to a bandage  passed round  the
waist.  These are always very  tronblesome, and are therefore
not recommended, unless those  of  another kind  have  failed to
answer;  but I have never met with a  case in  which the globular
pessary could  not be easily introduced, and conveniently  worn.*
  Pessaries once fairly introduced, may often be  worn for many
years without any, or very little inconvenience. But, sometimes,
from the  long  continuance  of a  common one,  or from the entan-
glement and strangulation  of the os uteri within  the opening at
the centre (which ought always to be very small) there has been
much difficulty in withdrawing it when necessary.  In the latter
case the strangulated os  uteri must be pressed firmly,  and  for
some time,  between the finger and thumb, till the  size is reduced,
when it may be extricated.  But if it be  possible to pass a piece
of tape through the circular opening, and if we pull in a proper
direction by both ends of it, with a firm and gradually increased
force, so  as to give the parts lime to distend, we can hardly fail
of success.   Should that not  be  possible, the rim of the  pessary
must be broken, or divided by a pair of sharp strong forceps, of
the kind  used  by watchmakers.f  The globular pessary may, at
any time, be extracted with a small  vectis.  But pessaries,  when
once introduced, may generally  be suffered to remain for a long
time, without any hazard or  inconvenience,  and  I  think I once
extracted one which had never been removed  for fourteen years.
   It has  been  observed, that the use of pessaries,  except the glo-
bular ones, does not  hinder the act of coition,  or conception ; and
when a  woman  has  a  procidentia or prolapsus,  in an infe-
rior degree, it is of great service that she should  live with  her
husband.J
   An opinion  was formerly entertained, that a procidentia of the
uterus was beneficial in several other complaints to which women
are liable,  and that it was  not proper to  replace  it; but I have
never seen any reason for this opinion, though the  reposition of
    The stem pessary has been very much improved by Edye, the
truss-maker, in Dean-street, Soho.
  t See Chapman's Treatise on Midwifery, chap, lxviii.
  X Pessaires n'empechent pas le femme d'user du coit, ni de deve-
nir grosse.—Mauriceau, vol. i. 1, 3. c. 6. 
INTERNAL  PARTS OF GENERATION.
145
the parts sometimes occasions a temporary uneasiness.*  In some
cases it is also said, that the uterus, the surface of which is  fre-
quently ulcerated, could not be  returned, from its long continu-
ance, or from the increased bulk of the neighbouring parts ;f  but
I presume that all such cases might have been managed  by per-
severing in the use of gentle evacuations, proper applications,  and
long confinement in a horizontal position; and a pessary is not
to be  introduced till the uterus is healed, as well as reduced in its
size.J
   * Contigit uteri prolapsus ;  quern ego affectum  salutarem illi fore
praedixi.—Harv. Exercit. de Partu.
   t Restitui non  semper debet, nee potest.—Ruysch. Advers. ix.
Anat. 9.
   X [The more immediate  causes of this disease are a relaxation of
the broad and round ligaments  which suspend the uterus, and a want
of due tone in the vagina.   Hence, whatever is capable of producing
a lengthened state of the ligaments, or a relaxed state of the vagina,
may be the  cause of procidentia uteri.  It is universally admitted,
that the most frequent occasion of this complaint is too early exertion,
and a too long continued erect posture of the body, early after deli-
very.  The  more immediate predisposing  causes of the disease are
then present, and the uterus weighs eight or ten times more than an
impregnated uterus, and is carried down  by its own  weight.  Mr.
Clarke assures us, that when the uterus has fallen out of the body so
as to become an external tumour covered by the vagina, the surface
of the tumour,  that is, the  membrane of the vagina, ceases  to  se-
crete,  although  it  did  so  before,  in  very considerable  quantity,
whilst the tumour was contained within the os externum.  This cir-
cumstance will account, he  remarks, for a fact observable in the dis-
ease, viz. that those cases of descent of the uterus, in which the tu-
mour is not  external, are attended  with  a  much  greater  degree of
bodily weakness, than when the tumour is external ;  in which latter
case, all  that strength is saved to the woman, which would have been
expended,  if the tumour had continued in the  body.  But, if the
parts are returned to their natural situation ; if that which is the co-
vering of an external tumour, is converted into the Mning of an inter-
nal cavity, the mucous membrane of the vagina begins again  imme-
diately to resume its functions.  Mr. Clarke had a striking case un- ■
der his care,  which illustrated this pathological fact.
   Chopart gives us the singular case of a girl, of fourteen years of
age, who, in consequence of violent exertions, became afflicted with
prolapsus uteri.  The displacement, however, was slowly produced.
   It is needless to enforce  the  importance of cold applications, the
cold bath, and cold astringent injections, in  this disease ; at the same
time that the powers of the  system are invigorated by the vegetable
or mineral tonics.
  Various pessaries have been  had recourse to, for supporting the
                          19 
146          INTRODUCTION TO  MIDWIFERY.
                         SECTION  VIII.
  Hydatids,* or small vesicles, hung together in clusters, from one
common stem, and containing a watery fluid, are sometimes form-
ed in the cavity  of the uterus. These have been supposed to pro-
ceed from coagula of blood, or portions of the placenta, remaining
in the uterus; and the opinion  is  generally  true;  but there is
sometimes reason for thinking, that they are an original produc-
tion of the uterus, independent of such accidental circumstances,
and sometimes the precursors of organic disease in that part.f
  The symptoms of this disease  are  such as are common in all
cases accompanied with an increased degree of uterine irritation:
and as there is also a suppression of the menses, with a consider-
able distension of the abdomen; from the enlargement of the ute-
rus, (for the  hydatids are  often excluded in an amazing large
quantity,) it is not surprising that  these cases should be frequently
mistaken  for pregnancy.   In the early part of the  disease, the
symptoms are like those which attend a disposition  to an abor-
tion, and though troublesome, are not alarming; but at some cer-
tain time before, or about the termination of nine months, the ute-
rus makes its efforts to expel them, and the attending circumstan-
ces are similar to those of labour.   If the hydatids should be ex-
pelled without the occurrence of any dangerous symptom, there is
no occasion for our assistance or interference.  But if an hemor-
rhage of any importance should attend, or if the action of the ute-
rus should be insufficient for their expulsion, it behoveth us  to
make gentle attempts to extract them, that the uterus may be at
liberty to contract, and  the orifices of the vessels be thereby les-
sened.   We must, however, act with great caution ; for, by hasty
and rude proceeding, we should incur the danger of greater mis-
chief than we mean to avoid, so that without some particular rea-
uterus, and it would be difficult to find one,  against which some ob-
jection could not be made :  those of wax soon have their shape alter-
ed by the heat 9/the body ; those of cork, from their porosity, im-
bibe the moisture of the parts, and become offensive and irritating.
Similar objections may be made to those formed of sponge.  Those
of wood  possess many  advantages.   Professor  James prefers the
oval pessary of gum elastic.   On the causes and treatment of pro-
cidentia uteri, see  Clarke on  the Diseases of Females.   F.]
  *  Hydatis.  Vesicula cuticularis   humore aqueo plena.—Cullen.
  t  Haec retentae moles placentae, penitus amittens genuinam suam
indolem, quia est merus vasorum sanguiferorum  contextus, integro
suocorpore mutatur in congeriem hydatidum.—Ruysch. Adv. Anat.
Dec. 2.   See also Dr. Baillie's Morbid Anatomy. 
INTERNAL  PARTS  OF  GENERATION.
147
son for giving assistance, it is commonly better to leave them to
be excluded by the action of the uterus.*

                          SECTION IX.
  There  are upon record many histories of the dropsy of the
uterus, which is described as a collection  of water, or thin gelati-
nous  fluid, in its cavity, the  os  uteri being so perfectly closed as
to prevent its escape.f  It is supposed to be occasioned by an in-
creased secretion, and a  diminished absorption of lymph, as in
collections of  water  in  other cavities.   The symptoms  of this
dropsy are the same as those which occur in the case of hydatids,
and when the action  of the uterus comes on, the patient is usually
imagined to be in labour; but after a sudden discharge of water,
the abdomen  subsides, and though chagrined at her disappoint-
ment, she recovers her former health.
   * [It is the opinion of Dr. Baillie, that hydatids of the placenta are
different from those of the liver, kidneys, and some other parts of the
body.   They consist  of vesicles of a round or oval  shape,  with a
narrow stalk, by which they adhere to the outside of one another.
Some of them are as large as a walnut, and others as small as a pin's
head.  Dr.  Baillie considers that the hydatids found in the uterus,
have not, uncommonly, been only hydatids of the placenta, which had
been retained there.   Sir Everard Home ingeniously concludes, that
the hydatid arises, not from a change in the structure of the placenta,
but from a general affection of the amnion.  When the disease takes
place, as he observes, the  natural healthy actions for the support of
the foetus are  so  much  impaired, that  its  growth is arrested;
when the patient does not early miscarry, the foetus disappears ; and
in all instances where a miscarriage has taken place  in a more ad-
vanced stage of the disease,  no foetus, as far as is known, has been
formed.  Naturalists  consider hydatids  as a kind of imperfect ani-
mals.   Mercury has been  deemed a remedy calculated to promote
the expulsion of hydatids of  the uterus, and there are some reasons
for this confidence.   From the circumstance that sheep, when  pla-
ced in salt marshes, have been relieved, common salt has been  sug-
gested ; and Mougeot has recommended an injection of a solution of
common salt into the uterus.   In a case published  in the American
Medical and Philosophical  Register, vol.  4. by Dr. Eightes, of Al-
bany, the mudated tincture of iron was  found successful.  Would
not the oleum terebinthinae be  a safe  and efficacious remedy ?  The
medical jurist will find some excellent  observations concerning hy-
datids of the uterus, in the masterly pamphlet, drawn up by Br. Bos-
tock, entitled, A vindication of the opinions delivered in evidence, by
the medical witnesses for the crown, on a late  trial at Lancaster for
murder.   Liverpool,  1808. F.]
  t Ascites  Uterinus.—Sauvag.  Hydrometra.—Callen. 
148
INTRODUCTION  TO MIDWIFERY.
  The common explanation of the manner in which the water is
confined in the uterus seems unsatisfactory, and in the  few cases
of this kind which I have seen, is not just.  For in these the  wa-
ter being discharged, a membranous bag was afterwards voided,
though not immediately, which, when  inflated, put on the form of
the  distended uterus, of which it appeared to be a lining ;  so  that
what has been called a dropsy of the uterus, is probably no more
than one large hydatid.
  Another kind of dropsy has been mentioned as appertaining to
the  uterus.  In this the water, originally contained in the cavity
of the abdomen, has been absorbed by the  termination of the fal-
lopian tubes, and conveyed  to the uterus, from which it was  dis-
charged ; but of this kind of operation or  process, I  have  never
known any satisfactory proof.   Yet I must confess, I have  seen
some  cases of water  collected and  repeatedly discharged from
the uterus, in the state of child-bed,  which I was unable to ex-
plain  on any other  principle.*

                         SECTION X.
  It has been said, that wind  may be collected and  retained in
the cavity of the uterus, till it is distended in such a manner as to
resemble pregnancy,  and to produce,its usual symptoms;  and
that by  a sudden irruption of the wind, the  tumefaction  of the ab-
domen  has been removed, and the patient immediately reduced
to her proper size.   Of this complaint I have never  seen an ex-
ample ; but many cases have occurred to me of temporary explo-
sions  of wind from  the uterus,f which there was no power of re-
  * [We have had many marvellous cases recorded of dropsy of the
uterus, in which prodigious quantities of water are said to have been
accumulated in the cavity  of that organ.   It  must, notwithstanding,
be considered as a disease  which perhaps never occurs independent
of pregnancy, unless under the form noticed by our author, as one or
more large hydatids.   If we reject this view of the disorder, we must
suppose a  stricture of the cervix uteri.  I am disposed, says Dr.
Baillie, (Morbid Anatomy,) to believe, that where water has been said
to be accumulated in the cavity of the uterus, it has been really in
one or more large hydatids formed in that cavity.  This opinion has
also the high authority of Sprengel in its  favour.  " Uterus,  qui non
gravidus est,  colligere aquam nequit, nisi peculiari sacco inclusam
aut cum os  uteri praeter naturam clausum  fuerit." See his late work,
Institutiones Medicae,  vol. vii. § 599. de hydrope uteri.  Sprengel
cites a case, ubi salivas fluxus totum hunc morbum solverit.   F.]
   t Physoroetra.  Tympanites uteri —Cullen, Ixx.
   Oedopsophia.   Flatuum per  urethram,  vaginam,  vel  uterum,
emissio.—Sauvag. 
INTERNAL PARTS OF GENERATION.         149
straining.  When no injury has been done to the parts in former
labours,  I presume that this complaint  happens to women  with
feeble constitutions, and some particular debility of the uterus ;  it
is reasonable, therefore, to expect advantage from such means as
strengthen  the habit in general,  or give energy  to the uterus it-
self, of which the best means seem to  be the injection of the Bath
water, or some composition of a similar kind, together  with the
use of tonic medicines internally.  It is, however, right for me to
acknowledge, that I have not been able, in many cases, to render
much service to patients labouring under this complaint, by any
means I  could devise ; but, as it has  not prevented conception, or
produced any injurious effects at the time  of parturition, it has
given me no uneasiness, and after a certain time, it has  either sub-
sided spontaneously,  or ceased to draw  attention.

                         SECTION XI.
  By the term mole* authors have intended to describe very dif-
ferent productions of, or excretions from, the uterus.  By some it
has been used to signify every kind  of fleshy substance,  particu-
larly those which  are properly called polypi; by others, those
only which are  the consequence of  imperfect  conception, when
the ovum is in a morbid or  decayed  state;  and by many, which
is the most popular  opinion, every coagulum  of blood  remain-
ing, which continues  long  enough in the  uterus to assume its
form,  and to retain only the fibrous  part, as it js properly called,
is denominated a mole.
  There is surely much impropriety in  including under one ge-
neral name, appearances so contrary, and substances so different.
Of the polypus we have already spoken.   Of the second kind,
which has been defined as an ovum deforme, as  it is  the conse-
quence of conception, it might  more justly  be arranged under
the class of monsters; for  though it has   the appearance  of a
shapeless mass of flesh, if examined  carefully with the knife, va-
rious parts of a child  may be  discovered,  lying  together in ap-
parent confusion, but in actual regularity.   The pedicle  also, by
which it is connected to the uterus, is not of a fleshy texture, like
that of the polypus,  but has a  regular series  of vessels like the
umbilical cord, and there is  likewise  a  placenta and membranes
containing water.   The  symptoms attending  the  formation,
growth,  and expulsion of this apparently confused mass from
the uterus, correspond with  those of a  well formed child.   By
the favour of Dr. Bland, I many years  ago saw  a very  curious
instance of this kind.
  * Mola.  Massa carnea, vasculosa, ex utero excreta.  Ovum de-
forme.—Vogel. ccclx. 
150
INTRODUCTION TO MIDWIFERY.
  With respect to the third opinion of a mole, an incision  into
its substance will discover its true nature; for, though the exter-
nal surface appears at the first  view to be organized flesh, the
internal part is composed merely  of coagulated blood.*  As
substances of this kind, which  most  commonly occur after de-
livery, would  always be  expelled by the action  of the  uterus,
there seems to  be no  reason for a particular  inquiry, if popular
opinion had not annexed the idea of mischief to them, and at-
tributed their  formation,  or continuance in  the uterus, to the
negligence or misconduct of the practitioner.  Hence the per-
suasion arose  of the necessity of extracting all  the  coagula
of blood out of the uterus  immediately  after the expulsion of
the placenta, or of giving medicines  to force them  away ;  but
abundant  experience  hath  proved, that the retention  of such
coagula is not, under any circumstances,  productive  of  any
dangerous  mischief;  and that they are most safely expelled by
the action of the^uterus, though at very different periods of time
after their formation.

                         SECTION XII.
  The ovaria are the  seat of a particular kind of dropsy, which
most  commonly happens  to women  about  the time of the final
cessation of the menses, though not unfrequently at a more early
period of  life.  It is of the  encysted kind, the fluid being some-
times limpid  and  thin, and at  others discoloured  and gelati-
nous.  In  some cases it has been found to be contained in  one
cyst,  often in several; and in others, the whole tumefaction has
been  composed of hydatids not larger than  grapes.  Of these
different kinds we may often be able to form a judgment by the
evidence or obscurity of the fluctuation,  and  by the inequalities
of the abdomen, especially in its early stage.  I have, however,
seen many cases of a beginning dropsy of the ovarium, which,
from  the firmness of the  tumour, had been considered as  fleshy
substances.
   From the vesicular structure of the ovaria, there may be in
them some inherent disposition to this disease, or they may at
first be affected like  any other  gland in the body, as it often
happens  to women, married or single, with  strumous constitu-
tions.  But this kind of dropsy has  usually been attributed to
other causes;  as accidents or rude treatment at the time of par-
turition,  suppression  of the menses, obstructions of the viscera,
or casual injuries of the  part.   The  symptoms attending it are
  *Excretiones uterinae,  sanguineae  saepe imponunt  pluribus.—
Ruysch. 
INTERNAL PARTS OF GENERATION.          151
pain in the lower  part of the abdomen, with a circumscribed
tumour on  one or both sides gradually extending higher up, and
across  the  abdomen, which,  when there is a suppression of the
menses, is often  mistaken for pregnancy; there is also, in some
cases, a swelling of the thigh or leg  of the same side  with the
diseased ovarium.   In the early state of the disease, this dropsy
may be distinguished from  the  ascites, for  which  it has been
often mistaken, by the circumscription and  position  of  the
tumour; but when it  is increased to  a large  size, unless it be of
an  irregular form,  and we are acquainted  with the early symp-
toms, the distinction  is very difficult, or sometimes impossible.
It is to be observed, that the secretion of urine  is  but little, if in
any degree diminished, and  the constitution  apparently  not
affected in  the beginning of the dropsy of the ovaria ; and that,
even after a long continuance of it, the  principal  inconveniences
seem to arise  from the pressure it makes, from the  unwieldiness
of the  patient, and from apprehension of future mischief.  It is
also very  remarkable, that  this disease  in  many cases  pro-
ceeds so very slowly, that twelve or fourteen years, and often a
much  longer  time,  may  pass from  its commencement to  its
greatest enlargement, though  in  others it makes a very quick
progress ;  and that if one ovarium only be affected,  the patient
may nevertheless conceive and bring forth healthy children.
  In the beginning of this dropsy, when the increasing ovarium
is first  perceptible through the integuments  of the abdomen, and
sometimes  in  its progress, there  is often  so much pain, as  to
require repeated local bleeding by scarification or  leeches, blis-
ters, fomentations, laxative medicines, and opiates, to appease it.
I have also endeavoured to prevent or remove the first enlarge-
ment by a  course of  medicines, the principal of  which was the
unguentum hydrargyri rubbed upon the part, or calomel, given
for a considerable  time in small quantities, with an infusion of
burnt sponge ; or theferrum tartarisatum or  ammoniacale ; trying
occasionally what  advantage was to be obtained from blisters,
from a plaster  composed of  gum ammoniacum dissolved in the
acetum scillae, or, lastly, from  electricity.  From all, or some
of these  means, I  have frequently had occasion to believe some
present advantage was obtained, or mischief prevented ;  but
when the disease has made a certain progress, though a variety of
medicines,  and of local applications,  have been tried, no method
of  treatment has hitherto been discovered sufficiently efficacious
to remove  it  or prevent its increase.  Incision into, or extirpa-
tion of the part, has  been recommended, but seldom practised;
though in the 381st  number of the Philosophical Transactions,
a case  is recorded, which is said to  have been cured by an inci-
sion.   I have also known one case, in which, after the discharge 
152
INTRODUCTION  TO  MIDWIFERY.
 of the fluid by  a puncture, some wine was injected ; but a gene*
 ral inflammation of the contents of the abdomen followed,  and
 the patient died on the sixth day.  But the fluid, once deposited,
 seems to be out of the  power of  the circulation, its absorption
 not being promoted by the use of any of those evacuating medi-
 cines, which  sometimes prove successful in  the other kinds of
 dropsy,  or  by  local  applications, though I  have tried a great
 number  esteemed the most  efficacious  and  powerful,  as  the
 squills, the digitalis and the  elaterium.   When the  disease is so
 much increased as to occasion difficulty  of  breathing or other
 untoward symptoms,  recourse must  be had to the  operation of
 the paracentesis, by which  present  relief is afforded; and by
 a repetition of the same operation, as often as the  return of the
 abdominal swelling to a certain size  may require it,  the life of
 the patient has been prolonged to extreme old age.  Nevertheless,
 I believe it is in general the best practice,  to defer the operation,
 till we are driven  by  necessity to perform it ;  the  progress of
 the disease  is  afterwards more  rapid.    Should there  be  any
 suspicion that  the water is contained in different cysts,  or  that
 the tumour may be composed of hydatids, or the fluid gelatinous, it
 is proper to inform the friends of the patient, that the operation
 may not  succeed, or not in a manner equal to our wishes;  and
 it should be established as a general rule, that  we be assured, by
 an  examination  per vaginam,  that  women  are not  pregnant,
 before this operation  is performed,  even supposing  they have
 undergone the operation before; provided  they are at a time of
 life and under circumstances which justify  any suspicion of preg-
 nancy.  For, through  the want of this circumspection, deplorable
 and  irremediable mischief has in  some cases  been  done  to the
 patient, and the profession very much disgraced.   I have been
 informed of several cases of the dropsy of  the ovarium, in which
 the disease was cured  by  some  unexpected  change or  natural
 process, as in the following example:
  A lady, who had had several children, was brought to bed in
January,  1798, and had  perfectly recovered  her health.  She
 menstruated regularly till the following June,  when she became
 sensible of a pain in the right side  of the abdomen, near the
 groin, which, though not violent, prevented her from lying with
ease, or sleeping on that side.  About the middle of January, 1799,
 she was  suddenly seized with a  violent  pain in  her bowels,
 tension of the abdomen, and  much soreness on pressure, accom-
 panied with  vomiting,  constipation,  and frequent  faintings.
 These complaints were relieved chiefly by glysters and gentle
 purgative medicines,  but  not entirely removed  without repeti-
 tions of them.   Before this attack, she  had been much weakened
 hy profuse discharges  of blood from the uterus, and about  ten 
INTERNAL PARTS OF GENERATION.
153
days after, she suffered very violent pain in the lowest part of
the back, seemingly  near the extremity of the sacrum, which
joins  the os  coccygis, extending to the loins and across to the
hips,  especially the right, and down that thigh.   The slightest
pressure on the sacrum or  hip brought on  excruciating pain in
all the neighbouring parts, which continued  for several minutes
after  the pressure was removed.   This pain was  considered as
the sciatica, and  it  was relieved  by the warm  bath, and the
occasional use of opiates.  By a return of uterine hemorrhage,
every six or  eight days, together with loss of appetite  and  want
of rest,  she became  extremely weak, irritable, and  emaciated.
On every return of uterine  hemorrhage, the pains in  the  back
were much increased, as they also were  by the evacuation of a
costive stool, for which reason glysters were daily injected.   She
never had  such difficulty in voiding her urine,  but frequent in-
clination  to  do it: yet there never was in it  any distempered
appearance.
   About the middle  of February, she could bear to be turned
from her back to her side, but at those times she felt as if  some
heavy substance was contained in the abdomen, which shifted its
place as she was turned.   After a  confinement of six  weeks to
her bed, the painful symptoms were mitigated, she was able to
sit in a chair, with her feet raised high and her  knees drawn up,
but she was soon obliged, by the pain in her back, to return to a
recumbent position; nor was she able to suffer the right leg to
approach the ground, or bear the least weight upon it.
   Her health and strength, however, gradually improved,  and
in March she was able to move and walk a little, but, instead of
her former complaints, there were great tension and pain above
the ossa pubis, and the whole hypogastric region was full  and
bard, but not sore to  the  touch, except on the right side, where
the hardness  was first perceived.  One  day about this   time,
while she was in the warm bath, she discovered a large  and  hard
tumour, extending to  the right side of the navel,  the increase of
which was so rapid, that in  the course of a few days it occupied
the whole abdomen.   She  was then  freed from pain in all the
parts  contained in the pelvis,  could turn herself in bed, and lie
on either side, and not only  move her legs, but walk much bet-
ter.   She frequently after this had  slight shivering  fits, and  a
sense  of  coldness down her back, followed by restlessness  and
feverish heat, especially in her hands and feet in the evening,
which went off  with a free perspiration toward morning.   Her
pulse was at all times  very quick.
   Though one  or more stools had been regularly procured
every day, an  immense quantity of hardened faeces, of a large
vo!ume> were now discharged for three  or four successive days,
                            20 
154
INTRODUCTION  TO  MIDWIFERY.
by which her size was much lessened.   She was soon after able
to bear a journey to London, her friends being solicitous that
the nature of her complaint should be ascertained,  as there had
been various opinions and representations made of  it, by differ-
ent gentlemen who had seen her in the country.
   On Sunday, March 31st, I  visited this lady, and  as it seemed
of principal importance to discover in the first place  the  seat
and nature  of her disease, it  was necessary to be  particular in
my inquiries and examination.  The whole  abdomen was  dis-
tended  by a circumscribed  tumour, evidently connected  with,
and springing from the right side, near the groin, thence extend-
ing across, and high up in the abdomen.  This tumour, though
not perfectly uniform  over its surface,  was  distinctly circum-
scribed, and I thought I could perceive an obscure fluctuation in
it.  I  could also  feel  an angle of the tumour in the  posterior
part of the  pelvis, by which the os uteri was projected so high,
and so far forwards, as to be almost beyond  my reach,  as is the
case in a retroversion of the uterus.   I could also ascertain  that
she was not pregnant.   I  did  not. therefore, hesitate to  give my
opinion, that  it was the  dropsy in  the ovarium ;  and by sup-
posing this, early in the disease, to have dropped low down in
the pelvis, and afterwards to have risen according to its increase,
all the symptoms  which had  occurred in the course of the dis-
ease could be satisfactorily explained.
   Having represented my opinion to the patient and her friends,
though I could  give but little hope of the disease  being cured,
I freed them from the fear and solicitude of any immediate dan-
ger.
   The under-mentioned  draught was the only medicine I ad-
vised :
                r> Flor. Chamamel. pulv. gr.  xv.
                  Rad. Rhei,  pulv. gr. v.
                  ----Zingiber,  pulv. gr. iij.
                  Aqu. Ment.  sativ. unc. ij. m. f. haustus.
                  Sumat ter quotidie.
    On  the following day, she informed me, that, after  suffering
  considerable pain in the bowels,  she had had four or five copious
  motions, and that alter  every motion she  was sensible of her
  size  decreasing.  The motions  were unusually offensive,  and,
  before they came away, the desire to expel them was unnaturally
  urgent and painful.  On examining them,  I  found  that they
  almost wholly consisted of a  gelatinous fluid with many streaks
  of blood, and with little  or no mixture of faeces.
    The same medicines were  repeated.
    On Tuesday,  after  several other motions of the  same kind,
  the distension of the abdomen was lessened more  than one half, 
INTERNAL PARTS  OF  GENERATION.        155
and  instead of being weakened  by the evacuations, the patient
felt herself very much relieved,  and cheered  with the prospect
of a speedy recovery.  She took a sufficient quantityof nourish-
ment, and continued the same medicine
  On Wednesday, I had neaily the same account of the num-
ber of motions, and of the  gradual  decrease of the  swelling of
the abdomen, which was  now in fact wholly gone, except that I
could feel the  small  tumour  formed by the cyst, in which the
fluid had been contained.
  On  examining this day, per vaginam, the os uteri was found
to be ascended into its  proper situation, and no tumour what-
ever remained in the cavity of the pelvis.   The patient, in short,
felt and  considered  herself as  well, in  which sentiment 1 en-
couraged her; concluding, in my own mind, that, in consequence
of preceding inflammation, an adhesion had taken place between
the cyst of  the tumour and some part of the intestine, probably
the rectum, the adhering portion of the bowel had given way,
and,  by that  opening,  the contents of the tumour had been
evacuated.
  But in  several other cases, the disease has been  entirely
removed   without  the  use  of any  medicine, or  any adequate
evacuation,  or my being able almost to discover how the fluid
was carried off.   I have, therefore,  recommended such exercise
as was most likely to  affect the part, as spinning, or turning the
lathe, by which the coat  of the cyst may. perhaps, be gradually
worn through.  It is  well  known,  when the abdomen is much
distended, that by a fall,  or some extraordinary motion, the cyst
has burst, and the water contained in it  been speedily absorbed
and carried off by the common emunctories.

                        SECTION XIII.
  The ovaria are also  subject,  especially a short time after de-
livery, to inflammation, terminating  in  suppuration,  and  to
scirrhous  and  cancerous  diseases,  with  considerable  enlarge-
ment.  In the  former state,  they  generally adhere  to  some
adjoining part,  as  the  uterus, the  rectum, the bladder, or the
external  integuments; and  the matter is  discharged  from the
vagina,  by stool,  by urine, or by an  external abscess of the
integuments of the abdomen, and of these cases  I have thought
it necessary to subjoin an example.   (See the Chapter on Puer-
peral Fever. ^  They are cases which always require much care
and skilful management;  but in general, instead of aiming to
cure them, it will be most serviceable to attend to the symptoms,
and by quieting these, and  supporting the strength, the constitu-
tion at length  cures the disease.  But in simple enlargements,
or beginning dropsies of the ovaria, they continue deia< lied and
free from any adhesion; and, sinking lower down in the pelvis 
166         INTRODUCTION  TO MIDWIFERY.
on one side, or in the  hollow of the sacrum, sometimes produce
inconveniences according to their size and situation, by obstruct-
ing the offices of the rectum  or  bladder.   Of those  by which
the progress of a labour may be impeded, we  shall  speak  in
the detail of the causes of difficult labours; but an instance of a
diseased  ovarium, occasioning the symptoms of a retroverted
uterus, is  so well described in a  case sent me by my very able
and most  ingenious friend, Sir Everard Home, now senior sur-
geon of St. George's Hospital, that I shall beg leave to relate it.
  " Susannah Fletcher,  in  the twenty-third year  of her age,
had a suppression of urine, which frequently required  the  use of
the catheter.  Not being able to support the expense of medical
attendance,  she  obtained admission into  the  Gloucester  Infir-
mary, where having continued for several months, without any
other than temporary relief, she gave up all hope of being cured,
and returned to  her husband.   She soon became pregnant, and
in a short time, was surprised to find that her complaint left her,
though it returned  immediately after her  delivery.  It disap-
peared a  second time in the same manner, and  under the same
circumstances.   Her husband  went abroad while she  was preg-
nant, and,  after her delivery, she was obliged to go to service
for her maintenance; but the daily necessity she was under  of
having the  catheter introduced,  rendering her unfit  for that
situation, she was admitted a nurse in the royal hospital at Ply-
mouth, of which I was one of the assistant surgeons, in December,
1778.
   " She was then unable to void any urine without the catheter,
she was habitually costive, her  stomach was  easily  disturbed,
and she was subject  to  hysteric  fits.  In all other respects she
was tolerably healthy, and menstruated with regularity.
   " In May, 1779, in the agitation of a violent fit, she vomited
a large quantity of blood;  and this  hemorrhage  frequently
returning, she died in the beginning of June following.
   " The body was opened  in  the presence  of several gentlemen
belonging to the hospital.
   " All the viscera of the abdomen were in a healthy state, ex-
cept the stomach and  duodenum, which were somewhat inflamed
on their external surface,  and the former internally also near the
cardia; but we could not discover the orifice of the vessel,  which
had been ruptured.
   " Examining  the contents  of the pelvis, we found the uterus
pushed forward toward the ossa pubis; and the right ovarium,
which  was enlarged beyond the  size of a hen's egg,  and lying
between the vagina and rectum,  had formed  a bed there, and
was so much fitted  to that position, that it could not  easily  be
retained in  any other.  The left  ovarium, uterus, and bladder,
were free from disease, or ?  -  ''    *' 
INTERNAL  PARTS OF GENERATION.        157
   " The situation of the right ovarium was no sooner observed,
 than it occurred to me  that it  had produced the same effect, as
 when the uterus falls back upon its  cervix in the retroversion of
 the uterus; and with this idea, all the symptoms of the disease
 under which the  poor woman had laboured, the removal of the
 suppression  of urine during pregnancy,  and  its return  after
 delivery,  could be readily explained.  The analogy between the
 symptoms of the retroverted uterus, and the effect produced by
 the diseased ovarium, were in  this case too obvious to escape
 observation; but if the cause of the disease had been discovered
 during the life of the patient, it would  have been  difficult to  have
 afforded relief, unless some surgeon had been  intrepid enough to
 have passed a trocar through the posterior part of the vagina
 into  the ovarium, and discharged the fluid which it was found
 to contain."
   There have been instances of one of the ovaria passing under
 Poupart's  ligament  into  the groin,  or  through  the tendinous
 opening of the oblique muscles, where it has put on the  appear-
 ance, and produced the same symptoms, as when  a small portion
 of the omentum or intestines is strangulated :  and relief has  been
 Obtained by the same mode  of proceeding, as if it were a real
 hernia of the intestine; that is, by dividing the stricture. In Mr.
 Pott's works  there is a very curious case of this kind, in which
 both the ovaria were extirpated.   The  patient recovered, but ne-
 ver menstruated afterwards.
  It is very remarkable, that, in  diseases of  the  ovaria, teeth,
 hair, bones, and other extraneous  animal substances,  are found
in them so frequently, that there is  scarce a collection of anatomi-
 cal curiosities, in which  there are  not  various examples.   These
 substances have hitherto  been considered as remnants or parts of
an imperfect conception,  but a celebrated anatomist* of the  pre-
sent time has fully proved, that they may be formed without  con-
ception, or even any connubial intercourse.!
   *  See a very  excellent work  published in 1812,  The  Morbid
Anatomy of some of the most important parts  of the Human Body,
by Dr. Matthew  Baillie, in which this subject  is exemplified and ex-
plained.
   t  [So numerous are the diseases to which the ovaria are liable, so
slight their diagnostic signs, and their assigned causes so dubious
and disputed, that our prescribed limits will  not allow us,  in  this
place, to enter into a formal discussion.
   Among the  diseased  appearances which have been  observed in
the ovaria,  Dr. Baillie has noticed their enlargement and  hardness,
their change of natural structure  into  a pulpy substance, and their
change into a fatty substance, with  hair and teeth:  he has also ob-
served that they are sometimes changed into a  true scrophulous mat- 
158          INTRODUCTION TO  MIDWIFERY.
ter, intermixed with cells.  But the most common disease to which       ,
the ovaria are liable is dropsy.   Numerous instances of this affection
are recorded : one of the most remarkable  is that published by Mr.
Chevalier, in the Transactions of the Medical and Chirurgical Soci-
ety of London, vol. 3.   The abdomen measured sixty-three inches
and a half in circumference, and thirty-eight inches from the point of
the ensiform cartilage to the top of the pubis. The legs were oedema-
tous  ; the left, considerably more so than the right;  and a great part
of the skin of the left leg was in a state of complete ichthyosis.  The
lower part of the belly was also oedematous, and the navel, when she
sat, was on a  line with the knee.  The fluid evacuated at different
times by an operation, amounted to seventeen  gallons.  The patient
died.  Upon  examining  the body,  the whole cavity  of the abdomen
appeared to be occupied by two large cysts,  formed in the left ova-
rium, closely connected together.  They  both adhered,  anteriorly
and laterally, to  the parietes of the abdomen.  The  upper cyst con-
tained about two quarts  of a brown, glairy fluid, like that which had
been evacuated in the first operation.  The inferior cyst contained
three gallons of  purulent fluid.  There were also  two  very small
cysts, formed in  this ovarium, one containing about four  ounces of a
soft, gelatinous substance, and  the other about half an ounce.  The
right ovarium and the  uterus, were  in a perfectly healthy state.
The author has  mentioned other morbid appearances.—Another re-
markable case of diseased ovary, which was considered as encysted
dropsy, may be seen in the London Medical Repository, vol. 9. Upon
examination,  after death,  the tumour was taken out: it weighed
eighty five pounds, avoirdupois,  exclusive of more than a gallon of a
discoloured fluid that escaped.
   Dropsy of the ovarium, according to Dr. Hunter, is an incurable
disease,  and that patient, in his opinion, will  have the best  chance
of living longest under it, who does the least to get rid of it.
   Yet, in this desperate complaint, tapping is often   resorted to for
present relief, and has occasionally been the means of ultimate cure.
Dr.  Richard S. Kissam informs me, that in the year 1806, a case of
this disease came under his care.   Tapping was had  recourse to with
success.  Nearly six quarts of water were drawn off.  The patient,
afterwards, proved pregnant,  and  became the mother  of five chil-
dren.
   Dr. M'Dowell,  in the Eclectic  Repertory, vol. 7. relates three
cases of diseased ovaria, in which, by extirpation,  the patients reco-
vered.   See also vol. 9.  F.j 
PARTS CONTAINED IN THE PELVIS.        159
                       CHAPTER IV.

                          SECTION I.

    ON THE PARTS CONTAINED IN THE CAVITY OF THE PELVIS.

   The principal parts contained in the cavity  of  the pelvis are,
 first, the urethra, which is connected with the internal surface of
 the symphysis of the ossa pubis, with its orifice terminating im-
 mediately below the inferior edge,  and joined  at its other extre-
 mity to the bladder;  which, when distended with  urine, ascends
 into the  cavity  of  the abdomen, in proportion to its distention,
 and rests upon the upper edge of the ossa pubis.  Secondly, the
 vagina, or  canal which  leads from the pudendum to the uterus,
 passing  obliquely  upwards  and  backwards;  connected poste-
 riorly with  the lower  part  of the rectum, and anteriorly with the
 urethra and inner surface of the ossa pubis, as is  the  uterus,  in
 part, to the  bladder.  Thirdly, the rectum, or intestine, the pos-
 terior part of which adheres to  the hollow of the  sacrum.  But
 we are not to conclude  that any part of the  cavity of the pelvis
 is unoccupied; for, besides these principal parts, the nerves, and
 blood vessels, some of which are of a considerable size, every
 space between them is filled with cellular or adipose  membrane;
 and it seems as if  by  the pressure upon this, at the time of par-
 turition, an  effect  equivalent to an  absolute enlargement of the
 cavity was produced.
   The cavity of the pelvis is considered, by anatomists,  as the
 inferior part of the cavity of the abdomen ; but, in a description
 of its contents, with a view to the  practice  of  midwifery, it ap-
 pears more convenient to speak of them as distinct cavities, sepa-
 rated by the peritonaeum, which, descending from the fore part
 of the abdomen, passes over the fundus, and posterior part of the
 bladder, ascends over the anterior part and fundus  of the  uterus,
 and  then,  making a deep inflection,  covers the back part of the
 uterus, and a great portion of the vagina.   It  then  reverts over
 the anterior part of the rectum, and  proceeds to form a lining  to
 the cavity of the abdomen.
   By this inflection of the peritonaeum, the uterus, during preg-
 nancy, is  permitted to expand more freely, and to rise without
 inconvenience into the cavity of the abdomeu.  But from the
 same cause women become liable  to  various diseases,  to the
 retroversion of the uterus,  to hydrocele, or  dropsy of the peri-
nasum, and to that species  of hernia, which is occasioned  by the 
160
INTRODUCTION TO MIDWIFERY.
descent of the intestines between the vagina  and rectum.  But
quadrupeds, by their horizontal position, are  exempt from every
disadvantage,  to  which the inflection of the peritonaeum  may
subject women.
  By the term retroversion, such a change of the position of the
uterus  is understood, that  the fundus is turned backwards and
downwards  upon its  cervix, between  the vagina and rectum  ;
and the os uteri is turned forwards to the pubis, and upwards in
proportion to the descent of the fundus, so that, by an examina-
tion  per  vaginam, it  cannot be felt, or  not  without difficulty,
when the uterus is retroverted or subverted.  By the same exami-
nation there may also be perceived a large round  tumour, oc-
cupying the inferior part of the cavity of the pelvis, and pressing
the vagina towards the pubis.   By an  examination per anum,
the same tumour  may be felt, pressing  the rectum to the hollow
of the sacrum; and if both these examinations are made at the
same time, we may readily discover that the  tifmour is confined
between the vagina and rectum.
  Beside  the  knowledge  of  the  retroversion  which  may  be
gained by these  examinations, it is found to  be accompanied
with other very distinguishing symptoms.  There is in every case,
together  with  extreme pain,  first a retention, and  afterwards a
suppression, of urine ; and by the continuance of this distention
of the bladder, the tumour formed by it  in  the abdomen  often
equals in size,  and resembles in  shape,  the  uterus in the  sixth
or seventh month of pregnancy.  But it is necessary to observe,
that  the retention of urine is frequently absolute only before the
retroversion of the uterus, or  during the time it is retroverting;
for,  when the retroversion is completed, there is often a discharge
of some urine, so as to prevent an increase of the distension of the
bladder,  though  not  in a sufficient  quantity  to  remove  it.
There is also an  obstinate  constipation of the bowels, produced
by the pressure of the retroverted uterus upon the rectum, which
renders the injection of a clyster very difficult, or even impossible.
But  it appears that all the painful symptoms are chiefly  in con-
sequence of the retention of urine; for none of those parts, which
are apt to sympathise in affections or diseases of the uterus, are
disturbed by its retroversion.
   The retroversion of the  uterus, has generally occurred about
the  third month of pregnancy, and sometimes after delivery; it
may likewise happen when the uterus is, from any cause,  enlarg-
ed to the size  it acquires about the  third month of pregnancy,
but not with such facility as in the pregnant state, because the
enlargement is then chiefly at  the fundus.   If the  uterus is but
little enlarged, or if it be enlarged beyond a certain size, it can-
not well  be  retroverted ; for, in the first case,  should the cause of
a retroversion exist, the weight at the fundus would  be wanting 
PARTS  CONTAINED  IN THE PELVIS.        161
 to produce it; and in the latter, the uterus would be raised above
 the projection of the sacrum, and supported by the spine.
    The retention of urine  has hitherto been supposed  to be the
 consequence of the retroversion of the uterus, which has been as-
 cribed to various  accidental causes.  But, if we consider the
 manner in which these parts are connected, and examine the ef-
 fect produced by the inflation of the bladder in the dead subject,
 so as to resemble, in some measure,  the distention brought on by
 a retention of urine in the living, we shall be  convinced that the
 uterus must be elevated,  before it can be retroverted.*  Now, as
 there appears to be no cause, besides the distention of  the blad-
 der, capable of elevating the uterus,  and at the same time pro-
jecting its fundus backwards; and, as such elevation and  pro-
jection necessarily  follow the distention of  the  bladder,  it is
 more  reasonable  to conclude that  the  retention of urine pre-
 cedes  the retroversion,  if we do  not allow it to be a cause with-
 out which the retroversion cannot exist.  Moreover, if the uterus
 be in a state which  permits it to  be retroverted, when  the bladder
 is much distended, a retroversion  is a necessary  consequence, or
 it may be produced by a very trifling accident.  If a woman, for
 instance, about the third month of her pregnancy, has  a  retention
 of urine continuing for a certain time,  and producing  a certain
 degree of  distention of the bladder,  we may be  assured that the
 uterus is retroverted.
   It would be vain  and absurd to contend for the opinion, that,
 first a retention, and then  a suppression of  the  urine, are the
 causes of the retroversion of the uterus ; for,  were it not just, it
would be contradicted by daily  experience.  But the matter no
longer rests upon the foundation of opinion or conjecture : for,
from the first case in which I thought I  had reason to suspect it,
I have so constantly observed it, either by the reserve of women
of superior rank in life, or by the restraint of those in inferior situ-
ations, neglecting or being prevented  from attending to  the calls
of nature, that there does not remain a doubt concerning it. The
fact hath also  been proved in a variety of cases,  by practitioners
of the first eminence, who have supplied me with  the most un-
questionable testimonies of its truth ; and, in this case,  it  is a mat-
ter of  great importance to discover the cause of the  disease, as
the method of preventing it, and relieving  the patient, with per-
fect safety, is thereby immediately pointed out.
   But the  preceding retention of urine  may  be overlooked, as
  *  By repeated and strong inflations of the bladder, and then press-
ing out the air in the dead Mibject, I could give a very  good idea of
the  retroversion of the uterus ; and  probably, if I could have had
an opportunity of making the experiment  in a state of pregnancy, I
might have succeeded in producing an actual retroversion.
                          21 
162
INTRODUCTION TO MIDWIFERY.
there is not occasion for it to be of long continuance, in order to
produce this effect; especially in a woman who hath a capacious
pelvis, in whom the retroversion  of the  uterus  is most likely to
happen.   It must also be observed, that, though the retention of
urine  gives to the uterus its first  inclination to retrovert, yet the
position of the os uteri is such, in  the act of retroverting,  and the
tumour formed by the fundus is  >ometimes so  large, when ac-
tually retroverted, as  to become, in their turn, causes  of the con-
tinuance of the retention of urine.
   Should any doubt remain of the cause of  the retroversion, it
cannot, however, be disputed, but that all attempts  to restore the
uterus to its natural position, before the distention of  the bladder
is removed, must be fruitless,  as the  uterus  will  be irresistibly
borne down by the pressure of the superincumbent bladder. The
first step, then, to be taken for the relief of the patient is, to <!iaw
off the urine:  yet there is always in  these cat.es great  difli« ulty
in the introduction of the common catheter, because the urethra
is elongated, altered  in  its direction, and pressed  against the
ossa pubis, by the tumour formed by the retroverted uterus ; and
many women, when the uterus was retroverted, have lost their
lives, from the  want of expertness in introducing the catheter.
But the attending inconveniences may be avoided  or surmounted
by the use of a flexible male or female catheter, slowly conducted
through the urethra.  I say  slowly, because, whatever  catheter
is used, the  success of the operation,  and the  ease  and safety of
the patient, very much depend upon  this  circumstance.  For, if
we affect to perform it with haste and dexterity,  or strive to over-
come the difficulty by force, we shall be foiled in the attempt, or
it will be scarcely  possible to avoid  doing very great injury to
the parts.  The catheter  should not be carried farther into the
bladder, when the urine, often collected in an immense quantity,
and mistaken for some other disease, begins to flow,  unless  it
ceases before the distention be removed ;  which, in  some cases,
happens in  such a manner, as to give us the idea of a bladder divi-
ded into  two cavities.   External pressure  upon  the abdomen,
when the catheter is introduced, will also favour the discharge of
the urine, after which the patient  is sensible of such  relief, as to
conclude that she is  wholly freed  from her  disease.  A  clyster
should then be injected, or some opening medicine given, and re-
peated^ if necessary,  to remove the faeces,  which may have been
detained in the rectum before, or during the continuance of the
retroversion.
   But though the distension  of the bladder is removed  by the
 discharge of the urine, and all the symptoms  occasioned by it
 relieved, the uterus  will continue  retroverted.   It has been said
 that the state  of retroversion  was injurious  to the uterus itself,
 and  would  soon produce some dangerous disease in the part;
it has also  been asserted,  that, if the uterus were permitted to 
              PARTS CONTAINED IN THE PELVIS.         168

 remain in  that state, it  would be  locked in  the  pelvis by the
 gradual enlargement of  the  ovum, in such a manner as to ren-
 der its reposition  impracticable, and the  death of the patient an
 inevitable consequence.  On the ground of these opinions we
 have been taught that it is necessary to make attempts to restore
 the uterus to its natural  situation, with all expedition, when the
 urine is discharged, and that we are to persevere in these at-
 tempts till we succeed.  In case of failure by plain and common
 methods, the means we  have been advised to pursue, many of
 w'lich  are severe, and some extremely cruel, as  well as useless,
 would  best  describe  the dread  of  those consequences which
 have been apprehended from  the retroversion.
   For  both those consequences there cannot  surely be  rea-
 son to fear  If  the uterus be injured, there will be  no  farther
 growth of the ovum ;  and if the ovum should continue to grow,
 it is the most infallible prooF that  the  uterus has not received
 any material injury.  But it  is remarkable, that  in the most de-
  lorable cases of the retroversion  of the uterus,  those which
  ave determined  fatally, the  death of the patient has been dis-
 covered to be owing to the injury done to the  bladder only.  It
 is yet more remarkable, in the multiplicity of cases of this  kind
 which  have occurred, many of which have been under the care
 of practitioners, who  had no  suspicion that the  uterus could be
 retroverted, and who would, of course, make no attempts to re-
 place  it,  that there  should be so  few  instances of  any injury
 whatever.   Yet every patient under these circumstances  must
 have died,  if their safety had depended upon the restoration of
 the  uterus to its proper situation by art; attention  having  only
 been paid to the   most obvious and  urgent symptom, the reten-
 tion of urine, and to the prevention  of the mischief which might
 thence arise.
   Opinions are often vain and deceitful, but, with respect to the
 matter  now under consideration, they have also  been very pre-
judical.  For it has been proved in  a variety of  cases, many of
 which  were attended to with particular care by unprejudiced and
 very capable witnesses,  that the uterus  may remain  in a retro-
 verted  state for many days or weeks, without any other detri-
 ment,  than  what  may be occasioned by the  temporary inter-
 ruption of the discharges by stool or urine; and, contrary to all
 expectation, it hath been moreover proved, that the  uterus, when
 retroverted, will  often be gradually, and sometimes  suddenly,
 restored to its position without any assistance, provided the cause
 be  removed by the  occasional use of the catheter.  It appears
that the enlargement  of  the  uterus, from the  increase of the
ovum,  is so far from obstructing the ascent  of the fundus,  that
it contributes to promote  the effect, the distension of the cervix
becoming a balance to counteract the depression  of the fundus;
for I have found no cases of  the retroverted uterus admit of a
1 
164          INTRODUCTION TO MIDWIFERY.
reposition with such difficulty, as in women who were not preg-
nant,  in  whom  the uterus underwent  none,  or  no  material
change.
  Allowing that  we have the  power  of returning  the uterus
when retroverted  to its proper situation; knowing, also, that it
may continue  retroverted  without  any  immediate  ill   conse-
quences ;  and presuming that it is capable of recovering its situa-
tion by the gradual exertion of its own power, at least that such
recovery is  an event which spontaneously follows the  change
which the part naturally undergoes;  it is  necessary to consider
the advantages  and disadvantages  which  may result from our
acting according to either intention.
  If the attempt to replace the uterus be instantly made after the
urine is discharged, so  much force will often be required for the
purpose as will, notwithstanding all precaution, give much pain,
induce the  hazard of  injuring  the  uterus, and  often  occasion
abortion; which, in some instances, is also said to have  happen-
ed  when  little  force was used, and  even when  the uterus was
actually retroverted; and of this I can no longer  entertain any
doubt.   It must  likewise be granted,  that, in some cases, by
passing two or more fingers into  the vagina, the  fundus of the
uterus may be raised beyond the projection of the sacrum with-
out much  force, and the  patient be soon and altogether freed
from the  complaint and  its consequences.  But  in other cases,
repeated attempts, with  various contrivances, and with the patient
at the  same  time  placed in the  most favourable positions, have
failed to procure success.   It hath also been observed, when the
uterus has been fully raised to  its natural situation,  that it has
for some  time afterwards, and from  slight causes, been  again
retroverted.
  If, on  the  contrary, we are persuaded,  that the uterus will
sustain no injury by its  retroversion, and that there is no danger
of  its  being locked in  the  pelvis, but that it  will   be gradually
restored to  its natural  position without assistance, we have then
only to guard against  those inconveniences,  which may be oc-
casioned  by the distention  of, or the pressure made upon the
bladder and  rectum.  By  the former of these  we shall be redu-
ced to the necessity of using the catheter daily  or frequently,
which is generally done without difficulty, except  the first time
it is introduced.   This operation, it  must be  acknowledged, is,
in all  cases, very disagreeable and  troublesome to the  patient;
and, in some situations, the necessity we are  under of  perform-
ing it so  often, and for  so long a  time,  is in itself a sufficient
reason for our  attempting  to replace the uterus speedily.  But
the retention of urine does  not always remain through the con-
tinuance of the  retroversion of the uterus; for, when the disten-
tion of the bladder has been  removed  for  a  very few days, its 
PARTS CONTAINED IN THE PELVIS.         165
 power of action will  be restored, the pressure upon it lessened,
 and the  patient will  become able to void  her urine  without
 further assistance, during the continuance of the retroversion.
   We  may then bring the  matter to this issue: if the  uterus,
 when retroverted, can  be replaced by art, without the exertion of
 much force, or  the  risk  of  mischief,  the  immediate reposition,
 though  not  absolutely necessary, is  at all times an event to be
 wished; as  further apprehension and  trouble are prevented,
 the safety of  the patient  ensured, and her mind quieted.  But,
 when  the uterus cannot be replaced without violence, it seems
 more justifiable to wait for  its return, and to  satisfy ourselves
 with watching and relieving the inconveniences produced by the
 retroversion.   We shall  also find, that the longer the attempt
 to  replace the  uterus is delayed, the more easy the operation
 will ultimately be, and the success more certain; though I have
 known many cases in  which the uterus was repeatedly retrovert-
 ed  in a  short  time  after its  reposition, without any additional
 mischief.
   To   those who have been  accustomed  to consider the retro-
 version of the  uterus  as productive of immediate and  urgent
 danger, it may seem strange to assert, that, when the urine is
 discharged, the patients are  often able to return to the common
 business of life without danger, and with  very little  trouble, if
 no  essential  injury has been done  to the  bladder  by the great-
 ness or long continuance  of the distention.   I do not mean that
 they will be as perfectly easy as if  the uterus was not retrovert-
 ed ; but  the inconveniences they may suffer will be trifling and
 of short duration, compared with those which  might arise from
 violent  attempts to replace it.
  I shall conclude  these remarks with  two observations which
 will appear extraordinary.   First, women who live in an humble
 situation of life, or in  an unrefined state of society, are scarcely
 ever liable  to  this complaint, because  they are free from the
 constraint of  company ;  and those in the highest ranks of the
 most  refined society, not being abashed  to withdraw from com-
 pany,  are nearly in the same situation.   But  those who,  in a
 middle  state  of life, with decent, yet  not over refined manners,
 have not cast off the bashfulness of the former,  nor acquired the
 freedom of the latter,  are most subject to the retroversion of the
 uterus.
  Secondly, from the  time when the first  accounts of the retro-
 version of the  uterus were given  in  this  country,  which were
 written  with  great  accuracy, but with too much apprehension
 till  within these few years, it was esteemed to be a case of great
danger, and to  require the most delicate management.   But, at
tfie  present time, no practitioner  of credit considers it as a case
of any difficulty, or  feels any solicitude for the  event, provided 
166          INTRODUCTION TO MIDWIFERY.
he be called to  the relief of the  patient  before  any mischief h
actually done.  (See Medical Observations and Inquiries,  Vol.
IV. and subsequent volumes.)*
   * [In this section  our author is little satisfactory either in his pa-
 thological or practical views : To Gregoire and Levret is due  the
 honour of first describing retroversion of the uterus ; but the atten-
 tion of the profession was more particularly aroused to its importance
 by the publication of Dr. Hunter.
   A retroversion  of the impregnated uterus is  most apt to take
 place between the second and fourth months of pregnancy.   Smel-
 lie, however, has given us an instance of it at the fifth month, and
 Dr. Dewees saw  a  case, in consultation with Dr.  Gallagher, at  be-
 tween the sixth and  seventh months.  But cases of this sort are
 very rare, and we must look for the concurring circumstance of an
 unusual size  of the  pelvis, or the small size of the ovum.   In the
 patient of Dr. Dewees there was retarded development  from her
 labouring under a confirmed phthisis puhnonalis ; her cough was
 severe, and, in a  fit  of more than ordinary severity and length, the
 uterus was retroverted.  Dr. R. S. Kissam, of this city, had a case of
 retroversion of the  uterus at the fifteenth week of gestation.  Our
 author's opinion, that if a woman, about  the  third month  of her
 pregnancy, has a retention  of urine  continuing for a  certain time,
 and producing a certain degree of distension of the   bladder,  we
 may be assured that the uterus  is retroverted,  manifests a singular
 want of precision in diagnosis, and is wholly untenable.   Instances of
 retention of urine frequently occur that are not followed by retro-
 version : though that state of the bladder is very  properly considered
 as  the  most  common occasion  of the disease.   Other causes may
 induce a retroversion, as a womb enlarged by disease, a severe blow
 across the back while stooping,  over exertion  in attempting to lift
 a heavy weight, a fright, kc.  " We  have many times,"  says Dr.
 Dewees, " known a  suppression of urine without a retroversion ;
 but  we have never known the converse of this."   See also, Bau-
 delocque.
  Retroversion of the uterus may occur at other periods ; as after
 delivery, and   when the catamenia cease.   The cases which have
 fallen under the observation  of  Dr. Merriman have principally oc-
 curred on the  second  day after the birth  of the  child,  the degree of
 contraction which  the womb has by  that time  undergone, having,
 in his  opinion, reduced it to a size the most fit to suffer such dis-
 placement.  In one  instance it  took  place  on  the ninth day after
 delivery.  Hence the great need of attending to the quantity  of the
 urinary discharge after parturition has been  accomplished.  Retro-
 version, though sometimes gradual in its  progress, in general  comes
 on  suddenly.
  When the disease exists,  it becomes our immediate  duty to draw
 off  the  urine, and Dr. Denman  has  very happily pointed out the
method.  For the purpose of relieving the bowels, enemata are to 
PARTS CONTAINED IN THE PELVIS.         167
                          SECTION II.
  Another complaint,  similar to that of which  we have been
speaking, and which  has been called a retroflection of the uterus,
has occurred in practice.   By this term is implied such an altera-
tion  in the position of the  parts of the uterus,  that the fundus
is turned  downwards and  backwards  between  the rectum and
vagina, whilst the os uteri remains in its natural situation ; an
alteration  which  can only  be  produced  by the curvature or
bending of the uterus in the middle, and in one particular state;
that  is, before it is properly contracted when a woman has been
delivered.
  A suppression of urine existing at  the  time of delivery, and
continuing unrelieved  afterwards, was the cause of the retro-
flection of the uterus in the single case of this kind of which I
have been informed by Dr. Thomas Cooper; and the symptoms
were like  those which were occasioned by the  retroversion.
  When  the  urine was drawn off by the catheter, which was in-
troduced  without difficulty,  the fundus of the uterus was easily
replaced  by raising it above the projection of the sacrum, in the
manner advised in the retroversion, and it occasioned no farther
trouble.
                          SECTION  III.

  That affection of the vagina  and  perinaeum, which I  have
termed the hydrocele, or  dropsy of the perinaeum, is  not an
be administered ; and  when, by ordinary means, this is found to be
impracticable, we may successfully employ a large male gum elastic
catheter for  the canula, as Dr. Dewees proposes.  Copious blood-
letting may prove a powerful assistance in  our  attempt at a reposi-
tion.   " We  shall  find," says  Dr. Denman, " that the longer the
attempt to replace the uterus is delayed, the more easy the operation
will ultimately be, and its success  more certain."   This declaration
is at variance  with  what he himself has previously asserted, that
an immediate reposition is, at all times, to  be wished, as  the safety
of the patient is thereby secured.   Indeed, the womb continues to
increase daily, and  its return to its natural position becomes  more
and  more difficult, and delay is calculated to lead to the  most fatal
results : the  death  of the patient, when it has taken place in this
disease, has almost always been from neglecting the proper period
of reposition.  Writers, in general,  have not ascribed a due impor-
tance  to retroversion  of  the uterus :  even Dr.  Merriman, so
judicious in  many respects, is faulty in  this  particular.—For an
ample and satisfactory exposition of this subject, 1 must  refer the
reader  to the Observations of  Dr. Dewees, published in Dr.  Chap-
man's Philadelphia Journal of the Medical and Physical Sciences,
vols.  I. and 2.   It would  be injustice to  the author to attempt an
analysis of his paper.   F.] 
168          INTRODUCTION TO MIDWIFERY.
original disease of the part, but a symptom of the ascites, or of the
encysted dropsy, occasioned  by the  pressure of the water  con-
tained in the  cavity of the abdomen, upon the inflected part of
the peritonaeum between the  vagina and rectum.  The former,
having no support from the adjoining parts,  and being unable to
sustain the  weight of the column of water which rests upon it,
after a certain time, begins to yield ;  and the pressure being con-
tinued or increased,  the posterior part of the  vagina is distended,
pushed down, and,  at  length,  protruded  through the external
parts, in  such a manner  as to invert the perinaeum.   A tumour
is  then formed at the posterior part of the pudendum,  of which
the vagina is the external coat,  and the  peritonaeum the internal.
This  appearance occurs too rarely, or the  instances recorded are
too  few, to  justify the establishment  of any general mode of
practice ; but,  by the history of the following case,  we may be
enabled to  make a  distinction of this particular tumour,  and of
the method of treatment which it may sometimes be requisite and
advisable to  pursue.   The only case likely to be mistaken for
this which we are now describing, is, when the vagina is protruded
through  the external parts, by a gradual distension from coacer-
vated faeces;  and this  may be  readily distinguished  by passing
the finger into the rectum.
   In the year 1772, I attended a patient, who was then pregnant
of her sixth child.  She had a slight cough, some difficulty in
breathing, and an obtuse pain in her right side.  Her eyes had a
yellow tinge, and she had an  uneasy sensation, as if her stomach
was swelled.   Her  urine, which was voided in small quantities,
was high-coloured, and deposited a red sediment.   Her pulse was
quick, she had a constant thirst, and very little appetite.  She
reckoned that she was in the seventh month of her pregnancy.
   Six ounces of blood were taken from the arm, a saline draught
was given, with a few grains of rhubarb,  twice daily, or occa-
sionally.  She was  advised to  drink whey, or ground-ivy tea,
with milk,  and sweetened with honey, for her common drink, to
live chiefly upon fruit and vegetables, and to go into the country.
There she resided two months, during which time little  alteration
was made in her diet and medicines; but the abdomen was dis-
tended to an  unusually large size.  She then returned to her fa-
mily in town, in daily expectation of being delivered.
   In the course of my attendance, she had often mentioned a com-
plaint, which was very troublesome,  and occasioned great solici-
tude.  This, from her description, I considered as  a prolapsus of
the uterus; and, expressing a desire to be more particularly in-
formed, she permitted me to examine it.
   I was surprised to find a tumour of the size, and somewhat of
the form, of an inflated calf's bladder, rising from the perinaeum
internally,  and passing forwards and outwards, so as  perfectly to 
PARTS CONTAINED IN THE PELVIS.        169
 occlude the entrance into the vagina.  By pressure the tumour
 lessened, and by a continuance of the pressure, it entirely disap-
 peared, leaving a loose pouch within, and on  the back part of
 the  vagina.  When  she stood up,  the  tumour  returned to its
 former  size and situation; but when she  lay down, and the pres-
 sure was renewed, it  again disappeared.  It  had not the feel of
 omentum or intestine, but clearly contained a fluid,  which must
 communicate with some other cavity.  I afterwards examined fhe
 abdomen, and could readily perceive a fluctuation in it. A doubt
 then arose whether she was with child; but, by an examination
 per vaginam, I could discover the head of a small child resting
 upon the ossa pubis.
   The  peculiarity of this tumour, its recession when pressed, and
 its return when the pressure was removed, and the patient stood
 upright, together with the assurance of there being water contain-
 ed in the cavity  of the abdomen, were presumptive proofs that
 there must be a communication between the tumour and that ca-
 vity ; and  this communication could not be explained so satisfac-
 torily as by supposing that the water had insinuated itself between
 the vagina and rectum, and, by resting upon, had at length pro-
 truded the posterior part of the vagina.
   If this opinion  were just, it might yet be debated what was the
 most reasonable method to be pursued for the relief of the patient;
 or whether it would not be more prudent to defer all attempts till
 she was delivered.   Several  gentlemen of the  first eminence in
 the profession were consulted upon the occasion,  and it was
 agreed, that we  should wait  till she  was delivered, before  the
 treatment of her other complaints was taken into consideration.
   About three weeks  after  this time  her labour came on.  The
 child being small, and presenting naturally, it was soon expelled,
 the tumour yielding gradually to the pressure of the head of the
 child ; though it appeared that the expulsion  was completed  by
 the action of the uterus only, the abdominal muscles being  too
 much distended to contribute any assistance.  The placenta came
 away with  great  ease, and she had no complaint till  the fourth
 day  after  her  delivery, when,  after a few  loose  stools, her
 strength failed, and she expired.
   After her death, I  was very desirous of knowing the truth of
 the opinion which had  been  entertained concerning  her case;
 but her  friends would not consent that the body should be opened.
 They, however, permitted me to examine the  tumour.   A trocar
being pushed into it,  upwards of a quart of water  was imme-
 diately  discharged.  The water then came away more slowly;
 but 1 observed that the abdomen subsided in proportion to the
 water discharged  through the  canula of the trocar.
   Mr.  Watson, a surgeon of  great experience and ability, who
 saw this patient,  informed me, that he  had met with a similar
                             22 
170          INTRODUCTION  TO MIDWIFERY.
case in a woman who was not pregnant.  He tapped the tumour
with a small trocar, and left the  canula remaining in the orifice
for  several  days.   The  water continued  to  drain  away till  the
abdomen was perfectly  empty.  This woman recovered, and
had no return of the dropsy.
  I once attended a patient, who had a tumour of the same kind
as that above described,  with Mr. Davison, surgeon in Chancery
lane.   But as she had  been many times tapped before  in  the
common way with  success, I was afraid to recommend his making
the puncture in the tumour, lest danger should be incurred by an
attempt to procure more perfect or permanent benefit.   But now
I think my fears were groundless, and that this  patient would
have  had a better chance of recovering perfectly,  if a puncture
with  a small trochar had been made into the tumour at the pos-
terior part of the  pudendum.   (See Medical  Communications,
Vol.  I.)  This protrusion of the vagina very frequently occurs
in  dropsies of long standing.

                         SECTION IV.
    By the  descent of the  intestines, or  omentum,  between the
 uterus and rectum, is constituted a particular  kind of hernia, of
 which the cases  recorded are very few*   The  inconveniences
 thence arising will depend upon the bulk of the tumour formed,
 and  the compression which the parts thus situated must undergo.
 The methods by which relief can  be obtained by art will  imme-
 diately occur to every practitioner, as they consist in  making all
 prudent and reasonable  attempts  to  replace  the disarranged
 parts, and keeping them in their proper situation when replaced.
 It is happy for the patient that no immediate bad consequences
 are  likely to follow this  complaint;  though  under  particular
 circumstances, it  may prove fatal as in the following case, which
 was communicated to me by Dr Maclaurin.
    A servant in a  gentlemau's family, in a state of perfect health,
 was suddenly seized  with all  the symptoms of a strangulated
 hernia, though from the most accurate inquiry and examination,
 it did not appear that  she then, or at any preceding time, had a
 hernia.  All the  means used for her relief were ineffectual, and
 she  died on the third day of her illness.  Leave  being obtained
  to  inspect  the  body, a considerable portion  of intestine was
  found  lying between  the uterus and  rectum, in a  gangrenous
  state; and it was confined and compressed in this situation by a
  membranous bridle, which passed from the fundus of the uterus
  to the opposite part of the rectum.
*Elytrocele.  Vogel. ccccii.   Hernia in vagina uteri eminent. 
ON MENSTRUATION.
171
                      CHAPTER V.

                         SECTION  I.

                     ON MENSTRUATION.

  From the uterus of  every healthy woman,  who is not preg-
nant, or who does not give suck, there is a discharge of blood,
at certain periods,  from the  time of puberty to the approach of
old age; and, the periods or returns of  this discharge, is called
Menstruation.
  There are several exceptions to this definition.  It is said, that
some  women never menstruate,  their constitutions or structure
not requiring,  or  allowing of this discharge, of which I have
known two instances, yet concealing the  circumstance, they im-
prudently ventured to marry, and were sterile.  Some menstru-
ate  while they continue to give suck, and others are said to men-
struate during pregnancy; but of this I  have never  known an
example.  Some are  said  to menstruate in early  infancy, and
others in old age ;  but such discharges may, I believe, with more
propriety, be called morbid, or symptomatic; for when the fe-
male constitution from any  cause is disposed to, or requires a
sanguineous discharge, it is commonly made from the vessels of
the uterus. There are also many varieties, as some have believed,
in the part from which the discharge  was  made, whether from the
vagina or uterus;  and with  respect to  its  periods and appear
ance, from permanent  causes or accidental influences; but the
definition is generally  true.
  At whatever time of life this discharge comes on, a woman is
said to be at puberty; though of this it is a  consequence, and
not a cause.  The early or late appearance of the menses may
depend upon the climate, the constitution, the delicacy or hardi-
ness of living, and upon the manners of those with whom young
women converse.   (Rousseau.) There seems to be some analogy
between the effect of heat upon fruits, and the female constitution
with respect to menstruation, for, in  general, the warmer the cli-
mate, the sooner  the menses appear.  In Greece, and other hot
countries, girls begin to menstruate  at eight, nine, and ten years
of age; but advancing to the northern  climates, there^i| a gra-
dual protraction of the time  till we come to LaplandjiTwhere wo-
men do not menstruate till they  arrive at maturer age', and then
in small quantities, at long intervals, and sometim^ only  in the
summer.  (Linnaei Flora Lappouicaj article Muscus.)  But, if
they do not menstruate according to the genius of the country, i% 
172
INTRODUCTION TO MIDWIFERY.
is  said  they  suffer equal inconveniences  as in warmer climates,
where the quantity discharged is much greater, and  the  periods
shorter.  In  this country, girls begin  to  menstruate from the
fourteenth to the eighteenth year of their age, and sometimes at a
later period, without any signs of disease ; but if they are of deli-
cate constitutions, and luxuriously educated, sleeping upon down
beds, and sitting in hot  rooms, menstruation usually commences
at a more early period.
  Many changes in  the constitution and appearance of women
are produced at the time of their first beginning to menstruate.
Their complexion is improved, their countenance is more expres-
sive and animated, their attitudes graceful, and their conversa-
tion more intelligent  and agreeable; the tone of their voice be-
comes  more  harmonious; their whole. frame, but  particularly
their breasts, are expanded and enlarged, and their minds are no
longer engaged in childish pursuits and amusements.*
  The difference in the time of life when the  menses appear, has
been assigned as the reason why women, in hot climates, are al-
most universally treated as slaves, and why their influence is  so
powerful and extensive in cold countries, where personal beauty
is  in less estimation.  (David Hume; but I  do not recollect in
what part of his works.)  In  hot  climates, women  are in the
prime of their  beauty when they are children in understanding;
and when this is matured, they are no longer the objects  of love.
In temperate climates, their persons and their minds acquire per-
fection at, or nearly the same time; and  the united  power  of
their beauty and faculties is supposed to be irresistible.
  Some girls begin to menstruate without any preceding indispo-
sition,  but there are generally appearances or symptoms, which
indicate the change that is about to take place.  These are usual-
ly more disturbing at the first,  than  in the succeeding periods,
and they are similar to those produced by uterine irritation from
other causes} as pains in the hack  and inferior extremities, com-
plaints of the stomach and viscera, with various hysteric and ner-
vous affections, often preceded by the discharge of  a colourless
mucus from the vagina.   These commence  with  the first disposi-
tion to menstruate, and continue till the proper discharge comes
on, when they abate or disappear ; returning, however, with con-
siderable violence in some women, at every  period during life.
  The quantity of blood discharged  at each evacuation depends
  * Nee minus notum est, quanta virgina alteratio contingat, incres-
cente primum et tepefacto utero ; pubescit nempe, coloratior evadit,
mamma; protuberant, pulcbrior vultus reuidet, splendent oculi, vox
canora, incessus, gestus, senno, omnia decora fiunt.—Harv. Exerci-
tat. de Partu. 
ON MENSTRUATION.
173
 upon the climate, constitution, and manner of living, but it va-
 ries in different women in the same climate, or in the same women
 at different periods.  Yet there is a common quantity to which,
 under the like circumstances,  women approach,  and it may be
 estimated in this manner: Supposing the quantity to be about
 eighteen ounces  in  Greece, and two  ounces in  Lapland, there
 will be a gradual alteration  between the two extremes, and in
 this country it may amount to about six ounces.
    There is also a great difference in the time required for the
 completion of each period of menstruation.  In some women the
 discharge returns precisely to a day or an  hour, and in others,
 there is a variation of several days, without inconvenience.  In
 some it is  finished in  a few hours, and  in  others, it continues
 from  one to ten days; but the intermediate time, from three to
 six days, is the most usual.
    There have been  instances of infants, in this country,  having
 sanguineous discharges, even in the month, or any time before they
 are seven years of age, but these are not to be considered as men-
 struous ; nor do they indicate any thing materially wrong,  ceas-
 ing when the  state of the constitution which  required or occa-
 sioned them, is  altered.
   There has been an opinion, probably derived from the Jewish
 legislator, afterwards  adopted by  the Arabian physicians, and
 credited by others, that the menstruous blood possessed some pe-
 culiar malignant properties.   The severe regulations which  have
 been made, in some  countries, for  the conduct of women at the
 time of menstruation, the expressions used,  (Isaiah, chap. xxx.
 and Ezekiel,) the disposal of the blood discharged, or of any thing
 contaminated with it, the complaints of women attributed to its
 retention, and  the effects enumerated  by grave writers, indicate
 the most dreadful apprehensions of its baneful influence.'  Under
 peculiar circumstances of health, of states of the uterus, or in hot
 climates, if the evacuation be slowly made, the menstruous blood
 may become  more acrimonious or offensive than the common
 mass,  or any other  secretion  from it;  but  in this country and
 age, no malignity is suspected, the  menstruous woman mixes in
 society as at all other times, and there is no reason for thinking
 otherwise than that this discharge is of an inoffensive nature ,*  It


   * Penis cum menstruata concumbentis excoriatur,  si novella vitis
 eo tangatur, in perpetuum keditur, steriles  fiunt tact* fruges  mo-
 nuntur msita, exuruntur hortorum germina;  si mulier praegnans al
 tenus  menstrua supergrediatur,  aut illis circumlinatur, ahortum fa
 cit ; ei autem, quae uterum non  gestat, concipiendi spem aciimit ■
 purgantis spintus, et vapor ab ore, specula atque eboris nitorem ob-
scurat: gustatus hie sanguis canes in rabiem agit, homines vero diris
cruciatibus affligit,  comitialem morbum,  pilorum  effluvium, aliaque 
174
INTRODUCTION TO MIDWIFERY.
is probable  that the true  reasons for the laws relating to this sub-
ject were political, though  those which  were assigned were phy-
SIC 3.1
   At the approach of old age women  cease to menstruate, but
the time of  the cessation is commonly  regulated by the original
early or late appearance of the menses.   With  those who  begin
to menstruate at ten or twelve years of age, the discharge  will  some-
times cease  before they arrive at forty  ; but if the first appearance
was protracted to sixteen  or eighteen years of age, independently of
disease, such women may continue to menstruate   till  they tiave
passed the fiftieth, or even approach the sixtieth year of their age.
But, in this country, jhe most  frequent time of the cessation of
the menses is between the forty fourth, and forth eighth year, ifter
which women  never bear  children.  By this  constitutional re-
gulation of the menses the  propagation  of the species is, in every
country, confined to the most vigorous part of life; had it been
otherwise, children  might  have become parents, and old women
might have had children, when they were unable to supply them
with proper or sufficient nourishment.
   When women  are deprived of  the common uterine  discharge,
they  are sometimes  liable to periodical emissions of blood from
the nose, lungs, ears, eyes, breasts, navel, and almost every part
of the body.*  These, which are certainly  very rare,  have been
deemed as deviations of the menses, and communicated with the
most scrupulous exactness, as if some great advantage  was to be
 obtained  by our knowledge of them.  They may proceed from
an inaptitude of the  uterus, some  defect in the organization of
that  part, or of  the ovaria, or from  some  accidental  cause, but
the  propriety of considering them in this  point of view  seems
 very doubtful.   I suspect  that they generally ought rather to be
 esteemed as discharges  belonging  to some disease under  which
 the  patient may labour, or  to the state she is in;  and that they
 often proceed from causes independent of those of menstruation;
 as hemorrhages of every  kind,  in either sex,  are  frequently ob-
 served to be periodical.
   Some men also have had  a periodical discharge of blood from
 various parts of the body,  butgeneally from  the  hemorrhoidal
 vessels.  We may suppose that  such constitutions  resemble those
elephantieorum vitia : idcirco a veteribus inter venena relatus ;  pari
malignitate  existimatur,  atque  sanguinis  elephantici  potus.—De
Graaf, p. cxxiv.
  * Ilia (menstrua) per vomitum, arvum, urinam,  per oculos, nares,
aures,gingivas, mammas, umbilicum, minimum manus digitum, ac alias
insuetas corporis partes interdum promanare.—De Graaf, p. cxxix. 
ON MENSTRUATION.
175
of  women, though  the essential  peculiarity,  independent  of
structure, may not be discovered without difficulty*
   * [Menstruation in the females of this country commences about
 the same time, as  in the temperate parts of Europe,  or somewhat
 earlier, that is, about the thirteenth or fourteenth  year, and ceases
 about the forty-third, or forty-fifth.   It has been inculcated by cer-
 tain European writers,  that the Indian females of America are  not
 subject to this discharge ; but such opinion scarcely needs refutation.
 Careless observers may have fallen into this  error from the circum-
 stances that  our female  Indians seldom begin to  menstruate until
 their eighteenth or twentieth year ; that the discharge  then is less
 in quantity than in the civilized inhabitants, and ceases earlier. The
 severity of their habits, scarceness of food, and  precarious modes of
 living, less dispose them to venereal indulgences, and may  be con-
 sidered as sufficient reasons why they are less prolific than the civi-
 lized race.
   Some few cases of  undoubted authority are  recorded,  in which
 menstruation continued  during the period of pregnancy : and Da-
 vanter and Baudelocque inform us, of women who had this evacua-
 tion only during pregnancy.  In  instances  of this  sort, I  think we
 may conclude, that the secretion of the menses takes place at or about
 the cervix of the uterus  ; otherwise, the ovum would most likely be
 detached and discharged.  We have, also, instances of women who,
 during lactation, have become  pregnant.  Nor is the previous ap-
 pearance of the menses  always indispensable  to conception.  Mr.
 Cruikshanks, in his lectures,  was in the habit of enforcing this fact
 by detailing the particulars of a case which  came within his know-
 ledge,  of a female who  was the mother of several  children, and in
 whom  there never had  been  the  least appearance of the  menstrual
 flux.   In proof that menstruation  is not always essential to impreg-
 nation, Sir Everard Home has recorded the following striking case
 in the  Philosophical Transactions of J 817.   A young woman was
 married before she  was  seventeen, and, although she had never men-
 struated,  became pregnant.   Four months after her delivery, she
 became pregnant a second time,  and  four months  after the second
 delivery, she was a third time pregnant, but miscarried.  Afterijj|
 she menstruated for the  first time, and continued to do so for several
 periods, and again became pregnant.
  We  have some remarkable cases, wherein the menstrual discharge
 has occurred much beyond  the ordinary period,  at sixty, and up-
 wards, as in the example of the celebrated Madame de Stael. A rela-
 tive of Haller's had two sons, after her fiftieth year : and, where pu-
berty is late, as in cold  countries, children have been  born of mo-
 thers above sixty years old.  Dr. Rush records an example of re-
gular menstruation occurring at  the seventieth year.
  The influence of the ovaria in the production of the menstrual eva-
cuation, has been long ago observed.   Their accidental removal bv
a surgical operation, in a case of inguinal hernias, in a healthy young 
1 76           INTRODUCTION TO MIDWIFERY.
                          SECTION II.
   The causes of menstruation have been distinguished into effi-
cient and final; and though little has been said upon this  sub-
ject which is likely to procure any practical advantage, sufficient
attention  has been  paid both to the discovery of the cause and
end of menstruation ; and, where  our senses  have failed to pro-
cure  evidence, the imagination hath  been called to  their aid.
To unsophisticated observation, and to a mere relation of facts,
or the inferences plainly to be deduced from them, men are  un-
willing to submit, as the powers of the imagination by such pro-
ceeding  would  be  checked or suppressed, the want of  under-
standing concealed, and  the  parade of learning lost.  Hence a
multitude of opinions are formed and transferred by  the  writers
of one age to be controverted by those of the next; and  we are
amused  or  perplexed, but not instructed.   Of this  truth there
will not be a doubt, if we consider for a moment the  number of
opinions which  have devolved upon us, with respect to menstrua-
tion and conception;  the  fallacy of which it would be the busi-
ness of one man's life to confute.  But,  though we  are  not to
woman, aged twenty-three years, induced  manifest changes in the
appearance and character of the patient ; though  many years had
elapsed from the time of the operation, to the date when the account
of the particulars was drawn up by Mr. Pott, she had enjoyed good
health, but became thinner, yet apparently more  muscular.  Her
breasts, which had been large, were gone, and she never  menstru-
ated.   A curious case, in which the ovaria were deficient,  was pub-
lished  in the  Philosophical  Transactions  of 1805.   This deficiency
seemed to occasion a considerable approach in the female, to the male
formation.  She died  at the age of  twenty-nine.  " Having ceased
to grow at ten years of age (says the narrative) she was in stature
not more than  four feet six inches  high.  Her breadth across the
shoulders was as  much as fourteen inches, but  her pelvis measured
    «nine inches, from the ossa ilia to the sacrum.  Her breasts and
    les never enlarged more than in the male subject : she never men-
struated :  there was no appearance of hair on the  pubes,  nor were
there any indications of puberty, either  in mind or body, even at
twenty-nine years of age."
   Dr.  Townsend  has noticed a singular case of periodical discharge
of blood in a male, which, for thirty-nine years, supervened at every
lunar month,  and  unaccompanied with pain.—American Medical Re-
corder, vol. 3.
   Notwithstanding Pliny has denominated woman animale menstruale,
there are grounds sufficient for belief that the function of menstrua-
tion is not solely confined to the female of the human species.  Cer-
tain of the simiae  possess the power'of menstruation, nor is the time
of their discharge wanting in periodical regularity.   F.] 
ON MENSTRUATION.                177
 be immerged in such inquiries, a cursory view of what has been
 said  of the causes of menstruation seems necessary, to preserve
 the unity, as it may be called, even of a practical discourse.
   It has been said, after Aristotle, that the fluids of the human body
 were, like  the ocean,  influenced according to the phases  of the
 moon, and that menstruation resembled the tides.   This discharge
 has been attributed to a plethora  of the constitution, or of the
 uterus; to a ferment generated in the uterus; or  to some humour
 of the  constitution, as the  bile,  producing  this specific effect
 upon  the  uterus.   (See  Charlton, Drake, and  many other
 writers.)  Some have presumed that it  was a simple discharge of
 blood, others that it was a secretion ; some that it was a consti-
 tutional discharge, and others that it was merely local.
   That menstruation  is  not occasioned by the moon,  or  any
 external physical  cause, is evident from the  circumstance of
 women menstruating at every moment of its increase or decline;
 and if this reason were admitted, it would prove that men  and
 animals should also menstruate-   It is not probably occasioned
 by plethora,  as the loss of several times the quantity of blood
 discharged previous to, or in the very act of menstruation, from
 the arm, or any other part of the body, does not generally pre-
 vent or interrupt  the flowing of the menses, and, in those com-
 plaints  which arise from  obstructions of the  menses, greater
 relief is afforded  by a few drops of blood from the  uterus itself,
 than by ten times the quantity from any other part. There seems
 to be  no  reason for  the opinion  of  any fermenting  principle
 being the efficient cause of menstruation, no part of the  uterus
 appearing fitted for its secretion or reception ;  and the idea of
 bile acting with any peculiar influence  upon the uterus was as-
 sumed, because of the  resemblance between the symptoms arising
 from an excess  or defect of bile, and those  depending on men-
 struation ;  together with  the aggravated symptoms, to  which
 those who are of bilious  constitutions   are liable at the time of
 menstruation.   But this reason,  like some of the former, would
 prove too  much  for the intended  purpose, if it were admitted.
 We may be satisfied with saying, that menstruation was ordained
 by the Almighty  as  an  appertainment to the  female  human
frame.
   Among the  early cultivators  of anatomy, it  seems to have
been thought of great  importance  to decide from what  vessels
the menstruous blood  was discharged,   some contending that it
was from veins,* and others strenuously maintaining that it was
  * Ex  venis  uteri  patentibus,  menstruas  purgationes evacuari
indubitatum est, at quomodo fiat, et per quas potissimum  venas,
&c, ambiguum.—Vesalius, lib. v. cap. xv.
                             23 
178           INTRODUCTION TO MIDWIFERY.
from arteries*   The  opinion of there being receptacles  in the
uterus for its  collection is of a modern date; (Simson's System
of the Womb ;) but this cannot be true, as, from the examination
of the uteri in women, at every  intermediate period, such recep-
tacles could  not have  been overlooked,  if they had existed.
From the appearance  of the menstruous blood in a healthy wo-
man, and  from that of the vessels  by which it is discharged,
which evidently run in a tortuous manner during the act of men-
struation at  least,  many  have not  hesitated to  pronounce  it
arterial.
  The  menstruous  discbarge has commonly been  considered
simply as  blood,  though of a  different  kind from the general
mass, as it has been  observed  not to coagulate. (See Dionis.)
All uterine discharges of blood, in which there were coagula,
have, therefore, been  d stinguished  from menstruation, and as-
signed to some other  cause, as conception, or some uterine dis-
ease.   Whether menstruation ought to  be esteemed a secretion,
made in a manner similar to that by other glands of the  body,
and  does not coagulate because it  is essentially different  from
blood, which  I believe; whether  it be a secretion   from the
uterus peculiar in its  manner to that part, without analogy or
resemblance to that of any other part,  or whether the* coagu-
lation is prevented  by a mixture with the discharge from the
mucous glands, may be proved by future observations and  expe-
riments.
  The various opinions of  menstruation being a local   or  a
constitutional discharge,  may continue to be supported by those
who  think them  of  consequence.   Every discharge  is  local,
though its effects  may  be constitutional;  but it does not appear
that  the  symptoms of the suppression of the menses  supply  a
stronger  argument in favour of the  latter opinion,  than  the
regurgitation of bile upon  the  skin, or its discharge by urine,
when the natural  passage is obstructed.f
  * Sanguis exit de corpore per dilatatas tectas arterias naturaliter,
in menstruoru.n excretione, in faemiuis.—Ruysch, Epistota ad Boer-
haavium.
  t [That menstruation arises from a plethora of the system, is one
of the oldest and least satisfactory causes to which the discharge has
been attributed.  I think we  are fully authorized  to  consider the
uterus as performing, in one respect at least, the  office of a gland,
and the catamenia consequently as a secretion.  Haller, in his notes
on the Praelectiones of Boerhaave, favours this opinion ; as does John
Hunter.
, The menstrual evacuation may be considered  as  a secretion from
the extreme arteries of the membrane immediately lining the uterus. 
ON MENSTRUATION.
179
                          SECTION  III.
   Numerous as  the opinions have been of the efficient cause of
 menstruation,  two only  have been entertained  of  its  final
 cause :  first, that it was  designed to put  and preserve the uterus
 in a state fit for conception ; secondly, that this blood, being more
 in quantity than  was necessary for the ordinary purposes of the
 constitution, became, during the state of pregnancy, nourishment
 for the foetus,  without any reduction of the strength of the  pa-
 rent.
   The first of these opinions, I believe, is not controverted ;  ob-
 servation having fully proved that  women who  do not men-
 struate from the uterus, or who are not in  a state disposed to men-
 struate, cannot conceive, even though they should have a period-
 ical discharge of  blood from any other part of the body.   Hence
 we may  conclude, whether menstruation be eventually  necessary
 for the constitution of a woman or not, that it is a circumstance on
 which the due and  healthy state of the  uterus  very  much  de-
 pends. It has also been observed, that all animals, at the time of
 their being salacious,  or  in a state fit for the propagation of the
 species, have a discharge equivalent to menstruation, which is ge-
 nerally mucous;  but in some instances, in very  hot seasons  and
 climates, becomes in many of them sanguineous, as  I have often
 observed.
   Of the truth of the opinion, that the menstruous  blood contri-
 butes to the formation  or  nutriment of the foetus, there is much
 reason to doubt  or to deny.   The former  seems to have been
founded on the observation, that women who did not menstruate,
could not conceive; and  this, if carried to  its full extent, might
have led  to another conclusion, that the time  of menstruation  was
most favourable to conception;  which is allowed not to be just,
 there being the readiest disposition to conceive,  not during, but
soon after a period of  menstruation.    As  to  the share which the
menstruous blood might have in the nourishment of the  foetus, as
In cases  of polypus uteri it has  been seen flowing out from the os
tineas at the same  time that the  vagina was  free from  moisture.
" Arterias equidem," says Sprengel, " certo capillares e villis fun-
dere  sanguinem pursuadeor,  cum  a Kaauw Boerhaavii inde tem-
poribus  saepius  manifesta  visa  fuerit  ea  origo.   Quae  arteriae
licet et in hoc viscere  continuo in venulas transeant, patuli tamen
sunt  earum fines  in   villi's   massa laxissima cellulosa clausis,  e
quibus sine  laceratione, ob impetum majorern, sanguis expeditius
effluere potest."   Institut. vol. 3.  The  menstrual  discharge has
been collected in cases  of prolapsus of the uterus, wholly free from
other matters, and  been subjected to chemical  analysis : no globules
could be discovered in it ;  and it presented chemical results differ-
ent from those which characterized blood.   F.] 
180         INTRODUCTION TO MIDWIFERY.
all animals,  whether menstruating or not,  supply their concep-
tion with nourishment of a proper kind, and in a sufficient quan-
tity to bring them to  perfection,  we may be permitted to con-
clude that it  is by some more common principle.  Had there
been a gradual abatement of the discharge, in proportion to the
increase of the foetus, its nourishment might have been presumed
to be one of the final causes of menstruation.   But, as there is an
instant and  total suppression of the menses, when a woman has
conceived, they  must either be superfluous in the early, or defi-
cient in  the advanced  stage of pregnancy.
  The mucous discharge from  the uteri of animals, proves that
they are in a state favourable to»the propagation of their species;
and the  menstruous discharge is a proof of the same in women,
as far as the uterus is  concerned.  For the reason of this differ-
ence, we are  to search in the structure of the uteri of the different
classes of animals.   The desire  of procreation  exists in animals
only at certain seasons of the year; by  these it is regulated  in
such a manner,  that the offspring will  be produced at the time
when it  is likely to suffer the least injury from  the climate in
which it is to live,  so that it is accommodated to  every climate;
unless the genuine nature of the  animal be changed, by indulgent
treatment, or by defect of nourishment.  Women, on the contrary,
having every month that  discharge which  proves them  capable
of conceiving, propagate their species at every season of the year,
and the gratification of the attendant  desire, when enjoyed with
prudence, may  be esteemed a peculiar  indulgence, granted by
Providence to mankind.

                        SECTION IV.
  All the common circumstances attending menstruation  have
been  well and  fully described  by various authors, but having
very often observed a substance expelled with the menstrual dis-
charge,  which  has hitherto escaped notice, and apprehending
the knowledge of this substance may be of use in practice, I feel
it incumbent on  me to describe it.
  In the examination of that discharge, for the purpose of inves-
tigating the  state of the uterus, and the discovery of some com-
plaints thereon depending,  a membranous  substance was often
shown me, which  was usually considered as  the token of an
early conception, or  as the casual  form  of coagulated  blood.
But on examining this substance with more attention, I  con-
stantly found that one surface had a flocky appearance, and the
other a  smooth one;  that it had  in all respects the resemblance
of that  membrane, which Ruysch had called the villous, of the
formation of which Harvey  has given a very curious description,
and which the late Dr. Hunter described with  his usual preci-
sion, and called the decidua.  To put the matter out of  doubt, 
ON MENSTRUATION.
181
several  years ago  I requested the favour of Dr. Baillie to ex-
amine some portions of this membrane; and he agreed with me
in  thinking it an organized membrane,  similar in structure to
the decidua.  As the first cases, in  which this membrane was
discharged, were those  of women who were married, a  doubt
arose in my mind,  whether it was not  really a consequence of
early conception; but I have lately  had the most  undoubted
proofs that it is sometimes discharged by unmarried women, and
may be formed previous to and without connubial communica-
tion ; and  that  the  uterus has,  occasionally or  constantly,  in
some women, the  property of forming it, at, or in  the interval
between, the  periods of the menstrual  discharges.  It  seems
particularly necessary to establish this fact, as the appearance of
the membrane  has more than once given rise to erroneous opi-
nions, and  unjust aspersions.  Nor is this the only circumstance,
in which some women,  at each  period  of menstruation,  have
symptoms  like  those which  accompany pregnancy  or parturi-
tion.
  In every case in which this membrane has been  discharged,
the women have menstruated with pain,  and  the discharge has
flowed slowly, and  apparently with difficulty, till the membrane
was come away, which  in some cases has been  in small flakes,
and in others in  pieces equal to the extent of half the cavity of
the uterus, or more, of which they retained the shape.  I suspect,
but my  experience  does  not enable me to decide, that this mem-
brane is expelled in every case of  habitual painful menstruation.
  No woman in the habit of forming this membrane has  been
known to conceive while that habit remained; and this observa-
tion leads  me to speak  of the means which have  been used for
making such a change in the state of the uterus, that it should
be devested of the  property of forming this membrane at  the
time of menstruation.
  There does not appear any external peculiarity of constitu-
tion,  or disposition  to  any  other complaint,  in many of those
who have  been liable to the  formation of this membrane, which
is in fact a  proper office performed at  an improper  time.  Re-
course has  been generally had to preparations of  quicksilver,
chiefly to the  hydrargyrus submuriatus,  given sometimes as an
active  purge,  and  sometimes in  small quantities, continued so
long as even to  raise a  slight salivation.   Together  with this, I
have  directed  a large dose of the Tinctura Cinchona? Animo-
niata to be given twice in the course of the day ;  the iniusion of
burnt sponge with bark; myrrh, and the different preparations of
iron, or the Tunbridge  or Spa  waters, and  lately the Liquor
Potassa; in  gradually enlarged doses.   In short, ail the medicines
which could have the power  of altering the state of the glandu-
lar  system in general, or that of the  uterus in particular, have 
182
INTRODUCTION TO MIDWIFERY.
    been  tried,  but not  constantly with success.   I  think I have in
    one instance known  the use of injection, chiefly composed of the
y  Aqua Zinci  Titriolati cum Camphora, remove this complaint,
    by its application perhaps exciting a new and distinct action of
    the part; and  those with a solution of antimonium tartarizatum
    have  been used.  But this membrane  not being uninterruptedly
    formed  at each  period of menstruation, the capability of con-
    ceiving may exist at any interval of freedom from  its formation;
    but whether it  be gradually formed through  the interval between
    two periods  of menstruation, or only from  the time when the
    disposition to menstruate comes on, remains to  be proved, though
    the latter opinion is most probable ;  and if just, its production
    might perhaps  be  prevented by such  means  as would  at that
    time abate or suppress the extraordinary action of  the uterus, as
    repeated  bleeding in  small  quantities.   I have  only farther to
    observe, that this membrane has sometimes been excluded at two
    or three periods after parturition, and then entirely  ceased.  But
    this subject ought to be more accurately investigated.*
  * [I fully concur in the opinion of our author, that this  subject
deserves a fuller investigation, and when it is considered that this
affection  is among the most operate of the causes of female barren-
ness, it cannot but excite regret as well as surprsie, that so little
notice  has been  taken of it.  The only information of any value
that has recently been published on this  disease, of which 1  am ap-
prized, are the papers of Dr. Dewees and Prof. Chapman of Phila-
delphia : the former in the  Medical Museum,  vol. 3., the latter in
the Eclectic Repertory, vol. 2.  Experience, I think, justifies the as-
sertion, that this membrane is not always thrown off in every case of
painful menstruation ; the converse of the  opinion is doubtless correct.
Dr. Dewees confirms the remark of Dr.  Denman, that whenever
the casting off of this coat has occurred  to married women, sterility
has invariably  attended such  habit.   My own limited  experience
accords with this observation.
  In the treatment of this distressing complaint, Dr. Dewees  recom-
mended, with great confidence, the volatile tincture of guaiacum, on
the supposition that the disorder  is of a rheumatic  character, and
the remedy in his hands seems to  have  been almost a specific ; but
in the cases which have come to my knowledge, it has not been fol-
lowed  with the same happy results.
  Upon the ingenious theoretical view of the disease, that the for-
mation  of this deciduous membrane is analogous to the   membrane
of croup, Dr. Chapman has prescribed the polygala seneka,  in de-
coction, one ounce of the  bruised root to one pint  of boiling water.
Where the medicine excites nausea, some aromatic, such as  orange
peel or cinnamon, may be  added.  Dr. Chapman  has  given four '
ounces of the decoction during the day, and, in  some cases, as much
as two  ounces every hour :  as an emraenagogue he found it one of 
ON MENSTRUATION.
183
                         SECTION V.
   It is a general opinion, that menstruation is to women a cause
of diseases from which men  are exempt; and their apprehensions
of danger are  chiefly confined to the times of the first  appear-
ance, and of the final cessation of the menses.  It is not how-
ever proved, that more women suffer at the time of puberty than
men, though there may be much difference in  their diseases: nor
is  it decided that the very dreadful  diseases  which  sometimes
occur at the time of the final cessation of the menses, and which
most commonly affect the uterus or the breasts, are more frequent
end  more dangerous than  those to which men are liable at an
equivalent age; though  I think it is  lately proved that women
are generally more subject to cancer than men. Some advantage
seems to be derived to women from  their natural capability to
menstruate, especially to those whose constitutions or particular
situations  require discharges of blood for their relief; for such,
Et all periods  of life,  are usually made  with  great facility from
the vessels  of the  uterus;  whereas,  in  men,  these evacuations
cften  happen from parts, which sustain much consequent injury.
The circumstances  attending menstruation are, however, some-
times  such as  to  require medical  assistance,  and these I shall
consider in the following order: first, obstruction of the menses ;
secondly,  excess of the menses;  thirdly, painful menstruation;
and then I shall speak of the treatment, which  may be proper at
the time of the final cessation of the menses.
  By the  term obstruction is properly understood  the defect or
future of  the appearance of the  menses at a time of life  when
they might be expected;  and by suppression, a total stoppage of
 the  most active and certain.  " In the  intervals of the  menstrual
 periods,  I always," says Dr C, " lay aside the medicine for a week
 or two, as without these intermissions, if  it does not lose its efficacy,
 it becomes nauseous and disgusting to the patient.   While under a
 course of seneka, the general system is to be kept properly regu-
 lated, equally obviating excessive excitement or debility.  Of all the
 emmenagogues  which I  have tried, this is the most efficacious, and
 will  be  found useful in all forms of amenorrhcea,  if administered
 with a due regard to the  state of the  system, and in all other re-
 spects, with correct discrimination.  But I think it to be  more par-
 ticularly  so in those where the decidua exists."
  As in other cases of dysmenorrhoea, 1  believe we  may often find
 much advantage, if not perfect relief for  our patient, by the use  of
 the lancet, a pervious state of the primae  viae, and the administration
 of that valuable  compound, Dover's powder, or judicious doses  of
opium nid camphor.   Where particular  symptoms do not forbid it,
cold  lavations or the cold bath proves serviceable.  F.] 
184         INTRODUCTION TO MIDWIFERY.
the menstruous discharge which had before appeared.*  But the
terms are indiscriminately used.
   These were generally esteemed original  diseases, producing
many troublesome, and sometimes dangerous consequences; but
the moderns  have,  with more propriety,  considered  them  as
symptoms  of some  disease,  with  which  the  constitution was
primarily affected.  Yet, in some  cases, the suppression of the
menses seems to be an original affection, often, though not uni-
versally,  succeeded by a certain train of untoward symptoms;
for it appears, in some women, to be a simple interruption of the
discharge, not necessary for the constitution at some  particular
times,  and when the interruption happens to those who are mar-
ried, it sometimes gives fallacious hopes of pregnancy.   The
precise reason of this temporary suppression it would be difficult
to investigate ; but I have observed it to  happen, together  wi:h
a  reduction  of the size of the  breasts, in  very chaste women,
who have been under the necessity of living separate from their
husbands.
   As very  different diseases may  become causes of the obstruc-
tion or suppression of the menses, and as these  may, in different
constitutions, produce very opposite effects, it is not extraordinary
that we should find those symptoms,  which  have been described
as attendant  on the suppression of the menses, so numerous and
so  unlike.   But the two principal distinctions  are to be made
from the appearance of the patients,  some of whom have  a pale
leucophlegmatic look, with every consequence and indication of
want of power and energy in  the  constitution, and a  fulness of
vapid fluids;  but  others have a florid  complexion, with signs  of
a hectic disposition.   To either of these states may be joined any
of the  various symptoms which  arise from the uterine disturb-
ance.
   In the obstruction  of the menses  with  a  pale  complexion,  a
variety of  medicines  have  been given, which were supposed  to
possess the properties of immediately influencing the uterus, and
of promoting the menstruous discharge  by some  specific opera-
tion, particularly all the preparations of iron.  But speculative
differences  have been lost in the uniformity of practice; for those
who have  differed widely in their theories of menstruation, and
in  their opinions of the operation  of the  medicines prescribed,
have agreed as to  the individual medicines  which  they recom-
mended ; and it was of no importance to the  patient, whether the
  * Chlorosis.   Cullen,  G. xlv.  Dyspepsia, vel rei non esculenta? "
desidenum, cutis pallor vel decoloratio, venae minus plenae corporis
tumour mollis,  asthenia,  palpitatio, menstruorum  saepe  retentio.
Amenorrhcea.  Cullen, cix. Mensium supressio. 
ON MENSTRUATION.
186
 effect was produced by some specific operation, or Was secondary
 to an alteration made upon the constitution.  Every medicine
 which has the power of strengthening or invigorating the habit,
 bitters, aromatics, and all the different preparations of iron,  be-
 come eventually promoters of the  menstruous discharge.  But,
 previous to their  use, it will often be necessary to give a gentle
 emetic and  laxative medicines,  for  the  purpose  of freeing  the
 constitution from a load  of  inactive fluids, and of  cleansing the
 prima? viae, by  which the operation of  such medicines will  be
 rendered  more effectual.   Of these, the preparations of iron  are
justly supposed  to be the most  powerful  and  best adapted to the
 case; and they may be given in a variety of forms and quantities,
 alone or joined with bitters and aronv-.tics, provided the patient
 has no fever.   The chalybeate waters of our own  country,  or
 those of Spa, are universally proper.  In some cases, tepid bath-
 ing, or pediluvia, are of  service; and in others bathing in the sea:
 and I have observed that the guides to the ladies continue to go
 into the water during the time  of menstruation, without any in-
 convenience.
  Medicines of this class do not always  produce the  menstruous
 discharge, or its return,  though they scarce ever fail  to improve
 the health.  In the constitutions of some  women, there is an idio-
 syncrasy,  which withstands  the effect of such medicines as are
 generally  found  to answer certain intentions; and yet the same
 end may be gained by some  other medicine,  in general less effi-
 cacious.   Different  preparations of quicksilver have  sometimes
 been given with advantage in this complaint.  The root of mad-
 der has been advised either in one or more large doses, about the
 time when the menses are expected, or to the quantity of half a
 dracfim twice or three times daily in the intervals.  (See Riverius,
 and.  before  him,  Sennertus.)   Repeated,  but  gentle emetics,
 which are supposed  to operate,  not by cleansing  the  prima? viae
 only, but by agitating ind calling forth the powers of the consti-
 tution to more vigorous action,  are sometimes successively used.
 Electricity, directed to the region of the  uterus and ovaria, has
 lately been practised and recommended  by men  of reputation;
 and often, I believe, with success.
  In the  suppression of  the menses, with a pale complexion, the
diet should be generous, and  wine may be allowed.   Exercise of
every kind is proper; but it ought  not to be more  than the pa-
tient can bear without fatigue, as great exertions have sometimes
produced  immediately dangerous, and even  fatal effects.   Such
patients may often be invited by dancing, or riding on horseback,
and these  seem best  adapted to their complaint,  though I have
lately seen  some instances  in  which swinging answered better
than any other exercise.
  The suppression of the menses, with  a florid complexion,  is
                              24 
186
INTRODUCTION TO MIDWIFERY.
usually combined with symptoms very different from those which
occur  when it is pale, and  a method of treatment reverse to the
former is required ; for the colour of the cheeks in these cases is
often the flush of disease, and not  the glow of health.   Such pa-
tients frequently have a slight cough, pains  in the breast, some
difficulty of breathing, fever, and  other  signs of a  consumptive
tendency.  In such situations, instead of pursuing the former  in-
tention, with the view of producing or promoting the menstruous
discharge, we must regard the disease, and endeavour to give  re-
lief by repeated bleeding  in small quantities,  by antiphlogistic
and emollient medicines, by a vegetable diet, and by repose, for-
bidding  all exercise but that of the most easy kind ; and when
those symptoms  are removed, the  suppression of the menses may
come under contemplation. The tinctura melampodii was strong-
ly recommended by Dr. Mead ; but the principal good which it
does, seems to be produced  by its operation  as a gentle laxative,
its other effects being very problematical.
  The menses are  sometimes suppressed by  sudden  exposure to
cold, or by violent  exercise and  agitation during the time they
are flowing.  Even in these cases,  the suppression is frequently
subsequent to the attack of some  disease; as a pleurisy, perip-
neumony, acute  rheumatism, inflammation of the uterus, or the
like; and under such circumstances, the same treatment is to be
advised as the particular nature of the disease may require, with-
out regard to the menses.   I have been  informed that, in  sup-
pressions or deviations of the menses, injections per vaginam, in
the composition  of which there is some preparation of quicksilver, "*'
are of  particular service; but of such I have not had any experi-
ence.*
  * [The different and opposite states of the constitution to which
the author adverts, as the  causes of obstruction or suppression of
the menses, lead to important practical  consequences.  Our chaly-
beate mineral waters will be found  highly serviceable in those ca-
ses in which the invigorating method of  cure is  indicated.   I would
insist, with more earnestness than our author, upon the propriety of
venesection in the other class of cases, where the suppression is con-
nected with a plethoric habit, or has arisen from exposure  to cold.
  Another point of primary consideration, is the effect so frequently
manifest by a suppression  or obstruction of the menses,  of irrita-
tion of the chest, and other symptoms of a pulmonary sort.  We may
safely attribute a large proportion of our pulmonary disorders to
this source, and the practitioner, in almost every case, will fjnd it to
the advantage of his patient, to advert to such condition of the system.
It is unnecessary tojrecommend, with increased regard, the depleting
practice of our author in cases of this nature.  From overlooking this 
ON MENSTRUATION.
187
                          SECTION VI.
   The excess or profusion of the menstruous discharge may be
of two kinds.*   It may consist either in the frequency of its re-
turn, or the superfluity of its quantity  at  each  period;  and the
causes assigned  for either  of these are,  too great fulness or acti-
vity, or an irritable and debilitated state of the constitution, or
the thin and  acrimonious state of  the  blood; together with ex-
ternal accidents.   Instances occur in practice, in  which  women
menstruate at each period a  larger quantity than  their constitu-
tions are able to afford; yet those cases,  which are usually re-
duced under the term profusion  of the menses,  are rare; what
are called such,  being  either hemorrhages accompanying early
abortions, or morbid or symptomatic discharges from the uterus.
The symptoms of the profusion  of the menses  are  the  same as
those which are produced by  hemorrhages from any other part of
the body, with some peculiar affections of the uterus.
   If there should be merely too  large a quantity  of menstruous
discharge at each period, or  too frequent returns, such medicines
and regimen  as  strengthen the constitution, or amend the health,
will be proper, particularly the cold bath ; and  when these com-
plaints can be supposed to arise  from the want  of a due degree
of contractibility in the blood vessels, gentle emetics,  occasion-
ally repeated, have been of great service.   However, in far the
greater number of cases of this kind which occur in  practice, the
discharge seems  to be symptomatic, and dependant on the general
feverish state of the patient,  or that of  the uterus  in particular ;
so that at the time when the menses are expected, she should  be
kept very cool and quiet, and confined to an horizontal position,
and perhaps such  medicines as  slacken the  circulation of the
blood may be  given  with  advantage.   But if  astringent  or
strengthening medicines be given in  the first instance, they are
so far from removing  the complaint,  that they often increase  it,
and the discharge  will continue as long as such  medicines are
administered; not to mention that a difficulty of breathing, and
other dangerous symptoms, are often produced  by too hasty  or
too liberal a use of astringent medicines.  But if  the feverish
disposition be previously abated by bleeding and a proper  regi-
men, such medicines as were before recommended for  the sup-
pression of the  menses may then be given with  propriety and
source of pulmonary consumption, many have fallen victims to that
very mode of treatment which, in an opposite state, would have end-
ed in success.   F.]
  *  Menorrhagia.—Cullen, G. xxxvii.  Dorsi,  lumborum, ventris,
parturientium instar, dolores ;  menstruorum copiosior, vel sanguinis
e vagina-oraeter ordinem fluxus. 
188         INTRODUCTION  TO MIDWIFERY.
advantage; or any of the class of astringents which  have been
before mentioned, beginning with those which are gentle in their
operation,  and advancing gradually to those  which  are most
powerful.   In many cases of hemorrhage from  any part  of the
body, the  natural  balsams, as that of copiava or Giiead.  or the
tinct. benzoin  comp. or even  the oleum terebinthina?, given  in
small but repeated doses, have been  found of great service ;
moderately astringent injections into the vagina may, in  some,
also be safely  and  properly used.  In discharges of blood from
the uterus, proceeding from  diseases of the part, the  treatment
must depend upon the nature of the disease, of which we cannot
form any just  opinion without an examination, per vaginam ; but
this  it not  to  be proposed,  till all the usual means  have been
tried, and  failed to answer our intention.   See the chapter on
abortion.

                         SECTION VII.
   The pain with w'hich some women  menstruate at each period,
is  sufficient,  from  its violence  and  duration, to render a great
part of their lives miserable.*   Healthy, robust worn-n, or  those
in whom the  process is speedily concluded, seldom suffer much
at that time ; the pain is therefore  to be attributed to an increased
degree of irritability in the habit, or to  the difficulty with  which
thoso vessels,  designed for  the menstruo'i  discharge, become
permeable.  This  pain, independent of the membrane  before
mentioned, is, in general, moderated, and sometimes  altogether
removed, by  the use of such  means as  lessen  uterine  irritation,
or facilitate the discharge, and these must be suited  to each indi-
vidual case.  Bleeding  in  small quantities, previous to  the
period, gently purgative  medicines, and opiates, of which the
most efficacious  is the Confectio Danxter'atis, repeated according
to the urgency of the complaint, may be occasionally directed
with advantage.   Soaking the feet in  warm waieli^r receiving
the steam of it upon the parts  principally affcctetfmUl often do
much service ; but no remedy of  thitffeind gives equwreliei' with
the  warm  bath, which  may  be us^d^every evening,  when the
symptoms  preceding  menstruation  come   on,  and   continued
throughout tiie period   Electricity applied to  the region of the
uterus, before the expected discharge, has, in some cases, afforded
much benefit.  Many medical writers have advised, and it is yet
a  popular custom,  to give medicines of that kind which have been
called deobstruent, with the  view£pf  promoting the  discharge by
quickening the action of the parts'concerned ; and  in some con-
  * Dysmenorrhoea.   Vogel, clxx.   Profluvium sanguinis uterini
menstruum dolorificum. 
ON MENSTRUATION.
189
 stitutions these may be proper.  But as many medicines of this
 class disturb and increase the heat of the body,  they are gene-
 rally found by experience, rather to increase than to abate the
 pain, which, in a few cases, I have found prevented by the daily
 use of the madder root,  given without interruption  for several
 weeks.
   During the period of menstruation, some  women,  who are at
 other times disposed to be costive, have their bowels  then much
 irritated; and others, who are in a common way disposed to be
 laxative, have then  their bowels constipated.   Perhaps the con-
 sideration of these circumstances may enable us to judge of the
 proper treatment; but in every case of this kind, it is scarcely pos-
 sible to abstain from the use of opium, in some  form or quantity,
 at each period.*

                         SECTION VIII.
   At the approach of old age the menses disappear, the constitu-,..
 tion of women neither requiring nor allowing a continuance  of
 the discharge.  It was before observed, that this  event  usually
 happens about the forty eighth year of their age, though some in-
 stances  have occurred of their final cessation so early as the thirty-
 fifth, or sooner,, and of their duration to  the sixtieth  year of the
 woman's age, but t! ese are very uncommon.
  The menses seldom disappear suddenly ; but, before their de-
 parture, they become irregular  in their periods, or in the quan-
 tity discharged.  .These irregularities are not unusually  accom-
 panied with some disturbances of the constitution, particularly of
 the viseera,  and those complaints which  are called hysteric.
  All women are alarmed at  the time of the final cessation of the
 menses ; and are persuaded, that the ill consequences which some-
 times ensue, are to be prevented by proper  care  and manage-
 ment at the time.  But it must be observed, that scarce one of a
great number of women  suffers more  than temporary inconve-
nience on that account;  and it  is not reasonable to  think, that
any disease should be a necessary consequence of the cessation of
a discharge, which is  as  perfectly natural  as its appearance or
continuance.  The  most common circumstances  which  accom-
pany or follow the cessation are, increased  fatness of the  person,
a more full and stronger pulse,  with more than ordinary  heat.
But if there be a disposition to  disease in  the constitution, espe-
cially in the uteru;,  a  more  rapid progress is made when the
menses cease ; not most probably because these  give existence to,
or promote disease by any malignant  quality, but because the
  *  [I believe we  will often  find opium, in the form of Dover's
powders, the most eligible prescription.  F.] 
190
INTRODUCTION TO  MIDWIFERY.
constitution, or the parts disposed  to disease,  are deprived of a
local discharge, by which they were before relieved.
   On the presumption that the menses retained became, by their
malignant quality, the cause  of diseases, many  medical writers
have advised aloetic,  and other  stimulating  medicines, which
were supposed to possess the power  of continuing the discharge
a longer time than the natural.   As the principle is  not just, this
practice is also in  general injurious; for I hardly  recollect  an
instance, in which such medicines  did not evidently do mischief,
by increasing all those complaints  which were  imputed to, be-
cause they occurred at the time of, the final cessation of the men-
ses.   But the present mode of practice is far more reasonable and
successful, it being now  usual to bleed  occasionally, which wo-
men  advanced beyond this period generally  bear with more ad-
vantage and less inconvenience, than  at any  other time of life;
to give  cooling  and gently aperient medieines,  avoiding every
kind  of diet and medicine which is  heating, or may occasion cor-
pulence.
   It is, however, a well known  fact, that the uterus, breasts, and
every part concerned directly or  indirectly in  the act  of concu-
binage, is more liable to disease at, or soon after  the final cessa-
tion  of the menses, than at any other time of life; aud  that these
too frequently terminate in scirrhus or cancer, with consequences
the most painful and deplorable.*
  *  [There  is  a  train of disorders following the cessation of the
menstrual discharge, which deserves particular attention ;  and sci-
entific as well as popular opinion,  has very justly considered the
time at which the menses cease,  as  a critical period of life.   The
various and  important functions  which the  uterus itself performs,
and its intimate and extensive connexions with the  whole system,
justify us in considering a suspension of its offices,  adequate cause of
diseased action.
  That the uterus is a prolific source of disease, and in an especial
manner exerts particular influence on the digestive organs, has been
forcibly asserted by  the accurate Heberden : Uteri  affectus  fere
omnes ventriculo nocent. ..-Its effects upon the glandular system are
not less remarkable : its sympathetic influence upon  the  mind is
manifest in the various  and frequent forms  of mental derangement
which ensue.
  The practice of provoking  the menstrual discharge by aloetic and
other active  medicines, upon its natural  cessation,  deserves  to be
deprecated.  Attention to the alvine  evacuations, by mild purgatives
and occasional blood-letting, will  be  found the most efficient means
of accommodating the system  to the exigencies of its new condition :
while the  patient should avoid every unnecessary cause of irritation,
as high-seasoned meats, spices, &c. and the improper exercise of the
passions.  F.] 
ON MENSTRUATION.
191
   Of cancer, it is to be lamented, we have at  present neither a
 tolerable definition,  nor a correct history, nor any  accurate dis-
 tinction  of the several  varieties,  which are certainly  known  to
 exist.  Nor is it yet  proved whether cancer, of any  part,  has any
 specific quality,  according to the structure  of the  part affected;
 nor have we, in fact, at present, any other idea than that it is an
 incurable  disease.   It  nevertheless  appeareth from a  number of
 authorities, that  at  different periods of time, much labour has
 been bestowed, and the most earnest  endeavours used, to discover
 the nature of this disease, and a remedy for it,  but  unfortunately
 without success;  perhaps,  because  we were not in possession of
 some sound principle on which to proceed.
   It may be doubted, whether we shall ever acquire a knowledge
 of a cure for cancer, till a  just foundation of principle  is laid,
 from which legitimate inductions may be derived; though it is
 not impossible, but we may gain a knowledge of the wished  for
 remedy by some  accidental discovery.
   The seat of cancer is not confined to any particular part, almost
 every  part of the body being liable to it, but those most generally
 affected in females are the uterus and breasts. When the former is
 the part affected,  the first symptom  is usuajfy inflammation, and
 if this  can  be effectually removed by strict abstinence, by bleed-
 ing occasionally, by antiphlogistic  medicines, and by constant
 repose in an horizontal  position, 1 have  often  persuaded myself
 that the disease has  been prevented  or removed.  But if the dis-
 ease should resist these means, the part becomes swelled  and en-
 larged, with an increase of pain, an accession of discharge gra-
 dually augmented, and a depravation of the general health of the
 constitution.
   The discharges are in some cases  purely serous,  in others, fre-
 quently returning sanguineous ones, ichorous, or  purulent,  of-
 fensive in smell, and  not tin frequently of such an acrimonious qua-
 lity as to excoriate  every part which it may touch.   All  the
 neighbouring  parts  become connected together into one  mass.
 Then generally begins erosion of the parts,  a  considerable por-
 tion of the  bladder and rectum is destroyed, the urine  flows con-
 tinually over the ulcerated parts,  the faeces are discharged into
 the vagina, and it is  not possible to  conceive a state of greater
 misery than that of a person in the last stage of uterine cancer.
   Within the last few years, more than ordinary pains  have been
 taken to discover a cure for this disease,  and  by  several it has
been asserted,  that one had been discovered ;  but,  I believe  on
 trial,  all of them have been found  nugatory  and  fruitless.   If
therefore, the means  used for putting a stop to  the  disease at its
commencement fail,  we are at length driven to the necessity  of re-
lying  on the  application and internal use  of opiates in  every
form and of every kind, which are found to  agree or answer best 
192           INTRODUCTION TO MIDWIFERY.
with each patient; as the hyoscyamus, belladonna,  but chiefly
of pure opium, or some of its officinal preparations.
  It is necessary, however,  to observe, that all enlargements of
the  uterus, though attended  with pain, do not proceed from a
cancerous'cause, though in many respects they resemble that dis-
ease.  These are sometimes  scrophulous, and then they  com-
mence with a tumour between the rectum and  vagina; and  when
the  uterus is primarily affected, they often terminate in abscess of
the  part.   These, and such like  cases, I apprehend,  often give
rise to unguarded  assertions that cancer has by  such  or such
means been perfectly cured.
  When one of the breasts is  affected, it usually commences with
a circumscribed tumour of a large or small size.  These tumours
often come on with rapidity and a sudden  increase of pain, but
they will often lie dormant and inoffensive for a great number of
years, and sometimes life is passed through without their ever be-
ing excited to morbid action.  So long as  these tumours re-
mained  unconnected with the neighbouring parts,  it was former-
ly  thought expedient and justifiable to extirpate  them  with the
knife, or by caustic.  But the operations  have so often failed,
that  is,  the disease^as so  often returned,  that the  most expe-
rienced  surgeons have hesitated to give their consent to perform-
ing them.
  But in a work lately published, a different mode of treatment
of these tumours has been recommended,  whether they  were oc-
cult or open, that is chiefly by  strong pressure.   It is supposed
that this pressure  is in general  equivalent  to eighty or ninety
pounds.
  The effects I  have seen produced  in several  cases under the
care of Mr. Young, the  author of the work, have really been sur-
prising, not only from the evident good effects immediately pro-
duced, but from the reasonable hope they gave of a perfect cure
of  the disease.   1  may say with truth, that my expectations of a
cure for cancer, are far more sanguine from the effects I have seen
produced by Mr. Young's method, than by  any  other  means I
have seen used or tried.
    It is remarkable, that the  cure of cancer affecting parts  of the
body, where applications could be made with the greatest facility
and advantage, has  not been attempted, when those of the uterus
have been undertaken  with  great confidence.   This  may be
among the instances, in which the credulity of patients renders
 them liable to the impositions of empirics,  who often  pretend to
 cure a disease which never existed, or extol as a cure its mitiga-
 tion.  If it be however allowed, that this disease is  incurable, and
 that regular practice despairs of giving assistance, when the dis-
 ease is  arrived  at a certain  state, the trials of empiricism, under
 some restrictions, may not only be  permitted, but encouraged, 
ON MENSTRUATION.
193
with the expectation of some casual good ; and if, by the expen-
diture of money, hope, though of short duration, can be procu-
red, the  purchase is cheap  at almost any rate.  Upon the prin-
ciple of guarding against the cruel effects of despondency, honest
men are sometimes obliged  to equivocate, or to promise more
than they are conscious they are able to perform.   But as by the
favour  of Providence,  and the labours of men,  remedies have
been discovered for many diseases, which were once thought in-
curable,  we may hope that  one  will at length be  found for this
most deplorable disease.
   More  than one case has occurred, of a diseased lip, considered
by able men as cancerous,  being cured by the constant applica-
tion of a layer of the root of the common red  onion.   I tried a
strong decoction of the same root internally,  and as an injection,
in a variety of uterine cases, but without any apparent advantage.
   A few years ago some  gentleman, now known to have been the
late most benevolent and liberal Mr.  Whitbread,  who added to
the merit of the donation by the concealment of his name, at the
expense of more than three thousand pounds formed an establish-
ment for this purpose in the  Middlesex Hospital, from which it is
hoped much  good will  be  derived,  and great  additions have
since been  made to its revenues.  Very lately,  an institution has
been founded professedly on the principle of investigating the na-
ture and  cure of cancer, but  this is yet in its infancy;  or is rather
for the present suspended.*
  *  [Our author speaks with too much confidence of the suecess at-
tending the treatment of cancer, by  compression.  Every friend of
humanity must lament the failure  of the  benevolent attempt of the
late Mr. Whitbread, and the active zeal of the excellent Mr. Samuel
Young, to  take from this disease its  fatal character.  In my  casual
visits to  the  Middlesex Hospital,  in the  winter of 1816,  I had
opportunities of learning the insufficiency of the practice by com-
pression ; and the candid acknowledgment of Mr. Charles Biell de-
serves to be recorded.  I find, by a Heport on Cancer, of the  Medi-
cal Committee of the Middlesex Hospital,  published since that time,
that the Committee have to lament " that compression cannot be re-
garded as a remedy for cancer." How is it possible that specific ac-
tion can be subdued by  compression ? As well might we attempt to
cure  syphilis by blood-letting.  Pressure,  I  believe,  accelerates
the coming on of the fatal symptoms of cancer.  F.]
25 
194         INTRODUCTION TO MIDWIFERY.
                     CHAPTER VI.

                         SECTION I.

                      ON CONCEPTION.

  By the  term conception is understood the formation of an
embryo, or of the rudiments of a new  being, in  consequence of
the mixture of the male and female semen, or of the  operation
of one or both of these, in or after the act of coition.
  It has been  much  disputed, whether  conception be merely an
assemblage of small  particles already prepared,  and constituent
of the kind; or first a production  or change of, and then a
coaptation of particles designed for that purpose.  But the first
part of the process by which  primordial existence is established,
by the minuteness and complication of the objects to be described,
and by the retirement of the  attending  circumstances,   is proba-
bly involved in too much obscurity to  be discovered by the hu-
man faculties.  Even when the first  changes have  been  made,
the parts remain too small to admit a very accurate examination.
But  neither the difficulty of the investigation, nor the acknow-
ledged uncertainty of all reasoning, without the support of facts,
has deterred ingenious and speculative  men, in every  age, from
hazarding their opinions on this subject.  It is  true,  that little
satisfaction or advantage is to be gained ; but if we do  not profit
by the knowledge  of their opinions, we may  be convinced, that
little has hitherto  been said on this subject for our information.
  The first opinion  recorded is, I believe, that  of Pythagoras.
He supposed, that from the brain and nerves of the male a moist
vapour descended in the act of coition, from which similar parts
of the embryo were formed.  These  were thought to be the seat
of the soul, and,  of course, the parts from which all  the senses
were derived.  All the grosser parts, he imagined, were composed
of the blood and  humours contained  in the uterus.   He said,
that the embryo was formed in forty days, but that seven, nine,
or  ten months were required for the  perfection of the foetus,
according to the laws of harmony.  He also supposed, that the
same laws which guided the formation of the foetus  influenced
the conduct of the man.
   It was  a custom  with the Scythians, to. cut the veins behind
the ears, when they  intended  to procure impotence or sterility ;
and it is remarkable, that this custom  remains, and an opinion
like that of Pythagoras is entertained,  among the inhabitants of 
                      ON CONCEPTION.                 195

 some of the islands lately discovered in the South Seas.   Chang-
 ing  the term  harmony for  magic,  occult quality, and the like
 expressions, by which an imperfect idea is conveyed, or a con-
 cession that we  have proceeded to the extent of our knowledge
 is actually made,  many succeeding writers  have given us  their
 conjectures.
   Empedocles presumed, that some  parts of an embryo  were
 contained in the semen -of  the male, and others in  that of the
 female, and that  by their mixture  an embryo was formed.   He
 likewise thought, that the desire of procreation originated in the
 natural tendency of the separated parts to be united.
   That conception  took  place in the cavity of the  uterus, by
 the mixture of due proportions of the male and female semen,
 in which  were equally contained the organic principles of the
 embryo, was the  opinion of Hippocrates.
   Aristotle denied the existence of semen in the female.   He
 imagined, that the material parts of the embryo were formed by
 the menstruous blood, and that the semen of the male furnished
 it, when formed,  with  the principle of life, by the operation  of
 which it  was  brought to perfection.  It is  remarkable that  a
 philosopher, with every advantage which a superior capacity,
 and  the most  extensive opportunities of acquiring knowledge,
 could  give, should  attempt to explain,  what is common  to all
 animals, by a  circumstance peculiar to one class.
   Galen thought that the embryo  was formed by the substance
 of the male semen, and that the humour  supplied by the female
 served the mere purpose of nourishing it.
   Harvey employed a considerable part  of his life in observing
 the structure of the  ovum, and the progress  of conception  in  a
 variety of animals.  When  he had completed his discovery  of
 the circulation of the blood,  this seems to have been his favourite
 study, which he prosecuted with the true spirit of inquiry, and in
 which he made many observations   worthy of that sagacity and
 industry which were never exceeded.  With his disposition, abi-
 lities, and advantages, it was reasonable to expect, that he would
 have been silent,  or have said something satisfactory upon this
 subject.  But after much previous apology, for an opinion which
 admitted no other proof, than an allusion to a  circumstance of all
 others the most incomprehensible, he tells  us, that as iron, by fric-
 tion with a magnet, becomes possessed of magnetic properties, so
 the uterus, by the act of coition, acquires a plastic power of con-
ceiving an embryo, in  a manner similar to  that by which  the
brain is capable of apprehending and thinking.*
  * Videtur sane fzemina, post factum  in coitu spermaticum, eodem
modo afiici,  nuUoque sensibili corporeo agente prohfica fieri,  quo 
196         INTRODUCTION TO MIDWIFERY.
   The opinion of Hamme, of the credit of which he appears to
 have been unfairly deprived  by Leuwenhoeck,  was afterwards
 received with great applause, became the doctrine of the schools,
 and gave universal  satisfaction,  because it was supported by a
 fact, which, by the help of his microscopes, he presumed he wa3
 able to demonstrate.  He asserted, that, in the semen of all male
 animals, there was  an infinite number of animalculae, in each of
 which were contained the perfect rudiments of a future animal of
 the same kind; and that these required  no other assistance from
 the female, but a  proper bed  for their habitation, and nutriment
 for their expansion.
   From him,  Needham, and many others, dissented ; and, after
 several other objections of less importance, they adduced the ob-
 servation of a mixed generation,  as  in  the case of a hybrid  or
 mule; which, being procreated by two  animals of different spe-
 cies, partakes in an equal degree of the nature and likeness of the
 male and female parent.   This seems to  be a decisive and  unan-
 swerable refutation of the  doctrine of animalculae, and  I believe
 the sentiments entertained at the  present time are, that  the mov-
 ing bodies, which Leuwenhoeck saw in the semen, were not ani-
 malculae, or organized parts, but parts fitted for organization.
   From the manner in which  the vagina and uterus are connect-
 ed, it has been thought, that the male  semen  was not  designed
 to be introduced into the  uterus  of the female; but being ab-
 sorbed from the vagina, that  it passed in the common course of
 the circulating blood, and was  conducted to one of the ovaria,
 where it  performed its proper office by the impregnation of one or
 more ova.  But the  examination  of the  uteri of animals  in the
act of coition, and even of many  women who have died imme-
 diately in, or soon after it, has  fully proved, that the semen  of
 the male is first received into the cavity of the uterus.*
   It has been generally supposed,  that conception was produced
 by the substance of the male semen.  But some have contended*,
 that the ovum, when enclosed in  the ovarium, was  impregnated
 by an aura, exhaled from the  semen, which contained the princi-
 ple and powers of life, of which aura the semen  was merely the
 vehicle.
   Many objections being made to these,  and every other opinion
 which has been advanced upon this subject,  the chemists under-
ferrum a magnete factum, hujus statim vi dotatur, aliaque ferrament
ad se allicit.—Harv. Exercit. de Concept.
  * Vidimus cavum uteri, albo, naturali atque bono semine masculi-
no repletum, utramque etiam tubam Fallopianam eodem semine ple-
nam.—Ruysch. Adv. Anatom. Dec. 1.  See also Cheselden's Ana-
tomy. 
ON CONCEPTION.
197
took to solve all doubts, and to explain all difficulties, by the ap-
plication of their principles.   They presumed, that the male se-
men was of an acid, and the female of an alkaline quality, from
the mixture of which, an effervescence arose.  From some parti-
cles which subsided on the conclusion of the effervescence, they
fancied that the embryo  was formed, the fluid parts  becoming
the waters of the ovum.  Others  imagined,  that the male semen
had the properties of milk, and the female  those of rennet, by
which it was coagulated, the  foetus  being formed from the curd,
and the waters of the ovum by those  parts  which  resembled
whey.*  Various other notions have been proposed with a view
of explaining this very abstruse operation; but they leave us in
a slate of uncertainty.  Some of them may  amuse, because they
are ludicrous;  and in the description of the  parts concerned, the
uses they are intended to answer, and the manner in which they
are supposed to perform  their respective  offices, the imagination
hath been indulged with a freedom not very consistent with the
dignity of philosophy.
   If we were  able  to discover the essential  properties  of the
male  semen, the precise share which the male and female con-
tribute toward  the formation  of the embryo, the part where, and
the manner how, the effect was produced, the advantages which
would thence accrue in practice do not appear; though it is diffi-
cult or impossible to say, to what the discovery  of any truth may
lead,  before it is discovered.   But it is happy  for us  that those
things which are beyond the  comprehension, or which elude  the
observation  of men of plain understandings,  are of the least
importance  in  practice;  Providence having ordained, that  the
honest and industrious application of common  capacities should
render  us equal to the exigencies of life, and the duties we  owe
to society.f
  * Sicut lac mulsisti me, et sicut caseum coagulasti me.—Job.
  Reverain illo tempore, cum embryones adeo exigui sunt, comperio
rudimenta nostra,  maximam haberi analogiam cum coagulo lactis.—
Ruysch. Thes. vi.
  t [If the reader is at all desirous of entering at any length into
an examination of  the numerous  theories of generation, he will find
enough to gratify his curiosity in the writings of Wolf, Buffon, Dar-
win, and  Spallanzani;  and much  more that will enlig*hten him  in
that great exposition of the Epicurean philosophy, the translation of
Lucretius'  poem,  De Rerum Natura, with Mr.  Good's elaborate
notes ; the Elementa Physiologic of Haller, and the works of Blu-
menbach and  Sprengel.  An abstract of some experiments on this
subject, will be given in a subsequent note.  F.] 
198
INTRODUCTION TO MIDWIFERY.
                          SECTION II.
   A general history of the  manner in  which the succession of
 all natural substances is preserved, and of which we shall take
 a short view, might be a  very useful introduction to an  inquiry
 into the generation of animals.  For,  though  there appears to
 be little resemblance  between this and the principle  by which
 inanimate  bodies are continued, it is not very unreasonable  to
 suppose, that there may be some common essential quality diffused
 through all nature, limited in its operation by the kind  of matter
 on which it is destined to operate.*
   Minerals constitute the lowest order of all  natural  bodies,
 every kind  of which has its own peculiar quality and external
 mark of distinction.   These  have  been thought to be increased
 by the  mere  assimilation or  apposition of such  homogeneous
 particles as were  contained  in the matrix or bed in which they
 lay.  But  many other causes have been assigned for the  conver-
 sion of bodies into peculiar modifications ; as the heat of the sun,
 of the  central fire, cold,  and alternate  heat and cold, by which
 the ultimate determination  of every mineral substance into a
 certain  form  was  supposed  to  be effected.   Some naturalist
 (Tournefort) has entertained more dignified opinions of the in-
 crease of minerals, believing that there  was in  these a germ or
 principle of generation,  and that a grain of  sand became  a
 stone, by the operation of a  cause,  equal and similar to  that by
 which  a vegetable  from  a   seed acquired  the  perfection  of a
 plant.   Others are persuaded, that in mineral substances of every
 kind there are two properties, the one specific, the other general.
 To the  first, to which the power of increase was attributed, the
 name of elective attraction is given; and to the latter, by which
 its form  was preserved, that  of attraction of cohesion.^  These
 which are most powerful  in the largest masses of matter, imply
 some  property superadded to matter,  which, though slow and
 obscure in  their operation, are equivalent for the purposes of its
increase and preservation, in all its various  forms, with that of
life, by  which vegetables  and animals are propagated  and pre-
served.   In this  view the term spontaneous generation, not al-
lowed in vegetables or animals, though not in  some instances
  * Naturalia dividuntur in regna Naturae tria, Lapideum, Vegeta-
bile, Animale.
  Lapides crescunt, Vegetabilia crescunt et vivuntj  Animalia cres-
cunt, vivunt et sentiunt.—Linnceus.
  t That force by which the parts of bodies cohere is stronger than
its gravity.   That force, whatever be its cause, we shall call the at-
traction of cohesion.—Desaguliers. 
ON CONCEPTION.
199
 disproved, may properly be  applied  to minerals.   It  is  also
 worthy of observation, that by the time  required  for the forma-
 tion  of matter, under every  individual modification, its  con-
 tinuance  under such  modification is regulated.  For,  if there
 had been no relation  between the power of increase and the
 tendency  to decay, the whole  world, in a course of years,  must
 have been composed of matter under one peculiar form.
   Through all nature there is not found a  single body which
 consists of materials lying in confusion.  However small and ap-
 parently insignificant, every particle exhibits proofs of  the ma-
jesty and wisdom of God ; and it  may be presumed, that the mi-
 nutest elementary  parts of every substance, are originally com-
 posed and wrought up in the most regular order, into  what is
 called form.   Yet in mineral substances, it is  a  form so immer-
 ged in matter, that it is ever restrained from the acquisition of the
 excellence of a living body, unless there be a previous destruc-
 tion of its present  form.*   But the more refined the matter, the
 more perfect is the form; and the more perfect  the  form, the
 more exquisite are the properties.  Hence the common observa-
 tion seems to  have been made of the encroachment, as it may be
 called, of one order of natural bodies upon another; of the  near
 accession  of the first minerals to the lowest vegetables, and of the
 first vegetables to the lowest animals,  in such a manner that they
 can  scarcely be distinguished.
   Of the  mineral, vegetable, and animal kingdoms, there is, to
 common sense, a clear and precise distinction, though language
 may be insufficient to give a definition of vegetables,  which will
 not  in some measure apply to animals.  It is  not  satisfactory to
 say, that vegetables have no power of locomotion, that they  have
less variety of parts, that their constituent parts are more simple,
that they  do  not breathe, have no appetites, and  do  not digest
food ; that they have no sensation, and are only  injured by  such
things as destroy their organization.  For it may be replied,  that
vegetables do perform some operation equivalent  to respiration,
as they  cannot live without air ; that they are  greatly affected by
light, which alters  their colour ; that they require, select,  absorb,
and digest food, or nourishment;  that some of them move, appa-
rently in search of nourishment,  and others  have a certain de-
gree and kind of sensation.
  * That state in which all bodies are, during the time they are lo-
sing their present form, or undergoing any change, was by the an-
cients called fermentation.  In this sense the term was applied to fe-
vers ; but many  modern physicians  have used the same term in a
more confined sense, and the application of it will not then bear ex-
amination. 
200          INTRODUCTION TO MIDWIFERY.
   Whatever may  be the essential difference between vegetables
and animals, it is probable, that  they are both  in some degree
subject to the same influences; as in those  seasons  which  are
most favourable to vegetation,  animals  are generated in  the
greatest number and perfection;  and there is evidently much re-
semblance in the manner of their propagation.  The sexual dis-
tinction  of plants  is  now fully  proved;  or it is allowed,  that
there is a distinction between two plants of the same kind, like to
that between a male and female animal; and that those  vegeta-
bles, in which such distinction is not observed, have both  the
male and female parts, and are  therefore  with propriety called
hermaphrodites.   For, though  a female plant  may  produce
seeds, to our view, in a perfect  state, these, without the interven-
tion of the fecundating principle from the male plant, remain ste-
ril, as  hath been fully shown in the tribe of melons, the palm-
tree, hemp, and many other vegetables.   But a more satisfactory
proof is afforded by hybrids, or  mule-plants and  flowers, which
are produced when a female vegetable  of  one species hath had
its  seed  impregnated  by the farina  of one of  another  species
growing near it.
  In the form and structure of the seeds of vegetables of every
denomination there is some peculiarity.   They all contain the
rudiments of a future plant, with  something added to their form,
of equal  efficacy for the perfection of the plant,  and therefore as
justly called life, as that principle by which animals are brought
to their perfection;  for we know nothing of life but by its effects,
the thing not admitting of any  definition.  Any seed, berry, or
kernel, would be  an adequate  example of this  subject; but we
shall select nuts, because they  are equally curious with the rest,
and more familiar.
  A nut is contained in a foliaceous  cup or husk, by the stem of
which it is connected to the tree.  The broad end of the nut is
closely attached  to the cup by small  vessels, which, in the early
state of the nut, are very numerous, but, as it  advances towards
maturity, these gradually  wither  away, till  the few remaining
ones  becoming too feeble to support the  nut,  it drops to the
ground.   This may in one sense be called the birth of the  nut,
though it may with more  propriety be  likened to  the separation
of the  impregnated  ovum  from  the ovarium in viviparous  ani-
mals, or to the expulsion of the egg  in  oviparous  ones.   When
the nut is fallen to the ground,  if the bed which receives it, and
other circumstances, are favourable to germination, a new pro-
cess begins,  the shell softening by the moisture absorbed  by  that
end of the nut, which  before adhered to the cup,  and which is
more porous than  the other parts.   The whole  internal surface
of the shell is lined with a flocculent substance for the prevention
of injury to the kernel from the  hardness of the shell, and for the 
ON CONCEPTION.
201
  reserve and preparation of the moisture already absorbed.  The
  kernel has also two membranes, the inner of which is  fine and
  pellucid, but the  outer is of a coarser texture, resembling that
  substance which  lines the  shell.  On the internal  surface of the
  broad end of the shell there  is a congeries of vessels, or a liga-
  ment, which passes between the kernel and shell,  to the apex of
  the kernel, to which it is attached, and probably serves  the pur-
  pose of an umbilical cord.  When the shell has continued in this
  situation for a certain time, it decays  or bursts, and gives room
  for the expansion of the kernel.  During this  interval,  the pro-
  cess of germination is  going on in the kernel,  which is not de-
  prived of its coverings, so  long  as they are necessary for its pro-
  tection.   The  corculum, or  bud, begins  to sprout; the outer
  membranes decay  or burst,  and, together with a great part of
  the kernel,  serve as the first  supply  of nourishment.  Then the
  radical  and  other  parts  of  the little  plant are unfolded; and
  when they have acquired a certain degree of strength, the kernel
  is devested of all its  subservient parts,  the root strikes into the
 ground, and the plant is perfected by the vigour of its own prin-
 ciple.
   Between the production of vegetables from slips, and the mul-
 tiplication of polypi from  the section of their parts, there is at
 least an equal similitude with the mode of  propagation of which
 we have already spoken.   It  is also deserving of notice,  that, as
 the operation of the principle  of life is often suspended for a very
 long time in the seeds of vegetables,  without destruction, in very
 unfavourable circumstances, the same hath been observed in in-
 ferior animals, particularly in snails, (Annual Register, vol. xvii.)
 though, in this respect, vegetables appear to have the advantage;
 and,  from  the proofs which  have been given, by philosophical
 men, of this suspension of  the operation of the  principle of life,
 divines have, by no forced  construction,  illustrated the doctrine
 of the resurrection of the human  body after its decay.*

                         SECTION III.
  Of the mode of propagation of all the inferior orders of ani-
mals, diversified and wonderfully curious as  it  is, particularly
in the Surinam toad and the  kangaroo, it  is impossible to take
notice.  The greater  part  of these are  oviparous,  and  it  has
even been asserted,  that every living body was  produced from
an egg; but this is a very unjustifiable use of the  term.f
  *  See Philosophical Transactions  for  the  year 1784, in which
there is a very curious paper on this  subject by Mr.  John Hunter,
by which that doctrine is supported
  t Diximus antehac ovum esse tanquam functum animalium.   Harv.
Exercitat. de Partu, and the plate prefixed to the English edition.
                             26 
202
INTRODUCTION TO MIDWIFERY.
  It is probable, that the eggs, properly so called, of all animals,
minute as many of them are, are composed of similar parts  with
those of  the  larger  oviparous animals.  We may  therefore  be
permitted to  take  our next  example from the  eggs of birds, in
which all the circumstances  relating to the formation of the ani-
mal  have been well described by many able  men, but  with
peculiar accuracy  by the illustrious Harvey.
  The eggs of birds are composed of two  principal  parts, which,
from  their  colour,  are called the yelk  and  the  white.  The
yelks only are found in the ovarium, to which they  are attached,
and where, it is presumed, such as are in a fit  state are impreg-
nated.  They are of  different degrees of magnitude, and that
which is  the most  perfect  first drops into the  infundibulum,  by
which it  is  carried into the uterus, collecting in its passage the
white.  In the uterus it is clothed with its membranes and shell,
after  which  it is expelled in a firm state.
  The texture of the shell is  admirably calculated for preserv-
ing the contained parts,  and for  receiving  and retaining that
heat, which  is  conveyed  to eggs by  incubation.  Immediately
within the shell is  the common membrane, which lines the whole
cavity of the egg, except  at  the  broad  end, where  there is a
small  space  filled  with air.  Within  this membrane,  the white,
which is said to  be  of two  kinds, is immediately  contained ;
and  near  the centre, in an  exquisitely fine membrane, the yelk.
The  white  is of the same form with  the shell, but the  yelk is
spherical.  At each extremity of the yelk, next to the ends of the
egg, is the chalaza,  a white firm  body, consisting  of three glo-
bules like small hail-stones.   In  the  chalaza the  several mem-
branes are connected, by which means the various parts, in every
position  of  the  egg, are retained  in their proper place.  Upon
the  yelk, near the middle, there is a small,  flat, circular body,
or  vesicle, called  the cicatricula,  in which the rudiments of the
chick are contained.   In consequence of incubation, or of con-
tinued heat  of any kind  to  a certain  degree, the respective
changes are produced with  great exactness; but, previous to
any  organization of  parts,  the  first observable  alteration  of
importance consequent to  incubation, is the formation of blood,
which Harvey has  therefore  described as the primum  vivens,
  In omni genere animantium quae ex coitione nascuntur, invenies
ovum aliquorum esse  principium, instar  elementi.   Ovum  vero
digestio est feminis.—Macrob. Saturnal. lib. vii. chap. xiv.
  * I cannot forbear quoting the following beautiful passage from
Harvey :  " Columba, praesertim ea, quae ad nos ex Africa advehitur,
gaudium a coitu mirum in raodum exprimit: saltat, caudam distendit,
eaque imam verrit humum,  rostro se pectit et ornat; quasi  foecun-
ditatis donura summam in gloriam duceret."—Exercitat. xxxiv. 
ON CONCEPTION.
203
ultimum moriens.   The heart, which is soon  perceptible,  is in
a short  time discovered to be in motion, then the vascular system,
and the other constituent parts  of the animal  in regular order.
The white of the  egg becoming thinner,  supplies the growing
chick with nourishment, as does  likewise  the  yelk, till it is of
too large a  size to be  contained in the  shell, which  bursting,
the chick  is set at liberty, and carries in the ductus intestinalis a
part of the  yelk for  its future  sustenance, till  its powers  are
sufficiently vigorous to enable it  to  take and digest extraneous
food.

                         SECTION IV.
   The  regular disposition and connexion of the various parts of
matter of which the world is composed, and of the various living
bodies  by which it is inhabited,  are not  more surprising than
the circumstances by which they are distinguished. For, though
there is an evident series of relations by which their connexion
is preserved, to  each different being there is some outward mark
or inward structure, by which it  is separated from those which
precede and  follow it.   Thus, in every order of animals there is
observed  a difference in  the structure of the parts concerned in
parturition, and in  the ovum or  conception which they severally
produce,  by which each class might be arranged as  justly as
by the  structure of any other internal or  external part.   The
human uterus  alone is  pyriform, and the placenta,  which is
flat and circular,  adheres to it  by a broad surface.   But ani-
mals have the uterus divided at  the  fundus into two branches,
or horns ; and   the gradation from the  human uterus,  to that of
an animal,  debased to the  lowest extremity of the viviparous
class, makes a  curious  part of natural history.   In the pecora
the  horns are  convoluted,  and terminated in a point, and the
connecting substance  between the foetus and  parent  is divided
into several  portions called cotyledons, which adhere to as many
temporary productions  of the  uterus, resembling glands.  In
the ferae, there is a variation in the horns of the uterus; and the
connecting substance between this and the foetus, though in one
mass, surrounds the uterus like an internal belt.   In the belluae,
the horns of the uterus are  reflected and  obtuse, and  the foetus
 has neither placenta nor  cotyledons,  but receives its nourishment
by the very capacious  vessels  of the  membranes.   These  and
 many other  varieties in every class, to which it is not possible in
this inquiry to pay attention, answer some very important pur-
 pose, in giving to each animal its distinguishing properties ;  and
in the offices performed there is  some peculiarity  in manner, de-
pendent upon  structure; so that  from the circumstances attend-
ing the parturition of animals of one kind, no inferences could
be made, which would not be liable to many exceptions, if we
compared them with those  of any other. 
204
INTRODUCTION
TO MIDWIFERY.
                         SECTION V.
  Of all viviparous animals, man is  the chief.   The manner in
which his race is  propagated is the object to which we  are now
to confine our attention.   But that  succession of opportunities
necessary for such an  examination not being  attainable in the
human species, recourse hath been had to inferior animals,  on
the presumption, that  there  is not only a common principle  by
which viviparous  animals are propagated, but also that  common
effects  are produced  by the operation of that principle.  Great
attention hath been paid to the cultivation of this subject; but,
in the detail of the circumstances which are said to occur in the
conception or production of the human foetus, several are admit-
ted which it would be extremely difficult to  demonstrate  or
prove.
  Previous to or  during the act of coition, it  is presumed, that
one or more  of the vesicles, or ova,  contained  in the ovaria, is
brought to a state fit for impregnation, and that the male semen,
being transmitted  into the cavity of the uterus, is thence conduct-
ed by one of the fallopian  tubes to  one of the ovaria,  where it
perfects the rudiments of the foetus, or impresses them, already
perfected, with the principle of life.  The prolific ovum, having
undergone its first  changes in the ovarium,  is then loosened
from its connexion, grasped by the fimbriae, and reconveyed by
one of the fallopian tubes to the cavity of the uterus.
  When the  ovum is impregnated, and while it remains in the
ovarium, the  uterus passes through some peculiar changes,  by
which  it is rendered fit for the reception  of the ovum.   The
blood  vessels of  the uterus then appear to be enlarged, as in a
slight  degree of inflammation :  the internal  surface  becomes
softer and more  spongy in  its texture;  and  a white mucus,
which has been likened, from the delicacy of its arrangement, to
the web of a spider, is secreted ;  which, gradually assuming a more
solid form, and becoming  vascular, adheres, or is closely united
to the  uterus, to  the whole cavity of which  it forms a lining,
except at  the orifices which lead to the fallopian  tubes  and the
os uteri.   (See Harvey, his Exercitatio sexagesima nona.)*
  * [Frustrate are  the  attempts which hitherto  have been made
to draw  aside the  veil with which modest  nature has concealed
the mysteries of generation.  There is no generally received theo-
ry on the subject, and recent  experiments have  rather tended to
subvert preceding hypotheses, than to establish  one in their stead.
Some of the leading facts, which seem to rest on  solid experiment
may here be added.
  Animals are of two sexes, and the concurrence of both is essen-
tial to the propagation of the species.  Some  animals, indeed, as the 
ON CONCEPTION.
205
  To this membrane various names have been given, and various
opinions entertained  of its formation.  (Villosam, flocculentam,
pseudochorion, spongy chorion.)   A justly celebrated anatomist
snail, unite in one  individual the organs of both sexes ; yet copula-
tion  is as necessary in them as in other animals.   They mutually
impregnate each other, and each is capable of producing.   But we
have other  much  more remarkable facts for which we are princi-
pally indebted to Bonnet: In a genus of small insects, aphides, (the
hemiptera of  Linn.) one impregnation seems  sufficient for ten  suc-
cessive generations of these beings ; all these  generations, except
the first from fecundated eggs, are  produced viviparous, and all the
individuals are  females, except those of the last generation, among
whom some males  appear to lay  the foundation of a fresh series.
  The theory of equivocal generation,  that is, that animals are pro-
duced from fermentation and putrefaction, without the  necessity of
any parent, was maintained  with much zeal by Aristotle, and was long
a prevailing belief.  In our own time, we have had writers of much
respectability who  have given it their countenance. (Mr. N. Webster,
in the New-York Medical Repository ;  G. Featherstonhaugh, in Me-
moirs of the  Board of Agriculture  of the State  of New-York, &c.)
Harvey,  however, who asserted that all animals spring ex ovo, was
also the first who formally refuted the Aristotelian doctrine, in which
he was ably supported by the Italian philosopher, Redi.
  It was an opinion long ago received, that  there  was a female se-
men as well as  a male  semen ; and that, by  the union  of these in
the uterus, the foetus was produced.  Leuwenhoeck, having obser-
ved  a great  number of animalculae in the male semen of different
animals,  attempted to  support a different opinion, which  obtained
great currency.   One of these  animalcula,  according to him, con-
stitutes  the  rudiments of the future foetus;  it is lodged in the ute-
rus  merely as  a nidus, and all  that the female does is to supply it
with  suitable nourishment.  Subsequent physiologists, not finding
these aniinalculae,  the hypothesis of Leuwenhoeck was speedily re-
jected.   The illustrious De  Graaf, whose services threw so  much
light  on the generative system of animals, ascertained by numerous
experiments  on rabbits, that the ovaries are the seat of conception •
that  one or more of their vesicles become changed ;  that they  are
enlarged, lose their transparency,  and  become opaque  and  reddish
coloured ; that  the number of  vesicles thus  altered corresponds
with the  number of foetuses ;  that  these changed vesicles, at a cer-
tain  period after they have  received  the stimulus of the male, dis-
charge a substance, which, being laid hold of by the fimbriated  ex-
tremity of the fallopian tube, and conveyed into the uterus, soon as-
sumes a visible vesicular form,  and  is  called  an ovum ; that this
ovum gradually evolves different organs, and becomes a foetus.   To
these conclusions,  he also added, that  the calyx or capsula, which
formed the parietes of the vesicles, thickens, by which the cavity is
diminished:   this cavity, together with  the opening though which
the fcetal rudiments escaped, becomes obliterated, and from the  pa- 
206          INTRODUCTION TO MIDWIFERY.
of the present time, in whose accuracy and judgment I willingly
confide, has considered it as the inner lamina of the uterus, cast
off, like the exuviae of some animals, after every conception, and
rietes of these vesicles having acquired a yellowish  hue, they are
called corpora lutea.
  Many  inquiries have been made to ascertain how  far  the semen
masculinum penetrates.  Galen always  found  it  in  the uterus of
brutes,  after copulation :  Leuwenhoeck, in the case of  rabbits :
Ruysch tells us he found it not only in the uterus, but in the fallopian
tubes of two women killed in the act of adultery.  Haller once found
it in the  uterus of a sheep forty-five minutes after venereal congress;
and John Hunter  is said to have seen  it  in the  uterus of  a  bitch,
which  he killed, while united with the male, by dividing the  spinal
marrow.  On the other hand, Harvey could never detect semen in
the uterus  after venereal intercourse : nor De Graaf in the vagina.
Haller also remarks, that some of those who assert that they saw se-
men in the uterus, probably saw mucus only.
  In this state of uncertainty, Dr. Haighton instituted a series of ve-
ry ingenious experiments, the account of which he published in the
Philosophical Transactions of London, vol. 87.   Dr.  Haighton more
particularly restricted his inquiries to three subjects : 1.  What are
the evidences of impregnation ; 2. What is the  proximate  cause of
impregnation ; and, 3.  Under what form  do  the rudiments of the
foetus pass from the ovary to the uterus.   Under the first head, Dr.
Haighton came to the conclusion that no corpora  lutea exist in virgin
rabbits, and that whenever they are found, they furnish incontestible
proof that impregnation does exist, or has preceded.   As to the se-
cond point, he concludes, that the  semen, by its presence, stimulates
either the vagina, os uteri, cavity of the uterus, or all of them ; that
the impression made on these is propagated to the ovaries by consent
of parts ; that one or more  of  the ovarian vesicles  enlarges,  pro-
jects, bursts, and discharges its contents :  that during  this process in
the ovary, the tube  is undergoing a  state of preparation for the pur-
pose of embracing the ovary,  and  receiving the  rudiments of the
foetus; that this preparation consists in part of an  increased tumes-
cence of its vessels, and a consequent  enlargement of its fimbriated
extremity, and when thus prepared, it approaches  the ovary.   After
the  tube has performed its office by a peristaltic motion, commencing
at the fimbria}, and terminating in the uterus, it gradually returns to
its former situation and condition : while these  different actions are
going on in the appendages of the uterus, others not  less important
to the design of nature are instituted in the uterus  itself: for the tu-
nica decidua, where it is obvious, is formed ready to secure firm-
ness of connection between  the tender ovum, and internal surface of
the  uterus, till  a proper attachment by means  of a placenta can be
 effected: that by  way of guarding with additional  security against a
 premature escape of the ovum, an apparatus seated in the neck and
 mouth of the womb,  now begins to develop its real structure, and 
ON CONCEPTION.
207
has, from this circumstance, called it the decidua ; and  from the
manner of its passing over the ovum, the decidua reflexa.  (Ana-
tomia Uteri Humani Gravidi Tab. Illustr.—Gul.   Hunter.)  It
perform its proper action, consisting in the secretion of a mucous-
like substance, sufficient in quantity to  fill, completely, the  whole
length of the neck, and, by that means, to seal up  the communica-
tion between the cavity of the uterus and vagina : nor does the care
of nature for the new animal  terminate here; for,  while she is by
various means  forming  and  perfecting her work, at least  as far as
comes within the province of the uterine system, she is, at the same
time, making preparations for  its nourishment after birth, by institu-
ting the proper secretion of the breasts.   These successive opera-
tions, I think, says Dr. Haighton, are the product of that law in  the
constitution, which is called sympathy, or consent of parts. Dr. H.
thinks his experiments overturn, as far as  experiment can, every ar-
gument which has hitherto been adduced  to support the  hypothesis
that the affusion of the semen  on the  ovaries, either in a sensible
form, or in that of  aura seminalis, is  essential to impregnation.  In
order to prevent the semen from passing along the tubes, the Doctor
divided one of them in virgin rabbits, and,  after the wound was heal-
ed, admitted the animal to the male.   The ovarium  on this side con-
tained corpora lutea equally with the other ; proving that the Graaf-
fiau  vesicle had burst, although the semen could not possibly have
reached the ovarium.  No foetus, however, was discoverable in any
instance.   On  the other side, foetuses were found equal in number to
the corpora lutea.   As to the form of that substance which passes
from the  ovaries, in  consequence of impregnation, Dr.  Haighton
did not find reason to determine it to be vesicular,  but more of the
gelatinous character ;  he never found any thing  of a regular form
in the uterus, before the sixth day.
   Mr. Cruickshank,  by a series of well-conducted  experiments  on
rabbits, instituted about the same time as those of Dr. Haighton,  de-
monstrated, among other things, that the ovum is formed in the ova-
rium, and comes out of it, after conception : that it  passes along the
fallopian tube, and  that it takes  some days in making its way to  the
uterus.
   John Hunter saw  the seminal fluid thrown into the  cavity of the
uterus of  the  cornea uteri of a  bitch ;  and proved,  by experiment,
that the effluvia from the seminal fluid of a frog,  would not impreg-
nate the ova of the female.  Mr. Hunter extirpated  one of the ovaria
of a sow, and   compared her breeding powers  with  another sow, of
the same age, and treated in every respect the  same as the first sow •
but retaining both her ovaries.  The spayed sow continued to breed
till she was six years of age ; the perfect sow till she was eight:  the
spayed sow had seventy six pigs ; the perfect sow one hundred  and
sixty-two.
   We might here enlarge, and  notice  the experiments on artificial
impregnation,  by Spallanzani.
   In a paper on  the  passage of the  ovum  from  the ovarium to the 
208
INTRODUCTION TO  MIDWIFERY.
is, however, unnecessary to debate  upon the manner in  which
this membrane is  formed, all writers upon this subject  agreeing
that its formation  is contemporary with conception ;  and  that it
uterus in women, published in the Royal Transactions of 1817, Sir
Everard Home seems  to  have determined more satisfactorily  the
length of time after coition, at which the ovum may be found in the
uterus of the human female.   The patient died on the  eighth  da)
after impregnation ; and the ovum, small as it was, bore a very fair pro-
portion to that represented by Dr.  Hunter at the end of three weeks,
It may  here be observed, that Haller denies the accuracy of all ob-
servations concering the  ovum, until the 20th day of its existence.
  But the most valuable addition which  has recently been made to
our stock of knowledge concerning the intricate subject of the gene-
ration of animals,  is that of Dr. Blundell, whose communication is
published in the  Medico-Chirurgical Transactions. of London, vol.
10.   In this paper of Dr. B.  we have the result of a series of expe-
riments on  rabbits, in which the communication was intercepted be-
tween the vaginal and fallopian portions of the uterine system :  the
consequences of sexual intercourse were, in these instances, merely
enlargement and development of parts, without actual impregnation.
Dr. Blundell has, I think, most satisfactorily shown, that the  corpus
luteum is  no certain sign of  impregnation :  for the luteum, in his
experiments, was  generated  under circumstances in which, as  the
event proved, impregnation was impossible.  Indeed, he adds, there
seems to be little reason for doubting that the corpus luteum may be
produced, even independently of the sexual intercourse,  by mere
excitement of desire in a very high degree.
  The  experiments of Dr. Blundell have, I think, conclusively  set
aside the sympathetic theory of generation, so ingeniously maintained
by Dr. Haighton and others.   The semen must have access to the
rudiments for the completion  of the generative process.   We are,
also, by the very experiments of Dr. Haighton himself, strengthen-
ed in this opinion, by adverting to the peculiar structure of the genitals
of the wombat, the existence  of a bifid  glans, with two orifices in
the penis of those male animals, the females of which have two ora
uteri: (see Sir Everard Home, Phil. Trans, vol. 98 ; also, Cuvier.)
and by the formation of extra-uterine conceptions.
  It has been contended by some  naturalists, that  the semen, in ge-
neration, is transferred to the blood-vessels, and as the purgative, or
emetic, when injected into the veins, exert their peculiar influences,
so also  the seminal fluid, transmitted by the absorbents, makes its
first  impression on the vascular surface,  and its second by a similar
sympathy on the genitals  themselves.  It seems evident, however,
from the fact related by Dr. Blundell, that the semen retains no such
generative influence.
  For my own part, when I consider the exact state of experimen-
tal research on animal  generation, 1 find the sympathetic doctrine of
Haighton of not  less difficult  credence, than the story of Pope
Joan's extraordinary impregnation.   F.] 
ON CONCEPTION.
209
precedes the time when  the  impregnated ovum  passes from the
ovarium into the uterus, as is found in the case  of an extra-ute-
rine foetus,  It may, therefore, be deemed an indispensably requi-
site preparation of the uterus, for the reception of the ovum, and
the substance by which this is afterwards connected to the uterus ;
so that if it were to receive a name from its use, it would not be
improper to call it the connecting membrane of the ovum.*

                         SECTION VI.
   The contents of the human gravid uterus are comprised under
the general  term ovum, or conception,  of which the com-
ponent  parts are, the foetus, the funis  umbilicalis, the placenta,
the membranes,  and  the waters.   Of these it  is reasonable to
think, that the foetus is the only  part immediately formed in con-
sequence of the  act of coition, and that the rest are previous or
subsequent productions  of the ovarium or uterus.
   It has been thought that some of the parts of the foetus were
formed  before the  rest,  and much labour hath been bestowed in
ascertaining  the order of their  formation.f   But as the skin of
the smallest embryo which can be examined is perfect, it may be
presumed,  that what  has been called  addition or coaptation of
parts, is, in fact, nothing more  than the expansion or unfolding
of parts already formed.  Of this  we  have a  curious  example
in the descent of the  testicles into the scrotum, which  happens
only a few weeks before the birth of the child, though their prior
existence in the abdomen is not to  be doubted.   This opinion
is likewise illustrated by the seeds of plants, which must contain
all the primordial  parts of the plants,  when they are first depo-
sited in the ground, from which  they can draw only the means
of nourishment and increase.
   Much industry  hath  likewise been used to  determine the
weight, length,  and dimensions of the  foetus, at different periods
of uterogestation.   The utility of this  inquiry, if the truth could
be  discovered, does not appear.   But as children born  of differ-
ent parents, or those  born of the same parents, at the  same or
different births, vary at all periods of pregnancy, it is reasonable
to believe, that there is an  original difference in their  size  and
  * Of the formation of this membrane, Harvey has  given the fol-
lowing very curious account:—Per mediam utriusque cornu atque
etiam uteri cavitatem, mucoso quaedam filamenta, tamquam aranea-
rum tela?, ab ultimo sive superiore cornuum angulo ducuntur; quae
simul juncta  membranosam ac  mucilaginosam tunicam, sive  manti-
Cam vacuam referunt.  Harv. Exercitatio sexagesirna nona.
  t Embryones dicendi sunt, quando membra non sunt absoluta.—-
Ruysch.
27 
210          INTRODUCTION TO MIDWIFERY.
in other respects.   Many of the varieties may also depend upon
the state of the health either of the parent or child before its
birth, so that it seems  impossible to bring this matter to a fair
conclusion
   During the continuance of the foetus in the uterus, its internal
structure is,  in many  respects,  different from that of a child
which has breathed; and  the external figure of a child  is very
unlike that of an adult, in the  proportions which  the various
parts bear to each  other.  Of those  peculiarities, which give a
disposition to  particular  diseases,  we  shall speak  in  another
place.
   From the time when the foetus is completely formed the head
is  large, if compared with  the body and extremities; and the
younger the foetus  is, the greater is the disproportion.  The su-
perior weight of the head is supposed to be the cause of its gene-
ral presentation at the time of birth ;  but there must be some
other reason ;  for the same presentation is equally common in
quadrupeds, in  which  the extraordinary weight of the  head, if
it  existed, could not produce this effect.
   The  principal circumstances in  which the foetus and adult
vary, are in the vascular system.   In the heart of the former a
communication is preserved between  the right and left auricle,
by an opening called the foramen ovale, which closes soon after
birth.   But a valve prevents the  return of the blood from the
left to the right auricle.*  There is,  also, a communicating
artery between the  pulmonary artery and  the  aorta, which is
called the canalis arteriosus, and  may  be esteemed a branch of
the pulmonary artery.   This branch, which diverts immediately
to the aorta a large portion of that blood  which  circulates in
the lungs when the  child has breathed, closes likewise soon after
birth.   In amphibious  animals, the foramen ovale, and  canalis
arteriosus, are said  to remain open during life.
   The liver in the foetus is very large, nearly filling up both the
hypochondria,  and  it has vessels peculiar to that state : first, the
vena  umbilicalis,  which arises from  the placenta, and, running
through the funis, enters the abdomen of the child, and passes to
the liver, which it penetrates on the inferior edge, terminating in
the sinus of the vena portarum.   This likewise closes soon after
birth, and, with the assistance of the  peritonaeum,  becomes  a
ligament called the falciform.   Secondly, the  canalis venosus,
which  proceeding from the sinus of the vena portarum, passes
across the liver to the hepatic vein, and thence to the vena cava.
  * See Medical Transactions, Vol. III. in which the imperfections
in the construction of the heart, with their consequences, are very
accurately described. 
ON CONCEPTION.                  211
 The  canalis venosus  is  smaller than  the  vena umbilicalis, and
 only carries a portion of the blood brought by the latter to the
 liver.
   The internal iliac arteries are very large in  the foetus in pro-
 portion to the external.   From these, two  branches arise, which
 running on each side of the bladder and the sides of the abdo-
 men, pass out of the navel of  the foetus, and form the two arte-
 ries of  the funis,  which,  closing  soon  after  birth,   become
 impervious, as far as to the bladder.
   These  peculiarities in  the vascular  system  of the foetus  are
 provided,  to  allow of that mode of circulation  of the  blood,
 which is calculated for  the life which  it possesseth during its
 residence in the uterus.   When  the  blood is  brought by the
 vena cava into the right auricle of the heart,  part  of  it passes
 by the foramen ovale into the  left, and of  course a smaller por-
 tion into the right ventricle.   When the blood,  thus diminished,
 is propelled by  the action  of the heart from the right  ventricle
 into the pulmonary artery, a farther portion of it is conducted
 by the canalis  arteriosus directly to  the  aorta.  It has been
 conjectured,  that  about  the fourth part  of the  blood  which
 circulates through  the  lungs of a child which  breathes, passed
 through them while it remained in utero.
   The two branches of the internal  iliacs,  which afford  the
 arteries of the  funis, conduct  a great portion of that blood,
which flows  through the  aorta, by the funis  to the placenta;
 but when  the child  is born, that blood,  which circulated through
them,  passes by the external  iliacs to  the  inferior  extremities,
which therefore  increase more speedily after birth than any
 other part.
   The blood brought by the vein of the funis from the  placenta
is carried to the sinus of  the vena portarum, from which it pro-
ceeds to the hepatic vein, and then to the vena  cava.
   The thorax is flatter  and narrower  in the  foetus,  than in a
child  which  has breathed, because it  has  not been expanded
by the inflation of the  lungs, which are then  of a  more  com-
pact and firm texture.*   This  state of the lungs, which  renders
  * [Professor Soemmerring has  observed, with great minuteness,
the gradual  changes which take place in the  external form of the">
foetus during the earlier periods of its development.  An embryo of
three or four weeks appears to the naked eye, according to Soem-
merring, somewhat like a grain of mustard  seed just beginning  to
grow : the head being like  the body of the seed, and the trunk and
remaining parts like the radicle. But, with a magnifying glass, a little
dark circle can be distinctly seen  in the region of the eyes,  and a
small slit  corresponding to  the orifice  of the mouth.  Four promi- 
212          INTRODUCTION TO MIDWIFERY.
them heavier than water, is esteemed a proof that the  child ha*
not breathed; but when  the lungs are found to  be lighter than
water, which is discovered by their floating on the surface when
put into that fluid, it is supposed to be an equally strong proof
that the child had breathed.   These circumstances of the lungs
were formerly produced in evidence in courts of judicature, and
inferences of the utmost  importance to  the acquittal  or con-
demnation of a presumed innocent or guilty person have been
made from  them.  But it is well known,  that  the lungs of a
child which has  lived many months, or even of an adult, may
be rendered heavier than water by disease; and the lungs of a
child which has  never breathed will  become lighter than water
by putrefaction;  or  if they have been  inflated artificially, with
the view of recovering a child  born  apparently dead.  It is also
to be observed, that  some children just born will breathe two or
three times, and  then die, though  every care be taken,  and  all
proper means used for their recovery; yet the lungs will become
lighter than water by this respiration, though of such short con-
tinuance.  The  appearance  and  state  of  the  lungs  may  be
altered  by so many circumstances, that a judicious or an honest
man would hesitate to put  confidence in any opinion, which they
nences are observable on the trunk in the situation of the four ex-
tremities ; and, between the two lower, there is a curious prolonga-
tion like a tail.  He also observed, that the younger the foetus, the
larger its head, compared to other parts of the body : the smaller its
face .in proportion to the other parts of the head, and the smaller its
limbs relatively to the trunk.   During the first, second,  and  third
months, he has remarked that the upper extremities are larger than
the lower ; but that about the fourth they are equal, and that, toward
the fifth, the lower have become larger than the upper.  In his
comparative  view of the male and female foetus, he has pointed out
the following distinctions in the external form :  The head of the
male differs from that of the female in being larger in proportion to
the whole body, less rounded, flatter in the crown, and more promi-
nent behind.  In  the male, the  breast is considerably more promi-
nent than the umbilical region, while in the female it is the reverse,
and this is a  distinction perceptible  in the youngest foetuses.  The
trunk of the body between the upper parts of the loins is arched in
(he male, but hollow in the female, and this, too, is a distinction  very
early observable.   The  upper extremities in the male are a  little
longer in proportion to the trunk than in the female, the arms are
less  cylindrical, the fore arms fuller, the wrists broader, and the
ends of the  fingers less  pointed. The circumference of the  body
at the  haunches, is less in the male  than in  the female, the thighs
are  more slender,  the  feet longer, the malleoli  and heels  more
prominent, and the great toe exceeds the others more in length.  See
farther the Icones Embryonum Humanorum.  F.] 
ON CONCEPTION.                  213
have been supposed to prove; and accordingly juries are now,
and have long been, directed to pay little regard to this kind of
evidence.  But when the murder of an infant by  its mother  can
be clearly and positively proved,  it deserves to be seriously con-
sidered,  on what principle  extraordinary  lenity ought to  be
shown to one, who, in the first instance, breaking through the
strongest ties and restraints  of human society, afterward com-
mits an  irretrievable injury  by the destruction of an innocent
and helpless child, with the  most powerful claims of nature to
her protection and love, merely for the preservation of her own
character.
  This crime of destroying, or omitting  the necessary means
for  preserving  the  lives of infants, formerly admitted  only of
capital punishment or acquittal by our laws.  But lately Lord
Chief Justice Ellenborough  has, with great humanity and dis-
tinguished knowledge, procured  an act of the Legislature, in
which  neglect to make provision  for the expected infant is made
liable  to  punishment,  which  is,  in these  cases,  allowed  to be
modified by the judge; and many evils, both moral and political,
may be thereby prevented, or, according to the degree of crimi-
nality, be corrected.*

                        SECTION VII.
  The funis umbilicalis  is that cord,  which, passing from the
abdomen  of the child to the placenta,  maintains the communica-
tion between the foetus and placenta.   In quadrupeds, the funis
consists of two arteries and two veins, but in the  human species
it is composed of two  arteries and one vein, the  space between
which  is  filled  up with a gelatinous  mucus contained  in cells,
which  prevents  any obstruction to the circulation of the  blood
from  accidental  compression, or even  when a knot is casually
made in  it by the irregular changes of the  position of the child.
The funis is covered by the  amnion  or inner membrane of the
ovum,  and the  vein is of a sufficient size to reconduct to the
foetus the whole or an equal quantity of blood,  to that which is
conveyed by the two arteries  from it to the  placenta.  The arte-
ries very often twist round the vein in a very curious  and  beau-
tiful manner; sometimes they run in a parrallel line with the
vein ; and, in some instances, the arteries are contorted in such
a manner as to make, upon the funis, one or more large tumours,
or bunches, resembling excrescences.f
  * [See a subsequent note on Infanticide.  F.]
  t [There have not been wanting anatomists of the highest charac-
ter who have affirmed the  existence of absorbents in the umbilical
cord, as Ruysch, Meckel, Mascagni, Ludwig, and others.  F.] 
214
INTRODUCTION TO MIDWIFERY.
   When the embryo can first be perceived, it  is found adhering
to what afterwards becomes the placenta, by a close connexion
of the abdomen.   In a short time the uniting part  is elongated
into a  flat and then a conical form, and  soon becomes a regular
umbilical cord, the length and thickness of  which are generally
in proportion to the  size of the foetus; though every part of the
ovum is  larger according to the size of the foetus in  early than
advanced pregnancy, when the  proportions are inverted.  The
funis seems to be a production of the placenta ; for, immediately
after the birth of the  child, there is a  line which distinguishes the
foetal   part,  where  the  spontaneous separation is  afterwards
made.
   In the thickness of the funis, which depends  upon the quantity
of mucus contained  in the  cells  more than  upon the  size of the
vessels, there  is much variety in different  subjects;  and in its
length, it being in some not more than one foot, and in others
exceeding three, four, or even six feet; but  it  is most frequently
about two feet in length.   It is thickest  near the abdomen of the
child, and gradually becomes more  slender as it approaches to
the placenta, into which it is usually inserted  about  one  third
from  the  edge.   But there is  much difference in this  respect
also,  and, in  some  instances,  the blood  vessels ramify before
they reach the placenta, and when this happens it may occasion
a difficulty in  the extraction, or a separation of the funis,  even
when little force is exerted.

                        SECTION VIII.
  The  placenta  is  a  circular, flat,  vascular, and apparently
fleshy substance, about six  inches in its  diameter, varying  in
different subjects,* and extending over about one fourth  part of
the shell or  outside of the  ovum.  It is more  than one inch in
thickness  in the  middle, and becomes gradually thinner  toward
the circumference, from which  the  membranes  are  continued.
The placenta is the principal medium by which the communica-
tion between the  parent and child is preserved; but,  though all
have  allowed  the importance of the office which it performs,
there has been a variety of opinions  on  the  nature of that office,
and of the manner in which it is executed.
  That surface of the placenta, which  is  attached to the uterus
by  the intervention  of the  connecting  membrane, is lobulated
and convex;  but the other, which is covered with the amnion
and chorion, is concave and smooth, except the little eminences
made by the blood-vessels.  It is seldom  found attached to the
  * In quibusdam placenta reperitur crassior, amplior, et sanguine
abundantior.—Harv. 
ON CONCEPTION.                  215
same part of the uterus in two successive births; and, though it
most frequently adheres to  the anterior part, it is occasionally
fixed to any other, even to  the os uteri; in which  state it may
become a cause of a dangerous hemorrhage at the time of par-
turition.
  The  placenta is composed of arteries and veins, with a mix-
ture of pulpy  or cellular substance.*   Of these there are two
orders, very curiously interwoven with each  other.   The first is
a continuation of those from  the funis, which ramify on the
internal surface of the placenta, the arteries running over the
veins,  which is a circumstance  peculiar to the placenta; and
then sinking into its substance, anastomose and divide into innu-
merable small  branches.  The second order proceeds from the
uterus ; and these ramify in a similar  manner  with those  from
the funis,  as appears when a placenta is injected from the vessels
of the  funis, and from  those of the parent.  The veins in their
ramifications accompany tiie arteries as in other parts.
  There have  been many different opinions with respect to the
manner in  which  the blood circulates  between  the  parent and
child during its continuance in  the uterus.   For  a long time it
was believed, that the intercourse between them  was uninterrupt-
ed ; and  that  the  blood propelled by the  powers of the parent
pervaded, by a continuance  of the same force,  the  vascular
system of the  foetus.   But  many unsuccessful  attempts having
been made to inject the whole placenta, funis, and foetus,  from
the vessels of the parent, or any part  of the  uterus  from the
vessels of the funis, it  is now generally allowed, that the two
systems of vessels in  the  placenta, one  of which may be called
maternal, the other foetal, are  distinct.   It is also admitted, that
the blood of the foetus is, with  regard to its formation, increase,
and circulation, unconnected  with, and totally  independent of,
the parent;  except that the matter  by which the  blood of the
foetus is formed must be derived from the parent.f
  It is  thought that the  blood, which  has  probably undergone
some preparatory  changes in its passage through  the uterus, is
conducted by the  uterine or maternal  arteries  of  the  placenta,
to some cells or small  cavities in which it is deposited; and that
some part of  it,  or something secreted  from it, is absorbed by
the foetal  veins of the placenta, and by them  conveyed to the
  * Placentae substantio non constat glandulis, sed mire vasculosa est.
—Ruysch.
  t Abunde me demonstraturum arbitror, viviparorum quoque fac-
tum, dum adhuc in utero continetur, non  matris  sanguine nutriri,
spirituque ejus vegetari, sed animo viribusque suis frui, ut pullus in
ovo solet, proprioque sanguine gaudere.—Harv. Exercitat. xxxiv. 
216
INTRODUCTION TO MIDWIFERY.
fcetus for its nutriment.  When the blood which circulates in the
foetus requires any alteration in its qualities, or when it has gone
through the course of the circulation, it is carried by the arte-
ries of the funis to the placenta, in the cells of which it is deposit-
ed, and then absorbed  by the maternal veins of the placenta,
and conducted to  the uterus,  whence  it may enter the common
circulation of the parent.   Thus it  appears, according to the
opinion of Harvey, that the  placenta performs the office of  a
gland, conveying air, or secreting the nutritious juices from the
blood, brought from the parent by the arteries of the uterus, and
carried to the fcetus by  the  veins of the  funis,  in a manner,
probably, not unlike to that in which milk is secreted  and ab-
sorbed from the  breasts.
   The veins of the placenta  are mentioned as the absorbents,
because no lymphatic vessels have yet been found  in the placen-
ta or funis; nor  are there any nerves in these parts; so  that the
only communication hitherto discovered, between the parent and
child, is by the sanguineous system.*
   The proofs of  the manner  in  which the blood  circulates be-
tween the parent  and child  are chiefly drawn from observations
made upon the funis.  When  it was supposed that the child was
supplied with blood in  a direct stream from the  parent, it was
asserted that, on the division of the funis, if that part next to the
placenta was not  secured by a ligature, the  parent  would  be
brought  into extreme danger, by  the hemorrhage  which  must
necessarily follow.  But this  opinion, which laid  the foundation
of several peculiarities in  the management of   the  funis and
placenta,  is proved not to  be true.   For, if the  funis be com-
pressed immediately after the birth of the child, and  whilst the
circulation in it is going on, the  arteries between  the part com-
pressed and  the child  throb  violently,  but  those between the
compression  and the placenta have no pulsation;  but  the vein
between the  part compressed  and the placenta  swells, and that
part next to the  foetus becomes flaccid.  But,  if under the same
circumstances the funis be divided, and that part  next the child
be not secured, the child would be in danger of losing its life by
the hemorrhage, yet the mother  would suffer no  inconvenience,
if the other  part was neglected.   It  is moreover  proved, that a
woman may die of an  hemorrhage occasioned by a separation
of the placenta,  and the child  be  nevertheless speedily born, after
her death, in perfect health.  But if the placenta be  injured,
without separation,  either by the rupture of the  vessels which
pass  upon its inner surface,  or in  any  way, the child, being
  * See a more particular account of the structure of the placenta,
in Mr. Hunter's Observations on the Animal Economy. 
ON CONCEPTION.
217
deprived of its proper blood, would perish, yet the parent might
escape without injury.*

                          SECTION  IX.
  By the placenta and membranes  which are expanded from its
edge, a complete  involucrum  of the foetus and waters is made.
They form  at  the same time a lining to the  uterus; and  when
expelled  after the  child is born, go under the  common  term of
after birth,  or secundines.
  In the  description of the  membranes  of the ovum, given by
different  writers, there is  great dissimilarity;   and  it  appears,
that much of that confusion  which became the ground of contro-
versy,  arose from the ambiguity of the terms used, and from the
examination of the ova, at  different periods of preguancy; so
that every  description might  have  been just,  though  no  two
representations had  been the  same.  Tliey have usually been
meutioned as two, the amnionf and the chorion ;{ and the  lat-
ter has  again been divided into the true and the false.  This
third  membrane,  which from its appearance has  likewise been
called  the villous, or spongy,^  and  from the  consideration of it
  * [Our author's ideas  of the structure  and  functions of the pla-
centa, are those which were first particularly set forth  by the Hun-
ters, and are the most generally received doctrines.  Sprengel has
lent them the aid  of his authority.  Latterly, however, these opi-
nions have been much contested ; and Dr. Hosack, Professor of the
Practice of Medicine in  the University of New-York, rejects them
entirely : he denies to the placenta the office of lungs,  and believes
that the blood,  already oxygenated, passes by direct communication
from the mother to the foetus in utero.   These views he first  pro-
mulgated in 1807.   The late Dr. Gordon, of Edinburgh, considers
Hunter's views as in part hypothetical and unsatisfactory.
  Hydatids occasionally  form  in the placenta; sometimes its struc-
ture is  unusually  hard,  and in part ossified.  Dr. Borrowe  had a
case in which, upon examination, a considerable part of the placenta
exhibited an osseous formation ; its maternal vessels seemed distinct-
ly ossified tubes.   The placenta  is also  sometimes found to appear
as if composed of mere  fatty matter.  Dr. Handy, of this city, has
furnished me  with  the particulars of several cases of this sort which
have come within  his knowledge.  In one instance,  upon examining
the placenta of a  patient after a natural labour, it was  ascertained
that nearly all the foetal part of it consisted of an adipose substance,
varying in  different  parts from a fourth to three fourths of an inch
in thickness.  In another  case, about half the placenta consisted of an
adipose substance, divided into lobes.  F.]
  t Quod foetum amiciat et obvolvat.—Harv.
  1 A venarum copia sive choro nomen obtinuit.—Idem.
  § Mihi liceat nominare membranam placentae, villosam.—Ruysch.
Thes. Anatom.  vi.  41.
                              28 
218          INTRODUCTION TO MIDWIFERY.
as the inner lamina of the uterus cast off, as was before observed,
like the exuviae of some animals, the decidua, has been described
bv Harvey, not as one of the membranes of the  ovum, but as a
production of the uterus.  How far a very accurate  account of
the constitnent parts of the ovum, with  all the changes they
undergo, may be wanted for the  perfection of natural history,
I cannot pretend to decide;  but in  the practice  of midwifery it
doth not appear necessary.
  It is,  however, requisite,  that we should have  a competent
knowledge of the membranes of the ovum at the full period of
utero-gestation, and the following explanation seems to be suffi-
cient.   There is,  first, the outer or connecting membrane, which
is flocculent,  spongy, and extremely vascular, completely invest-
ing the  whole ovum, and lining the uterus  ; secondly, the middle
membrane, which is nearly pellucid, with a very few small blood-
vessels  scattered  over  it, and  which  forms a covering to  the
placenta and funis, but does  not pass between the placenta and
uterus ; thirdly, the inner membrane,  which is transparent, of a
firmer texture than the others, and lines the  whole ovum, making,
like  the middle  membrane, a covering  for the placenta and
funis.   With the two  last the ovum is clothed when it  passes
from the ovarium into  the uterus,  where the  first is provided for
its reception.  These membranes,  in the advanced state of preg-
nancy, cohere slightly  to each other,* though in  some ova there
is a considerable quantity of fluid collected between them, which,
being discharged when one of the outer membranes is broken,
forms one of the circumstances which have  been distinguished
by the name  of by, or  false waters.
  Between the middle and  inner membrane,  upon or near  the
funis, there is a small, flat, and  oblong body, which, in the early
part of pregnancy,  seems   to  be a  vesicle  containing  milky
lymph,  which  afterwards  become of a  firm and  apparently
fatty texture.  This is  called the vesicula umbilicalis, but its use
is not known.

                         SECTION X.
   All that fluid, which is contained in  the ovum,  is called by the
general name of the waters, or the waters of the amnion or ovum.
The quantity, in  proportion to  the size of the different parts of
the ovum, is  greatest by  far in early pregnancy.   At the time of
parturition, in some  cases,  it amounts to,  or exceeds, four pints,
and in others it is scarcely equal to as many ounces.  It is usually
in the largest quantity, when the child has been some time dead,
or is born in  a weakly  state.
* Amnion et chorion sibi invicem leviter cohaerent.—Ruysch. 
ON CONCEPTION.
219
   This fluid is generally transparent, often milky, and sometimes
 of a yellow or light brown colour, and very different  in consist-
 ence ; and these alterations seem to depend upon the state of the
 constitution of the parent.  It does not coagulate  with heat,  like
 the serum of the blood; and chemically examined, it is found to
 be composed of phlegm, earthy matter,  and sea bait, in different
 proportions in different subjects, by which the varieties in its ap-
 pearance and consistence are produced.   It has been supposed to
 be excrementitious, but it is generally thought to be secreted from
 the internal surface of the ovum, and circulatory as in other ca-
 vities.
   It was  formerly  imagined that the  foetus was  nourished by
 this fluid, of which it was said to swallow some part frequently ;
 and it was then asserted, that the qualities of the fluid were adapt-
 ed for its nourishment.   But there have been  many examples of
 children born without any passage to the stomach; and a few, of
 children in which the head was wanting, and which have, never-
 theless, arrived at the full size.   These cases fully prove, that  this
 opinion is not just, and that there must be some other medium by
 which the child  is nourished, besides the waters.   The incontro-
 vertible uses of this fluid are to serve the purpose  of affording a
 soft bed for the residence of the foetus, to which  it allows free mo-
 tion,  and prevents any external  injury during  pregnancy: and,
 enclosed  in the  membranes, it procures the most gentle,  yet effica-
 cious dilatation of the os  uteri, and soft parts, at the time of par-
 turition.*
   Instances have been recorded, in which the waters of the ovum
 are said to have been voided so early as  in the sixth month of
 pregnancy, without prejudice either to the child or parent.  The
 truth  of  these reports  seems to be doubtful, because  when  the
 membraues are intentionally broken, the action of the uterus  ne-
 ver fails to come on, when all  the  water  is  evacuated.   A few
 cases  have occurred to me in practice,  which  might have been
 construed to be of this kind; for  there was a daily or frequent
 discharge of  some colourless fluid from the vagina, for several
 months before delivery ; but there being  no diminution  of  the
 size of the abdomen, and the waters  being regularly discharged
 at the  time of labour,  it was judged that some  lymphatic vessel
 near the os uteri was occasionally ruptured, and did not perfectly
close again till the  patient was delivered  ; yet without  any other
difference, except that in such cases the labours are usually pre-
mature, and the  children  born of a comparatively small size.   I
  *  [See a paper on the Nourishment of the Fcetus, by Professor
Chapman, in the Philadelphia Journal of the Medical and Physical
Sciences, vol. I.  F.] 
220
INTRODUCTION TO MIDWIFERY.
have also met with one case, in which, after the expulsion of the
placenta, there was no sanguineous discharge,  but a profusion  of
lymph, to the quantity of several pints, in a few hours alter deli-
very ; but the patient suffered no inconvenience, except from the
surprise.
   The diseases of the different parts  of the ovum will be consi-
dered when  we speak of the causes of abortion.

                         SECTION XI.
   It hath been observed,  that the state of the  uterus is, in many
respects,  altered in  consequence of impregnation.  Besides the
derivation of a greater  quantity of blood  to  it, and the ntigh-
bouring parts, on which the enlargement of the person chiefly  de-
pends in  the early part of pregnancy, and the  formation of the
connecting  membrane of the ovum,  it becomes endued with the
properties of distention  and ascent into the cavity of the abdomen.
   The fundus of the uterus is  the part first distended, and after-
wards the inferior parts in regular order;  at length the cervix is
obliterated,  except the mere circle of the  os uteri, and the uterus,
which was  originally pyriform, becomes nearly or  completely
oval.  The distention is also more considerable on the posterior,
than the anterior  part, which is one cause of the change of posi-
tion and course of the fallopian tubes and ligaments.  These,  in
the unimpregnated state, depart from the corners of the fundus of
the uterus nearly at right angles;  but, towards the conclusion of
pregnancy,  they  go off from the fore part near the cervix, as was
before observed.   This distention  is evidently not  mechanical
from the  increasing size of the ovum,  but from the accession of a
new principle ;  for the uterus is never fully upon the stretch, like
a bladder inflated with  air, but relaxed in such a manner as to be
apparently  capable  of  bearing the farther increase of the ovum
without inconvenience.
   The uterus is  placed between the bladder  and  rectum, the os
uteri being  generally projected a little backwards, so that the axis
of the cavity of the uterus  corresponds with that of the pelvis.
After conception, the weight of the uterus  becoming greater,  it
subsides lower into the vagina, the shortness of which is, therefore,
reckoned one of the equivocal signs of pregnancy.   But, after a
certain time, the uterus, though more increased in  weight, begins
to ascend, which it  continues to do till it emerges  out of the pel-
vis,  acquiring support from the superior and anterior part of the
aperture ; in which disposition and state it remains,  till the chan-
ges previous to labour come on.  In the latter  part of pregnancy,
the vagina must therefore be elongated, and the effects of the tem-
porary  abbreviation and elongation  are readily  discovered in
those pregnant women who  have a procidentia of the uterus, or a
tendency  to it, :n whom the complaint is  aggravated  in the early,
and  lessened in the latter part of pregnancy. 
ON CONCEPTION.
221
  In the first pregnancy, the uterus rises almost directly upwards,
because the  integuments of the abdomen  support it forwards;
and the  distention may be readily perceived on each side, but
commonly on one side more  than the other, from  the position of
the child.   In subsequent pregnancies, the  uterus projects for-
wards, the  integuments  generally  yielding with greater or less"
readiness, according to the number  of children  which a woman
hath before  had ;  but it  always lies before the viscera of the ab-
domen, which are raised higher, and protruded backwards,  in
proportion to its ascent and distention.
  Through  the integuments of the abdomen, the uterus may be
felt springing out of the  pelvis,  about the fourth month of preg*
nancy ; in the fifth, about the midway between the pubes and na-
vel ; in the sixth, as high as the navel; in  the seventh, half way
between  the  navel  and  scrobiculus  cordis; in  the  eighth,  as
high  as the scorbiculus cordis ;  in the  ninth   month it usu-
ally begins  to subside,  so that, at  the  time of parturition, the
fundus of the uterus  is not higher in the abdomen than in the se-
venth,  if the uterus be in. a proper disposition to act; but when
that is  not the case, the fundus will be*as high as the scrobiculus
cordis, even  when  the woman is in labour.
  At the time of labour,  a new principle supersedes those  of dis-
tention and  ascent.*   This gives a disposition to the uterus to ex-
clude whatever is contained in its cavity, and the effect produced'
is in proportion to the energy of the principle, and the power of
the uterus.  A perfect intelligence of this principle, and  of the
mode of its operation, would  probably be of infinite use in prac-
tice, as we might be enabled to suppress  the action thereby occa-
sioned  when premature, moderate it when too violent, strengthen
it when too feeble, and regulate it in a variety of ways conducive
to the welfare of our patients.   On the knowledge we at present
have of the manner in which  this principle  operates, and  the cir-
cumstances  by which it is influenced, the assistance which sci-
ence and dexterity can give in cases  of difficult parturition, and in
preventing abortions, very much depends.
   But  this expulsatory  power, which takes place at  the time of
parturition,  does  not seem to b? peculiar to  the  uterus,  but to
proceed from a general principle diffused through the  vhole body,
which  acts in a  like manner whenever  an offended  part  makes
an  extraordinary effort to free itself  from  any offending  body j
and the mode of its  operation is according to the general laws
of the  animal economy,  as is usually the  degree according  to
the difficulty.  It is in common  observation,  that no violent
action  can  be of  long duration; and it might  therefore  be ex-
pected that  the efforts made by the  uterus for the purpose of ex-
  * Expultrix uteri facultas insurgit et  excitatur.  Foetus ab  utero
compressus, propulsatus atque expressus.—Fabr. ab. Aquapend. 
222
INTRODUCTION TO MIDWIFERY.
pelling the child at  the time of birth, would be periodical;  and
attended with pain,  from the  distention and pressure which the
resisting parts undergo,  as we shall  have occasion to observe
when we speak  of natural labours.
   It was said, that this  expulsatory action was not  peculiar to
the uterus,  but  a property common  to all parts of the  body,
when the longer continuance of any thing extraneous was likely
to become hurtful.  Their  efforts on  such  occasions, like those
of the  uterus at the time of labour, are observed to be periodical,
and accompanied with pain proportionate to the  action and the
sensibility of the part.  Thus, in the case of a  stone in the blad-
der, what is called a fit of the stone seems to  be a consequence
of an effort made by the  bladder to expel the stone when injured
by it; or when a small  stone is passing  through  the  ureters
from  the kidneys to  the bladder.  In  the coacervation of the
faeces in the  rectum  also, when the common action of the intes-
tines is not sufficient for their expulsion, an extraordinary action
is excited periodically, which is  attended  with pain, returning,
like the action, at intervals, and  proportioned  to it.   Perhaps a
more opposite illustration of a labour  may  be taken from stones
passing from the gall-bladder to the intestine.  These may con-
tinue  inoffensive in  the  bladder for  a  considerable  time  after
their formation ; but when an effort is made to exclude them, it
is always accompanied with pain, periodical in its returns,  and
excruciating in its degree, from  the sensibility of the parts im-
mediately affected or drawn into consent;  the effort continuing
till  the stone is  forced into the intestine, or till the expulsatory
powers are wearied, or cease to act,  and the gall stone returns
to its primitive situation.
  Of the primary causes  of this general property we may justly
be said to be ignormit, as we are  likewise of that  of the action of
the uterus in  particular, except from its effects.   But  the imme-
diate causes appear  to be different.  First,  there  is the genuine
or original  cause,  which  produces the  action of  the uterus at a
proper  time,  and in a proper manner; secondly, adventitious
causes operating upon the uterus, and producing that action to
which  it is disposed, at  an improper  time, and in an irregular
manner ; thirdly, sympathetic  causes, when a disturbance origi-
nates in some part connected with or consenting with the uterus,
and is  transferred or spreads to  the  uterus from the part first
affected.
  We  may search for the original or genuine cause of the action
of the uterus in its structure, form, or qualities, or some peculiar,
though inexplicable  impression made  upon it by  the child at the
full period  of uterogestation.  The manner in  which the  effects
are produced  is much influenced also by the  circumstances of
the constitution, as  its strength and disposition to act; and it 
ON CONCEPTION.
223
appears, that the blood is of much importance in  this respect;
or, in  hemorrhages,  though there be a disposition in the uterus,
to act, there is no  power of action ;  and in other cases, when
there is apparently no want of  strength, the disposition to act is
wanting.
  The action of the uterus is totally independent of the will, and
therefore often comes  on during sleep, having produced its effect
before the patient is  awake.  But, if the whole frame  be distur-
bed by any violent emotion of the mind,  the action of  the uterus
may be induced, obstructed,  or  suppressed.  The progress of a
labour is, therefore, often retarded  by such passions as depress
the spirits; as,  on the contrary, it is accelerated by cheerfulness,
by resolution, and a certain preparation of the mind for enduring
pain and fatigue.
   Opinions were formerly much divided with respect to the state
of the uterus during pregnancy; but it was generally imagined to
become thinner in proportion to its distention.   Later observa-
tions,  however, have proved, that if healthy, it retains its thick-
ness through the whole  period,  to whatever degree it may be dis-
tended.  By this thickness, which is  the medium of its strength,
the human uterus is capable  of exerting  infinitely greater power
for the expulsion of its contents, than that of any animal.   Had
there been a necessity for an equal degree of force, animals would
have failed  to  perform  the office of parturition,  because there is
not the same medium by which that force could  have been ex-
erted.   As greater proportionate force is, therefore, required and
exerted in human parturition, than in that of animals, there must,
of necessity, be a greater degree of pain, even if we allow them to
have an equal  degree of sensibility.   But of comparative partu-
rition we have  yet a very imperfect knowledge.
   The adventitious causes of the action of The  uterus,  which are
numerous, may arise from the  general state of the body, as a
fever; or the particular state of the uterus, as a  disease of the
part itself; or  some extraneous irritation of the  os uteri, between
which and the  uterus, there seems to be a consent similar to that
between the cardia and  the stomach.  This was known to the an-
cients, who occasionally introduced irritating substances into the
vagina, for  the purpose of facilitating or accelerating the birth of
the child.  But, with regard to adventitious causes of every kind,
it appears that their effect continues only so long as they are ap-
plied, and the  action of the uterus produced by them  is less per-
fect, than when it arises  from the genuine cause.  Thus, if the
premature action of the uterus  be brought on by irritation of the
os uteri, it proceeds only  during the continuance of the irritation,
unless it be urged till the natural cause of the action of the uterus
should supervene.  Hence the  observation was made, that if the
os uteri has been untimely dilated by any improper management, 
224            INTRODUCTION TO MIDWIFERY.
or any other cause, it will close again, and  the woman often go
on to her full time, if she be kept in a quiet state.*
  The sympathetic causes of the action of  the uterus may arise
from the disturbance of any part, with which the  uterus is con-
nected or disposed 10 consent, as is the case  with all the contents
of the abdomen, especially with the lower  part of the intestinal
canal and the bladder, as in a tenesmus or strangury.   On the re-
moval of these, the action of the uterus caused  by them will  pre-
sently cease ; but  if the disturbance be violent, and of long con-
tinuance, the  uterus, though the original  cause be wanting, may
assume that action, to which, by its structure, it is disposed at any
period of pregnancy,  and  the  exclusion of its  contents will of
course follow.
  From adventitious  and sympathetic causes, the action of the
uterus is often produced prematurely, at  the latter part of preg-
nancy, and from the want  of a just distinction, they may be en-
couraged, to  the great detriment of the patient.   In such cases,
the action of the uterus may go on during the continuance of the
cause,  or it may become regular, proceeding after the cause is re-
moved, or it may cease entirely on the removal of the cause.   Of
all these; there are frequent  instances in practice :  and seeing
there is such variety in the causes of the action of the uterus, it is
not surprising,  that there should be such difference in the effect
produced, and  so  many deviations  from the ordinary course of
labours.
  All the difficulties attending parturition may be  reduced to two
kinds;  first,  those which arise  from  the imperfect action of the
uterus; secondly,  those which are  occasioned by the resistance
made to that action when duly  exerted.  The  regulation of, ox
best methods of assisting that action or power, when  defective,
and the removal of the impediments  to its  effects, constitute the
chief objects in the practice of midwifery.
* See Chapman's Treatise on Midwifery, chap. V. Case 1. 
SIGNS AND DISEASES OF PREGNANCY.       225
                      CHAPTER VII.

                          SECTION I.

          ON THE SIGNS AND DISEASES OP PREGNANCY.

   Conception is succeeded by many important changes  in the
 constitution, and usually by  affections of various  parts, which,
 in the beginning of pregnancy,  are  merely  considered as signs
 that a woman hath conceived.   In  the more advanced state, the
 same or similar changes and affections, increased in degree, toge-
 ther with some supervenient ones, have been termed the diseases
 of pregnancy.   Yet,  in either  state, these evidently do not de-
 pend upon pregnancy as a specific cause, being often occasioned
 by irritation, or disturbance of the uterus from other causes, espe-
 cially during the act  of menstruation.   Nor do they commence
 with conception,  and  continue to the time of parturition;  but are,
 in general, most frequent, and most  troublesome also, soon after
 conception, or in the  early part of pregnancy, gradually abating,
 and often wholly disappearing,  as  the  patient advances  in her
 pregnancy.  The signs of conception must, therefore,  be very
 ambiguous and uncertain ; though, from the common occurrence
 of the case, and the particular attention  which is paid,  a faculty
 of discriminating them is acquired,  which  generally prevents
 error.
   It is a popular observation, confirmed by experience, that those
 women are less subject to  abortion,  and ultimately  fare  better,
 who have  such symptoms as  generally  attend pregnancy, than
 those  who  are  exempt from  them.   The state of pregnancy is
 then an altered, but  cannot  with propriety   be called a morbid
 state.  But if the term disease be used on this occasion, with the
 intention of giving a more intelligible explanation of the tempo-
 rary complaints  to which women  are then liable,  or to denote
 their  irregularity, or  an excessive degree of them, it may  be re-
 tained. With this view, the diseases  of pregnancy may be divi-
 ded into two classes; in the first of which  will be  included all
 those which occur in the early,  and in the  second,  those  in the
 latter part of pregnancy.  The time of quickening may constitute
 the line of distinction  between them, and  we  shall thus be  led to
 the most useful  method of proceeding, that of observing the com-
 plaints in the order in which they arise.
  It appears, that every part of a living body has two principles,
 or performs two offices;  one of which  regards  its  own di tinct
preservation and ease; the other, by  which each part contributes
                             29 
226          INTRODUCTION TO MIDWIFERY.
to, and partakes of the harmony or disorder of the whole frame.
The degree of disposition and ability to perform these offices, and
the manner in which they  are performed, vary in different parts,
and for peculiar purposes; but it may be  presumed, that they
both potentially exist in every part,  though not at all times actu-
ally exerted, as in the case of convulsions from an injury of some
minute part.  When these offices are  executed  in a manner and
degree necessary for, and consistent with, the common  purposes
of being, they  are called natural;  but when they are irregular or
excessive in their manner or degree, or are excited on extraor-
dinary occasions, though the existence of the occasion may ren-
der them needful or unavoidable,  they  are not improperly  termed
violent or morbid.  The disposition to act  is called  irritability,
and the action, when produced, irritation.  Irritation is described
to be of two kinds.   It may be confined to the part in which the
cause exists, or it may be transferred  and extended to some dis-
tinct  or distant part.  The  first is called simple irritation, and
the latter sympathy, or irritation by  consent.  Sympathy,* or ir-
ritation by consent, has again been distinguished  into two kinds,
primary or direct, as between the  uterus and stomach; and  se-
condary  or intermediate, as between the uterus and the brain, by
the intervention of the stomach.    The modes of this  consent be-
tween distinct and distant  parts,  have been variously explained,
and  assigned to many different eauses :f but with the propriety
of the  explanations, or the ingenuity of theories, we are not, on
the present occasion, concerned.
   The truth of no observation in  medicine has been  more gene-
rally acknowledged, than  that of the extreme irritability of the
uterus, and of the propensity which the whole body has to be af-
fected or disturbed by its influence.J  Some parts are, neverthe-
less, more disposed  to this influence than others, some  by direct
  * Distinguitur irritabilitas in primarium seu directam, etsecunda-
riam seu perconsensum.—Glisson, Tractat. de Ventric. et Intestin.
  t Ojuinque adminicula, quibus una pars alterius affectum fua nata-
rali perceptione eousque cognoscat, ut eideui compatiatur, proposu*
ero.  Primum est immediata continuitas, praesertim fibrarum et tu-
nicarum partium ; secundum, nervorum a communi stipite  derivatio ;
tertium, influxus per arterias mutatus ; quartum, reductio per venas
praepedita aut diminuta ; quintum, contactus vel alia idonea vicinitas,
qua una pars in aliam agat.—Idem.
  Glisson, who was physician to queen  Elizabeth,  has a right to be
esteemed the father of the doctrine of irritability.   He often seems
to use the word perception for irritability, and the word  irritability
for sympathy, or disposition to consent.
  X Est enim uterus pars principalis, quae  totum corpus facile in
consensum trahit.—Harv. Exercitat. de Partu. 
SIGNS AND DISEASES OF PREGNANCY.       227
 consent, and  some by the interposition  of other parts.  Those
 affections which occur most frequently during, or in consequence
 of pregnancy, it is necessary that we should understand, that we
 may be able to form a competent judgment of the subject; and
 for this purpose the following account will be sufficient, either in
 the way of illustration or example.
   Between the uterus and the breasts the consent is so intimate
 and constant, that it is scarcely possible for them to  be affected
 separately.   The  enlargement of, and  shooting  pains  in  the
 breasts,  are  therefore not  improperly enumerated  among the
 symptoms of pregnancy ;  though they are also observed to occur
 at the time of the final cessation of the menses, when these are ca-
 sually obstructed, and in some women in a slight degree, at each
 period of menstruation.
   The areola, or  brown  circle round  the nipples, has been re-
 presented as  an indubitable mark  of pregnancy.  This is not,
 however, suspected to be a primary consequence of a particular
 affection of the uterus,  but  of the preceding enlargement and
 alteration of the breasts: and, though it generally  occurs  in
 pregnancy, it may be produced by any cause capable of giving
 to the breasts a state resembling  that which  they are  in at the
 time of pregnancy, of which it can only be  esteemed a  doubt-
 ful sign.  The areola is, therefore, found in  many of the com-
 plaints which resemble  pregnancy, and  though  generally, not
 universally, I  think, in  pregnant  women.   Equally  or more
 uncertain, for the same reason, is uneasiness in the region of the
 uterus, and about  the navel, though frequently attendant upon
 pregnancy ; yet the latter, as far as I know, is a symptom pecu-
 liar to  affections of the uterus.   The navel, also,  according  to
 the progress of pregnancy,  is constantly emerging till it comes
 to an even surface with the integuments of the abdomen ; and to
 this circumstance much regard is to be paid in cases of doubtful
 pregnancy.
   There are few diseases of much importance in any  part  of
 the body in  which the stomach  is not affected ; but the consent
 between this and  the uterus is peculiarly frequent,  and often
 violent.  It is not, therefore,  surprising, that the stomach during
 pregnancy should  so generally be disturbed with nausea, vomit-
 ing, heartburn, loss  of appetite,  and  indigestion ; or that such
 complaints should, under  certain circumstances, have been con-
 sidered as symptoms of pregnancy.
   In  consequence of these affections of the stomach,  and per-
 haps  by direct consent with the uterus, any part of the intesti-
 nal canal may be disturbed during pregnancy ; but the particular
 part may be casual,  and the manner  will depend upon some
peculiarity in  the constitution of different women, as  the same
cause may produce  very  different or contrary effects.  Some 
228          INTRODUCTION TO  MIDWIFERY.
 women, who are at all other times constipated, have a diarrhoea
 at  each  period of menstruation; and those who are  at  other
 times subject to a diarrhoea, then become unusually costive ; and
 similar changes often take place when women are pregnant.
   The whole habit of the body  may be disturbed by a certain
 state of  the  uterus, and  yet  no individual  part be  peculiarly
 affected.   Hence,  at the time of pregnancy,  there  frequently
 occurs a feverish  disposition,  with debility,  emaciation, and
 many symptoms common to hectic fevers; by which the counte-
 nance  becomes altered, the eyes appear larger,  the mouth wider,
 and a sharpness is given to every feature.  In consequence, also,
 of this general and  perpetual irritation,  the temper of pregnant
 women is sometimes rendered less gentle and patient  than  is
 consistent with their usual character, and this claims compassion
 instead of resentment.
   The consent between  the uterus and  stomach seems to  be  of
 that kind which has been called primary or direct;  but  affec-
 tions of the brain, heart, and  lungs, appear to  be secondary, or
 by the intervention of the stomach.   Pain and giddiness of the
 head, dimness of the sight, sleepiness, convulsions, palsy, pal-
 pitation  of the heart,  and peripneumonic complaints, though
 they sometimes occur during  pregnancy, are  less frequent than
 such  as are produced by the direct consent of any part with the
 uterus.
   There are, also, many instances  of affections of the uterus
 from  its  consent with other parts.  A strangury, or tenesmus,
 may occasion a similar  affection  of the os uteri ; and if it were
 to continue, a premature  expulsion  of the  foetus.  Pain in the
 stomach or bowels, or of any part contiguous to the uterus, or with
 which  it is prone to consent,  may disturb it;  and if extremely
 violent, or of long continuance,  may  produce the same effect.
 From  these it appears, that,  when  an abortion is apprehended,
 there is not only occasion to attend to and moderate those cir-
 cumstances,  which may arise  from original  affections of the
 uterus, but  those  also, which may be produced  in some  other
 part, and extend to the uterus.
  From  these observations  it  will  not be inferred,  that every
 complaint which happens to pregnant women, is to be attributed
 to uterine irritation.  For some  appear  to be  caused mechani-
 cally by the  pressure of the enlarged uterus,  and all of them to
 be aggravated by the erect position of the body.   The distinction
 which was made will, nevertheless, be equally proper ; for, before
 the time of quic keniug, the complaints are generally owing to an
 increased irritability of the constitution, or to the  admission of a
 new cause of irritation into the habit, and  afterwards to the en-
largement of the uterus.  But, without a very strict adherence to
 any general distinction, we will recollect  that  a small degree of
enlargement of the uterus, with  its  consequent irritability, may 
h
          SIGNS AND DISEASES OF PREGNANCY.        229

become the cause of disease in early pregnancy; and that such a
degree of irritability may arise or continue toward the  conclu-
sion, as may create symptoms like those  which might be pecu-
liarly expected at the commencement.*

                          SECTION II.
  By  the term  quickening is understood the  first  sensation
which the mother has of the motion of the child which she has
conceived.  This  happens at different periods  of  pregnancy,
from  the tenth to the  twenty-fifth  week, but  most commonly
about the sixteenth after conception; yet the motion  of the child
is in some women so obscure, or such little attention is paid to it,
that it is not perceived or regarded; and in others so indistinct as
to be confounded with various  other sensations.f In cases, there-
fore, of supposed,  but mistaken pregnancy, women often fancy
that they feel the motion of a child ; or, if the child  has died in
utero, when  there  is, after birth,  the fullest proof that it must
have ceased to move for a long time.
   It is not unusual for women to have a few drops of blood dis-
charged from  the vagina at the time of quickening, without any
inconvenience; but the symptoms  which  attend, are generally
such as are occasioned by surprise  or agitation from any  other
cause, as fainting, or some hysteric affection.   These  being of
short duration, require no other means of relief than exposition to
the open air, a glass of  cold water, or some light cordial, and a
short  confinement to a horizontal position.
   *  [It must always be borne in mind, that there is no one decisive
sign  of pregnancy ;  and that our best evidence, in cases of a doubtful
nature,  is gathered from an association  of symptoms.   Our author
justly rejects the discolouration of the areola, as alone an indubitable
mark of pregnancy ; a circumstance upon which medical jurists have
placed too much reliance.  The same  error exists in regard to lac-
tation, which often  arises from other causes.  The maxim of Aris-
totle, Lac habit ergo peperit, is now rejected by  the best physiolo-
gists.
   Professor Post has lately communicated to me  the following sin-
gular fact : A lady of this city was, about fourteen years ago,  deli-
vered of a healthy child, after a natural  labour.   Since  that period,
her  breasts have  regularly secreted milk in  great  abundance ;  so
that  to use her own language, she could at all times easil> do the of-
fice  of a nurse, and she has uniformly enjoyed good health.  She is
now about thirty-five years of age ; has never proved pregnant a se-
cond time, nor had any return of her monthly discharge.  F.]
   t  [This calculation  of our author is conformable to the best autho-
rities ; and,  according to the minute observation of Roederer, as  quo-
ted by Professor James, from that time the patient may expect ges-
tation to continue five additional months.  F.J 
230
INTRODUCTION TO MIDWIFERY.
    The changes which follow quickening have been attributed to
  various causes.  By some it has been conjectured, that the child
  then acquired a new mode of existence; or that it was arrived to
  such a size as to be able to dispense with the menstruous blood,
  before retained in the constitution of the parent, which it disturb-
  ed  by  its quantity or malignity.   But it is not now suspected,
  that there  is any difference between  the  aboriginal life of  the
  child,  and that which it possesses at  any period of pregnancy,
  though there may be an alteration in the proofs of its existence,
  by the  enlargement  of its size, and the  acquisition of greater
 strength.  It was before observed,  that  the notion of some per-
 nicious  influence from the retained  menses  seemed to have  been
 admitted without foundation.   Others  have  believed, that the
 changes ought to be assigned merely to the enlargement of the
 uterus^ increased by the growth  of the ovum to such a size, that it
 was supported above the brim of the pelvis; by which means  all
 the inconveniences, which arose  from the dragging or subsidence
 of the uterus in the vagina, were removed: and this seems to  be
 the true reason.   Because, in morbid enlargements of the uterus,
 not of a scirrhous or cancerous  nature, there vs  an abatement of
 the  symptoms, when they become of a  certain  size; which cir-
 cumstance has often rendered patients an easy prey to empirics,
 who have availed themselves of  the impressions made by the ca-
 sual and temporary relief, as the critical moment for  imposition.
 But though this explanation  may  not be satisfactory, the chan-
 ges are  very  important and certain; for,  whatever  complaints
 women before suffered,  in general after  the time of quickening
 they decline, or are wholly removed.

                         section III.
   A suppression of the menses is one of the never-failing conse-
 quences  of conception, at least I have not met  with a  single
 instance of any woman continuing to menstruate when she  was
 pregnant;  though 1 know, that popular opinion is against the
 assertion, and that exceptions to it are frequently mentioned by
 men of science.   What gratification  the  human mind is capable
 of receiving  by the affectation  of singularities  of constitution,
 which do not depend upon our will  or power, and from which
 neither  reputation or  advantage can  be derived, philosophers
 may determine.   But it is well known, that in practice there  is
 great occasion to  be circumspect;  for, either from the misrepre-
 sentations of patients, or the credulity or vanity of writers, many
medical  works are  filled  with the most useless and improbable
histories, defective in the  essential article of all  records, truth;
and  this charge  hath been  made  in the  most pointed terms
against  many writers on  the subject of midwifery.   (Plena  er-
roribus fabulisque.  Ruysch.)  Some who  have said  that wo- 
SIGNS AND DISEASES OF PREGNANCY.
231
men might menstruate during pregnancy, have  supposed the
discharge to be  made  from the vessels of the vagina or neigh-
bouring  parts;  or  they have  considered  every eruption of
blood  from the  uterus  as  a regular menstruous discharge.   But
if menstruation,  according to the definition already given,  had
continued in pregnancy, it is scarcely possible, but that abortion
must often have followed,  as a part of the ovum would necessa-
rily have been detached from the uterus at every period;  unless
we conclude  that, by  some subsequent process, their connexion
had been  occasionally re-established.   As, therefore, in cases in
which  pregnancy can  be  suspected, we have, in the  suppression
of the  menses, the best proof of  its existence, and in their con-
tinuance, of the contrary  ; it will be wiser to leave the business
to be determined by time, or to place our confidence in, and to
form our judgment by  this circumstance, as least liable to error;
rather  than  to  involve ourselves in  doubt,  by searching after
equivocal appearances, which, deserting this circumstance, can-
not lead to any  satisfactory conclusion.   But though it may be
laid down  as a general principle, that, when women continue to
menstruate, they are not  pregnant, it  will not follow, that in
every case of  the suppression of the menses women are  certainly
pregnant,  though pregnancy is  always to be suspected; as  I
have known  many instances  of young  married women  who
have ceased to menstruate for several  months, independently of
any disease, when they were not with child.*

                         section IV.
   All  the  complaints  attending  pregnancy, and perhaps the
state of pregnancy,  are accompanied with a febrile disposition
or  increase of heat, which, when  duly regulated, is  probably
intended to answer some  important purpose to the child.   This
seems  to  be proved by the blood of pregnant  women, which,
independently of disease,  is always found to have what is called
a  sizy appearance,  though of a peculiar kind, and  evidently
  * [Our author is too  positive in asserting that the suppression of
the menses is always a consequence of conception.  Many authen-
tic cases might be cited, wherein the menstrual evacuation regularly
returned during the whole period of utero-gestation.  I knew  one,
says Heberden, in  his  commentaries, who never ceased to have
regular returns of  the menstrua  during four  pregnancies, quite to
the time of  her delivery.  A  lady of this  city, under the  care
of Dr. Hosack, has, during the last three pregnancies,  menstrua-
ted until within  a few  weeks of her delivery, and has,  at each
labour,  brought  forth a healthy child.   A healthy female  in  my
own practice, the mother of five children, has had regular  returns
of the menses during her last two pregnancies  until  the  seventh
month.  F.] 
232          INTRODUCTION TO MIDWIFERY.
very different from that which is observed in cases of inflamma-
tion, and which  may be considered as a  consequence of some
new and specific action.  But if an inflammatory disease should
occur in pregnancy, then the blood loses its pregnant appear-
ance, as it may be termed, and assumes that of the disease.  An
extreme degree of those symptoms which appertain to pregnancy
may also produce the true inflammatory  appearance  of the
blood.   From  this state of the blood, and from the relief which
bleeding almost universally affords in  the  urgent complaints of
pregnant women, even in constitutions which at other times do
not well bear  that evacuation, occasion  hath been  taken, to
attribute all the  consequences of pregnancy to  a plethora, of
which the retained menses were thought to be the cause.   But
if it be true, that pregnant women have  such feverish  dispo-
sition, we have no reason to be solicitous about the investigation
of the cause, as, by bleeding at proper times, in quantities suited
to the  constitution and indications, both  the  effects of uterine
irritation and plethora are generally lessened or removed.
  Particular kinds of diet are found to add to this disposition
to inflammation, and to increase irritability.  Of these, the prin-
cipal is  animal  food, though it is usually recommended, together
with liquids of a cordial and nutritive quality, to women  wheu
pregnant, on the presumption that  they are then in greater need
of such. support than  at any other time;  and because it was
thought  serviceable to the child.  To  some constitutions, and
under  particular circumstances, these  may be  necessary; but if
it be justifiable  to draw inferences from the  appetites of pregnant
women, or if we may  judge from  the  common  consequences of
such diet, we shall soon be convinced,  that  it is often improper :
for they  have  generally a dislike to animal food of every kind,
and under  every form, and if prevailed upon to eat it incau-
tiously,  are sensible of much inconvenience.   What is improper
for the  mother can hardly be supposed beneficial to  the child.
On the contrary, they usually prefer vegetables, fruit, and every
thing cOoling,  which  they eat and drink  with avidity, and in
which they indulge without prejudice;  though  in some constitu-
tions a directly contrary method  of treatment may be required.*
  * [Indulgence in animal food, and in strong or fermented drinks,
particularly porter, is among the most  powerful causes of increasing
the continual irritability attendant on pregnancy.  Moderate exer-
cise in the open air, and an abstemious mode of living, should be
enjoined on pregnant  women ; and, unless in some few instances,
fermented drinks  should be  strictly prohibited.  As in pregnancy
the habit inclines toward plethora, moderate  venesection is among
the best means of relief, where symptoms of fullness and irritation
prevail.   F.] 
SIGNS AND DISEASES OF PREGNANCY.       233
                         SECTION V.
   Pregnant  women are not only encouraged to live more luxu-
 riously,  but  more  indolently also,  exercise  being  thought  im-
 proper, unless  toward the conclusion of pregnancy, when it has
 been supposed to procure a more favourable delivery.   Great
 and  continued  care may, in  some  cases  of pregnancy,  be
 absolutely necessary, in order to prevent abortion or premature
 labour;  but, in general, the contrary method of proceeding  is
 the most eligible and proper : for the lower class of women, who
 are by necessity obliged to  follow  laborious  occupations in the
 open air,  and  who  are exposed  to all the vicissitudes of the
 weather, not only pass the time of their  pregnancy with fewer
 complaints than the affluent,  but have also  more easy labours.
   Much allowance must, however, be made to former habits of
 living; but those who are in possession of all the advantages of
 rank and fortune,  which the eyes of inferiors are apt to look at
 with envy, must use them with the most cautious moderation, or
 they will suffer for every unreasonable  indulgence.  By every
 kind of habitual irregularity the constitution  becomes loaded, or
 the activity of its powers lessened or perverted, and a disposition
 to disease is often given,  or all sense of natural enjoyment is lost.
 We have been  accustomed to consider parturition as a distinct
 act of the constitution, unconnected with any which precedes or
 follows;  but there would be more utility in  considering it as a
 part only of  a process,  which begins with conception, and ter-
 minates with childbed, or even with lactation.  We should then
 presume, that such as the state of the body is at the time  of con-
 ception, such will it probably be during pregnancy ; and, accord-
 ing to the state in  pregnancy, will be that at the time of parturi-
 tion ; and on this  again  will depend the recovery from childbed,
 unless there be some peculiar imperfection in the constitution, or
 some disease not  dependent upon that state  should supervene.
 On the due and regular exercise of all the functions and  powers
 of the body, their  disposition and  ability to act,  according to
 their  original frame, must  ultimately depend; and  such as is
 their  general condition  at the time of labour, such  will  be that
 of  the   uterus,  and  of all the parts  concerned  in parturi-
 tion,  though the  health of some  women is always  improved
 during pregnancy.  But if  there has been indulgence in  impro-
 per habits, or if exercise has been  neglected at all other times,
 there is little cause to  expect advantage  from unfit and extraor-
 dinary efforts toward  the conclusion of pregnancy; as no other
 end can then be answered by such conduct, but that of disturbing
 the frame, and  bringing on  premature labour.  In quadrupeds,
 which apparently suffer little other inconvenience when they are
 with  young, than that which  arises from  mere  increase  of
bulk, their common pursuits   are  neglected, the  gregarious
                            30 
234          INTRODUCTION TO MIDWIFERY.
disposition is  suspended,  and, if left  to their  own inclinations,
thev gradually lessen the exercise they use as they  advance  in
pregnancy.*

                         SECTION VI.
   Vomiting is one of the most frequent complaints to  which wo-
men are liable in the early part of pregnancy,  and it sometimes
continu s to, or returns toward  the conclusion.  If it should not
be violent, and occur only in the early part of  the day, though
very irotiblesome. it is so far from being detrimental, that it is ge-
nerally found  to be serviceable,  by exciting a  more vigorous ac-
tion of the uterus, and by bringing the stomach into a  better state;
for the vomiting of pregnant  women is  not always a mere effort
of straining, or a discharge of the food and common humours of
the stomach.   The  matter  evacuated sometimes  shows a very
muli c Curbed,  or a morbid secretion of such  a kind  as to be
offensive  to the stomach itself;  and besides correcting or evacu-
ating the offending humours, it  is necessary that we use our en-
deavours  to change, or to appease the present action, before the
indication to vomit be  suppressed.
   In plethoric habits,  the act of vomiting may render bleeding
necessary, though the disease or state of which  it is a symptom
might  not  require this evacuation.   For  that  reason, and be-
cause it lessens the general irritability of the habit, bleeding will
be  necessary  in  some cases of incessant  vomiting,  though  in
others  it  may not be either  requisite  or proper.   But medicines
of  any kind are not wanted to restrain the vomiting,  except it
should be extreme, so that the strength of the  patient is reduced,
or  other  untoward  consequences follow.  Then the  common
means used for the relief of this  symptom in other cases, may be
safely and properly advised for  pregnant  women; as the  saline
draughts in the state of effervescence,  or mixed with some absor-
bent earth, in the manner of  the mistura  corrallata of Fuller;
or magnesia in simple  peppermint-water ;  or  the  Seltzer water,
natural or artificial, whilst it effervesces with a mixture of lemon
juice and sugar,  or ice;  or  small doses of the acid  of vitriol in
cold or  mint  water; or  small  quantities  of  Colombo root;  or
chamomile  flowers, joined with  some aromatic, in substance or
infusion.  Moderate  cordials  are sometimes  required; and  of
these, the most grateful is the confectio  alkermes, in  simple mint
  * [Immoderate  fatigue  or exertion may bring on premature la-
bour at any period of pregnancy.  Exercise on foot should never
be indulged so as to induce pain in the  back :  on this, as  well  as
on other accounts, riding in a carriage in the open air is greatly to
be preferred.  F.] 
SIGNS AND DISEASES  OF PREGNANCY.       235
or  cinnamon water.  Many  other medicines of the same  kind
may be directed, in such forms as are found to be most accepta-
ble to the patient.
  In cases of excessive vomiting, opium, in tincture or substance,
is generally given, and often with great advantage.  Perhaps no
well grounded  objection can  be made to the occasional use of
opiates, when violent pain, or any other urgent symptom de-
mands them. But I have persuaded myself that their habitual or
very frequent use is prejudicial to the foetus, either by debarring
it from a proper supply  of nourishment, or by  depraving that
with which it is actually supplied; but of this opinion I begin to
have some doubt.   The same observation  hath  been frequently
made on spirituous liquors, and probably the effect of both may
be explained upon the  same principle.
  Local applications of  various  kinds have been recommended,
to abate  excessive vomiting; and  consent is readily given to
their use, though without the  expectation of great advantage, be-
cause no  harm is apprehended from them.  But a  physician of
great experience and strict veracity, (Dr.  Heberden,) informed
me, that he  had in these cases  seen the application of a  piece of
folded cloth, moistened with tinctura opii, to the region of the sto-
mach, do much service, when internal medicines of the higest esti-
mation had  proved  ineffectual.
  It is a general observation, that the vomiting  of pregnant
women is most frequent and  importunate in the morning; and
the  circumstance evidently depends  on the  change  of  position
which then takes place,  and  not the peculiar time.   When the
position is horizontal, the patient may not  have the least sense
of uneasiness or disturbance of the stomach ; but the moment she
rises from her bed, these come on, and continue till she again re-
clines,  unless she  is careful to bring the body  erect by rising
slowly.  Confinement to a horizontal position is, therefore, found
both necessary  and useful, not only when the stomach is  violent-
ly disturbed in consequence of pregnancy,  but from many other
causes.
  When there  is a nausea or inclination to vomit  without any
evacuation,  a gentle emetic is  the best remedy : and  this  may be
repeated,  whenever the urgency of any  symptom  requires it;
experience having  fully proved, that emetics may  be  given to
pregnant  women with perfect safety; but  a glass of lukewarm
water, or  a  little weak chamomile tea,  usually answers the  pur-
pose.*
  *  [This  irritable state of the  stomach generally decreases, as
pregnancy advances ;  and females who suffer the  most  from it,
have, not unfrequently, the  healthiest children, and are the  least 
236
INTRODUCTION TO MIDWIFERY.
                        SECTION VII.
  Indigestion,  and depravity or  loss of appetite, proceed from
the same cause as  the  foregoing  complaint, of which  they  are
only different modifications ; and the treatment commonly enjoin-
ed for their relief will be suitable  for pregnant women.  Of that
depravity of  the appetite, which in pregnancy has usually gone
under the name of longing, the instances recorded in books, and
those formerly reported in conversation, are incredible, and  too
absurd  to deserve,  or at  least, at this time, to require a serious
refutation.  Longing was not  supposed  to depend upon  the
fancy or other circumstances of the mother, but to be a peculiari-
ty in her appetite,  produced by the influence of some cause ex-
isting in  the  child.  Nor was it supposed, that  the effect was
confined to  the simple  refusal or gratification  of the  appetite,
however extravagant it was, or however unnatural it might ap-
pear ; the longing of pregnant women was to  be indulged, not
merely  through kindness to the parent, but for the interest of the
foetus also. If her  wishes and inclinations were not gratified, she
might suffer;  but the worst consequences were to be apprehended
on account of the child, which  would either  be retarded in its
progress, or bear the mark of the thing longed for on some part
of its body; as if there were a connexion  between  the  two be-
ings, incomprehensible by us, and infinitely  more exalted than is
observed  under any other circumstances.  Nor was the observa-
tion of  similar accidents in animals, or even  in plants, considered
as a valid argument against this extravagant opinion.
   In times and countries barely civilized, can we suspect, that it
was thought necessary to  adopt and to support the opinion of the
power of the imagination, in order to secure to pregnant women
that indulgence and tenderness of treatment,  which  their  situa-
tion was  supposed to require ? Or  does there really exist any
mysterious consent  between the parent and the foetus in utero in
the human species ?  I believe, that  the opinion originated in the
former  cause; but that in the course of time, and by the habit of
likely to miscarry.   Beside the means of relief stated by the author,
others may be noticed : a drink, composed of equal parts of lime water
and milk ;  soda water ; a few grains of capsicum ; a table spoonful or
two of fresh cream in a small quantity of spirits and water.  When
all these means have failed, the loss of a few ounces of blood from
the arm has sometimes removed this gastric irritation.   Anodyne in-
jections by the bowels, have occasionally proved highly serviceable ;
and, when the sufferings of the patient have been very  great, at the
advanced period of pregnancy, the bringing on a premature labour
has, in all probability, saved mother and child.  A case of this sort
is recorded in the London Medical and Physical Journal, vol. 2.   F.J 
SIGNS AND DISEASES OF PREGNANCY.       237
thinking and acting in  a certain  manner, a general conviction
did take place, that some consent of an inexplicable, and perhaps
of a divine nature, not to be defined or illustrated, really existed.
An opinion which might have been useful  and necessary at the
time when it was first adopted,  continued when there  was  no
longer occasion for it, and became a source of real disadvantage.
For the  minds  of  women were  frequently disturbed, and them-
selves rendered miserable, by the dread of an effect, the  cause of
which was wholly imaginary; sometimes,  also,  sinister purposes
were intended to be answered by the  pretence.   It then became
necessary  to examine  the  opinion, and  it was proved  to  be
groundless.  In the early part of my own life, nothing was more
common, than  to hear of innumerable examples of the dreadful
events  which  were caused  by disappointed longing; or to see
instances of the great confusion  and distress in  families, from a
persuasion of  its importance.   But at the present time,  and
in this country, the term longing is  seldom mentioned, except
among the lowest class of people; though the cause, if any had
existed, must have produced  its effect at all times and in all situa-
tions.   Something is, however, to be granted to longing, consi-
dered as an appetite depending  upon  the constitution, of a cer-
tain state of which it may be esteemed an indication.  If we be-
lieved the doctrine, that diseases and tendencies to them were pro-
duced by an excess  of acid  or alkalescent  humours, we might
readily  understand, why one  pregnant woman prefers the most
savoury and  high-seasoned  food,  and another  acid fruits and
cold  water ; and why they might both be indulged, not only with-
out prejudice, but with  advantage, as has been  frequently obser-
ved,  in these cases, and in  the  delirium of fevers, for a similar
reason.   The appetite, unsophisticated by bad habits, will proba-
bly never mislead us  as to  the quality of our food.   It  may ra-
ther be  esteemed a  guide implanted in us  by nature, which we
shall never err  in following, if we act with discretion as to  the
quantity.

                        SECTION  VIII.
  The  heart-burn is  a  painful sense  of heat   in the throat and
fauces, with sudden regurgitations of thin, sour,  or acrid saliva in
the mouth.  In some  cases,  it seems to be a mere sensation ari-
sing  from  the consent between the stomach and uterus; and in
others, to be caused by an accumulation of sharp humours, secre-
ted in  the stomach by  wrong action.  There is often reason to
think that it is  occasioned by food which  is salt and high  sea-
soned,  or otherwise hard of digestion, and by fermented liquors;
and perhaps by sleeping in  an erect position after  a  full meal.
The  medicines  usually directed for this complaint, are given with
the intention of abating or  removing  the  sensation, of altering 
238          INTRODUCTION TO MIDWIFERY.
the properties of the fluid collected  in the stomach, or of evacua-
ting them.   These generally consist of the various kinds of ab-
sorbent earth, as the testaceous powders, or magnesia, alone, or
mixed with rhubarb;  or lime-water, or small  doses of saline me-
dicines, of which, perhaps, the best is the aqua kali, to the quan-
tity of twenty drops, in a large glass of cold water.   But my
highly respected friend,  Dr. John Sims, has published the follow-
ing, as a form of medicine which seldom  fails  to give immediate
relief; and many trials  have  convinced me that  his opinion of
the efficacy of this medicine is just.

                 r> Magnes. ust.
                   Aq. Amnion, pur. aa 3j.
                  ----Cinnamom. 3'ij.
                  ----Pura, 3vss. M.
 Sumat cochlearia ij vel iij ampla, sapiusin die, urgente cardialgia.

  When the complaint is violent, a gentle emetic  is the  most es-
sential remedy ;  and should the disposition to it originate  in the
debility of the powers of digestion, such means  are to be used, and
such medicines given,  as promise to restore and invigorate them.

                        SECTION XI.
  Costiveness  is another troublesome complaint  to which preg-
nant women are  liable.   It is often hurtful in   its  present effects,
and sometimes in its  consequences,  being not  uncommonly the
cause  of head-ach, fever, tenesmus,  pain in  the  bowels,  and
abortion.   Care must therefore be taken to obviate  costiveness,
by  the cautious  but occasional use  of manna,  magnesia, senna,
electuary of senna or of cassia, oleum ricini,  soluble tartar, Jes-
sop's well  water, and the like medicines.   But I was formerly
much more assiduous  in preventing costiveness than I am at the
present time,  having observed,  that all women who go on  pro-
perly, especially in the early part of pregnancy, are liable to this
state of the bowels, which may have some relation to the strong
action of the uterus at that time.   Costiveness may, therefore, be
considered as a state of the bowels corresponding with that of the
uterus ; and we  can never believe that to be injurious, which oc-
curs so frequently as  to be esteemed a  common consequence.
Experience has proved  that abortion most frequently happens to
those who are subject to too relaxed a state of the  bowels.
   The more gentle the means used for  the removal of costive-
ness, the more eligible they are, provided they answer the inten-
tion.  Aloetic medicines are forbidden during pregnancy, lest
they should do mischief by their supposed deobstruent qualities :
but they are in common use among the  lower class of people,
because  they are cheap, and conveniently given  in the  form of
pills, and I have not observed any bad effects from them.  The 
SIGNS AND DISEASES OF PREGNANCY.       239
stomach of pregnant women is often  in  such  a state, that no
internal  medicines  can be retained, and we are obliged to have
recourse to clysters, which are generally efficacious, and always
safe.  It is  remarkable, that small doses of the sal catharlicus
amarus,  dissolved  in  plain  water, or simple mint-water, or in
common emulsion, will often be kept upon the stomach, when
things less obnoxious to the taste are immediately rejected.

                         SECTION x.
   By long continued costiveness the faeces  are sometimes  col-
lected  in so  large a quantity, and by long  confinement  in the
rectum  and lower  part  of  the  colon,  become  indurated to
such a degree, that they cannot be voided by the common action
of the intestines ;  and the medicines  usually  given,  and the
means used  to procure stools, prove insufficient for the  purpose.
This complaint is not peculiar to  women when pregnant, being
found  to occur indiscriminately in either sex, if compelled by
disease or accident to remain  for a long time in  a horizontal
position ; and it is not unfrequent in children, or even in animals.
It has often  been  mentioned by medical writers, though no pro-
per name has  been given to it.  It is vulgarly called the ball-
stool.
   There is reason to believe, that this complaint has often been
overlooked  in practice;  for  though the column  of indurated
faeces is sometimes enormous, a small quantity  in a liquid state,
escaping  between the column of hardened  faeces  and the  side
of the intestine,  may be daily discharged ; so that no  suspicion
of the real  nature  of this case  may be entertained, unless the
Stools be inspected,  or the  patient be examined,  per anum.
   When  it  has  continued for a certain time, and  the  common
efforts of the intestines, though repeatedly excited, are not equal
to the expulsion of the faeces, their  extraordinary action is raised,
which is attended with pain, periodical in its returns, and violent
in its degree.  This action  continues till the difficulty is over-
come, or by the effect of the long and fruitless action, the parts
adjoining to the  anus, and perhaps the internal parts, become
inflamed ; and, if proper and timely  means were  not used to
prevent  the mischief, this complaint has sometimes proved fatal
by bringing on a sphacelation of the parts.
   Purgative medicines rather increase  this complaint, by im-
pelling a greater  quantity of faeces  into the lower part  of the
intestinal canal, when they cannot be discharged.  Supposito-
ries and  clysters,  at least in the way in which they are common-
ly administered, cannot be received, on account of  the greatness
of the obstruction,  to the removal  of which they are not equal.
Effectual relief is only to be obtained by dividing the indurated
faeces into smaller pieces by manual assistance, or by some con- 
240            INTRODUCTION TO MIDWIFERY.
venient instrument conducted into the anus, and used with cir-
cumspection, and then  by washing  them  away with  repeated
clysters.  In  women  there is less difficulty in the management
of these  cases, because  the  column  of faeces  may not  only be
broken by the finger passed  into the vagina, but their exclusion
very much assisted.

                         SECTION  XI.
  Perhaps women are by constitution, and by the sedentary lives
they lead, more  subject to the hemorrhoids than men.   They
are generally esteemed as indications  of too great fulness of the
habit,  or as critical  depositions of something  noxious,  had it
remained in the constitution: they are, also, an ordinary conse-
quence of long-continued costiveness,  and, during pregnancy,
they may be caused or increased by the derivation of a greater
quantity of  blood to the parts, or by the  pressure made upon
the vessels by the enlarged uterus.  When this complaint is in a
moderate degree,  the patient is soon relieved by gently purgative
and diuretic  medicines  ; and those  composed of sulphur are,
in this case, usually preferred ;  though some physicians have
suspected their propriety.  Cooling applications are also advised,
and of these the best  is  a weak solution of the cerussa acetata
frequently  renewed.   Should  the  patient  be feverish,  or  the
hemorrhoids much tumefied  and painful, bleeding, in quantities
suited to the constitution, and the exigence  of the case, is neces-
sary ;  or one or more leeches may be applied to those which are
most prominent, if they do not discharge spontaneously.   Emol-
lient  fomentations and  cataplasms are sometimes proper.  In
general, unctuous applications do  not agree; but ointment  of
elder flowers, mixed with an equal quantity of brown sugar, or
a small quantity  of some lixivial salt, is thought, in some cases,
to have  done much service.   When  the hemorrhoids  are very
numerous, and tumefied  even to strangulation, immediate relief
may be obtained by firm and gentle pressure, between the finger
and thumb, of each distinct hemorrhoid, till they are  all com-
pressed,  and  reducible  within the  anus, scarce any tumour re-
maining  but  the external  covering, like  the empty husks  of.
grapes.*
  * [In this very troublesome affection, costiveness is particularly to
be guarded against;  and the saline cathartics, and repeated  blood-
letting in moderate quantities, will be found especially serviceable.
After the inflammation  and pain are subdued, and  the bulk  of the
hemorrhoidal vessels diminished, cold washes and astringent  appli-
cations maybe used.  Of these, the gall ointment is among the best.
All stimulating drinks and food should be carefully avoided,  where
there is a disposition to  this disease.  F.] 
SIGNS AND DISEASES OF PREGNANCY.       241
                        SECTION XII.
  The skin of women with child is often discoloured in spots or
blotches, especially about the neck and face, which, though dis-
agreeable to those who are solicitous about such matters, is not
otherwise important.   Women have sometimes, also, a true jaun-
dice, and, whether we attempt to remove the obstruction to the
due secretion of the bile, by emetics, purgatives, or deobstruents,
as they are called, there  appears to be no reason  why pregnant
women should not bear their operation, when they are necessary.
Men of discretion will readily see the  impropriety of giving a
medicine, the operation of which might be more dangerous than
the disease  which it is intended  to  cure; and the  necessity  of
accomodating its  quantity to the state of the patient, as well as
its quality to the disease.
SECTION XIII.
  Women  with child are chiefly subject to those complaints of
the  intestines,  which  may be  supposed  to  arise  from  their
inert action; but they are sometimes liable to  those, which are
occasioned by too much  irritability.  Yet the  latter are far less
frequent  than the former, though a tenesmus, a diarrhoea,  or
dysenteric  complaints, may happen at any period of utero-ges-
tation.                                           .
  When  these affections of the bowels  are of sufficient  conse-
quence to  require medical attendance,  the  common mode  of
treatment is equally efficacious and consistent with the safety of a
pregnant woman, as under any other circumstances.  When  there
is a feverish disposition, bleeding  is proper; and  when there are
signs of  disturbance in the stomach, from offensive  humours, or
preceding  crapulous complaints,  gentle emetics may be given,
and  the  repetitions, if necessary, may be unlimited.  If  there
be  much pain in the bowels,  or  frequent efforts to go to stool,
with  little or insufficient evacuations,  purgative medicines,  of
which perhaps the best is the magnesia vitriolata, (See  Cleg-
horn's Treatise on the  Diseases of the  Island of Minorca,)
alone or  joined with rhubarb, ought to be given, and occasion-
ally  repeated, according to the  continuance  and  pain, in any
stage of the disease.  Should the complaint  remain after the
evacuations, opiates are  proper,  mixed with some  mild  astrin-
gent medicines, as the mistura cretacea with tinctura cinnamomi.
In some cases, ipecacuanha in small doses, not exceeding a grain,
or even half a grain, mixed with some asorbent powder or  two or
three grains of rhubarb,  and given every six hours, answers the
purpose  of quieting the disturbance of  the bowels,  without pro-
curing any evacuation.  The free and frequent use of opiates is,
in many  of these cases, indispensable.   Clysters, composed of a
       J                      31 
242          INTRODUCTION TO MIDWIFERY.
decoction of linseed,  or of flower and  water boiled to the con-
sistence of thin starch, or of mutton broth, are both comfortable
and useful;  and  to  any  of these thirty or  forty drops of the
tinctura  opii  may be occasionally added.   The introduction of
two or three grains of the opium  purificatum,  in the form of a
pill, into the rectum, affords great relief in all cases of painful
disturbance of the uterus,  rectum, or bladder, especially during
pregnancy.
  Tenesmus,  and  also diarrhoea, are common  attendants on a-
bortions, of which they are justly  esteemed  to be sometimes the
cause.  In these cases it appears, that the existence of the irrita-
tion iu the rectum is unfavourable to the proper action of the ute-
rus, and may directly, or by consent, become the cause of abor-
tion.  Emetics, by relieving the present inconvenience, and by
changing the seat of the irritation, will often prevent any ill con-
sequences, but the greatest reliance in such cases is to be placed
on opium, in any of the usual forms, especially in clysters.*

                        SECTION XIV.
  The strangury, which  is  a  frequent inclination to void the
urine, and a painful discharge of it in small quantities, is not an
unusual complaint  in pregnancy, in the early periods of which
it seems to be occasioned by the  consent between the uterus and
bladder; but, toward the  conclusion, by the mere  pressure  of
the enlarged uterus.  It is frequently caused, also,  by  the res-
traint which women sometimes dangerously impose  upon them-
selves, from motives of delicacy, when they are engaged  in com-
pany.  Under any of these circumstances, it always produces
much inconvenience,  and  may terminate in a  suppression  of
urine, which, when the uterus is of a certain  size, that is,  about
the third month of pregnancy, becomes  the cause of its retrover-
sion.
  For the relief of the strangury, it is in some cases necessary to
bleed, and  in  all  to procure  stools  by  clysters, or very gen-
tle aperient medicines.  A small quantity of oil of almonds, with
manna, in the common emulsion, and the addition of a few grains
of nitre,  is a commodious  and  often an effectual remedy.   The
common  emulsion, with  the spiritus aetheris  nitrosi,  or  barley-
water with gum arabic, may be drunk at pleasure; opiates  are also
  * [Our author seems, on some occasions, too partial to the use of
emetics, during pregnancy.  It deserves to be recollected, that a re-
laxed state of the bowels is often among the most serious of the in-
conveniences of the pregnant state ;  and that,  except in cases of ac-
cident, miscarriage rarely occurs, but with a loose and irritable con-
dition of the intestinal canal.  F.j 
          SIGNS AND DISEASES OF PREGNANCY.       243

frequently necessary.   In a retention of urine the catheter must
be introduced ;  and of the retroversion of the uterus we have al-
ready spoken very fully.
  At  the  latter part  of uterogestation, it is not uncommon for
women to have an incontinence of urine, not  perpetually, but oc-
casionally, when they  stand upright, or make any sudden though
slight motion, especially if they have a troublesome cough.   As
far as either the  strangury or incontinence of urine depends upon
the pressure of the enlarged uterus, it will only be  in our power
to alieviate them, for the cause must remain till the time of deli-
very; and the peculiarity of the complaints may be owing to the
compression being casually made upon the neck or fundus of the
bladder.   It is some comfort to women to  be informed, and I be-
lieve the observation is almost universally true, that affections of
this kind are never produced, except in those cases in which the
presentation of the child is natural.

                        SECTION xv.
   The  fluor albus was before mentioned, as a  complaint to
which women were at all times liable ; but in pregnancy the dis-
charge is sometimes exceedingly profuse,  and has very much the
appearance, as if it was caused by, or accompanied with, inflam-
mation.*  It may then  be  occasioned by   some  extraordinary
fulness  of the  parts  adjoining to the uterus, or  by more  than
usual irritation.   It does not appear that any bad consequences,
either to the  mother or child, follow this complaint, or  that it
requires any particular treatment.   Perhaps, by the  relaxation
of those parts, which  are to be dilated at  the time of parturition,
they may  then  make  less resistance;  at least  it  is commonly
observed, that  women who suffer  much   from  this  symptom
during  pregnancy have easy labours.  It  is also  proper to ob-
serve, that, in women who with a profuse discharge of this kind
are subject to  miscarriages, an injection  of the zincum vitriola-
tum two or  three times a day, into the vagina, has great power
in preventing them.*

                        SECTION XVI.
   No complaint happens more frequently  to pregnant women,
than  pain in the hips, with numbness of  the inferior extremities.
This  seems to be occasioned  by the untoward pressure made by
the enlarged uterus upon the ischiatic nerves, and those which
pass through the perforations on the anterior part of the sacrum-
As it is found to be increased in certain positions of the body,
  * [Moderate venesection will often prove serviceable when this
discharge arises from these circumstances.   F.] 
244
INTRODUCTION TO MIDWIFERY.
especially when  the patient is  accustomed to sleep on one side,
a change of the position generally affords temporary relief.   At
all events, it is not in itself of sufficient importance to require any
medical assistance,  and is entirely removed soon after delivery ;
the application of a mixture of the white of egg and laudanum
is a very common remedy in these cases.
  Erratic pains  in various parts,  especially about the face, ears,
and  teeth, so often occur in  pregnancy, as to be thought certain
indications of that  state.   They  are evidently occasioned  by
uterine irritation; and although they will sometimes be eased by
aether, by solutions of opium,  or other  such local applications,
or by blisters applied behind the ears, yet these commonly afford
only temporary relief, and, in some instances, they aggravate the
pain.  The same observation may be  made of the cramp, what-
ever part of the  body it  may affect.  This is a very pertinacious
symptom, and often exceedingly troublesome,  especially in the
nighf; but being void of danger, has too little attention paid to it.
In either of these cases, real benefit  is to be obtained  only by
bleeding, and the use of such means as  abate irritation in gene-
ral, or that of the uterus in particular,  such as  small  doses of
tinct. opii, of the syrup,  papaver.  alb., the inspissated juice of
cicuta, and other medicines of that class.  However, in cases of
violent and repeated cramps,  it  is not  unusual to meet  with
unfavourable separations of the placenta  after  the birth of the
child.

                       SECTION  XVII.
  The veins of the legs,  thighs,  and  abdomen,  frequently
become varicose in  the later   part of  pregnancy,  to  such  a
degree,  in  some instances,  as to exhibit  a strangely tortuous,
and  a very alarming   appearance.   Varices,  which  are  both
elongations and enlargements  of the  Veins, may be reasonably
supposed to proceed from  the  pressure of the uterus preventing
the reflux of the blood  by  the veins; and, perhaps, they may
often be esteemed as consequences of the  general fulness of the
habit.  They  are usually accompanied with the cramp; but which
of these is the cause or effect has  been much disputed.   No det-
riment has been observed to follow this very painful and  trouble-
some  complaint; but if any thing is required to  be done,  it
should be with  the intention of emptying the vascular system,
as moderate  bleeding, gentle  purging,  and  a  spare diet.   In
some cases it may be judged necessary to give  support, by mo-
derately tight bandage,  to the veins of any part which are par-
ticularly  distended; or  sometimes to tie  the vein above and
below the tortuous part, but the time of pregnancy is not to be
chosen for this operation. 
SIGNS AND DISEASES OF PREGNANCY.       245
                       SECTION XVIII.
   Inquietude and want of sleep are very troublesome complaints
 toward the conclusion of pregnancy.  They are also frequently
 attended with slight pains in the region of the uterus, hardly to
 be distinguished from  the  pains of labour, and other feverish
 symptoms.  These are most grievous in the night, the patient be-
 ing restless, in spite of a strong disposition to sleep, and obliged
 to rise frequently, and expose herself to the influence of  the cool
 air; yet 1 know not for what reason,  after a short repose  at the
 dawn of day, she appears  as much refreshed, as after the most
 quiet night.
   Perhaps the confinement of the air of the room, and  the heat
 of the bed, may be the immediate causes of these complaints; but
 I  have generally considered them as  arising from  the  constant
 and  strenuous demands for nourishment, made by the child upon
 the  constitution of the parent; for it   is  remarkable,  that those
 women who suffer most  on this account, though reduced  in ap-
 pearance, bring forth lusty children, and have easy labours. But
 if the mother has  little uneasiness, and  grows corpulent during
 pregnancy, the child is generally small;  and, if the  child should
 die before the time of parturition, the inquietude entirely ceases.
 In the first case,  the absorbing powers  of the  child seem too
 strong for the parent; but in the latter, the retaining powers of
 the parent are stronger than the absorbing ones  of the child,  so
 that, on the whole, it appears natural that women  should become
 thinner when they are pregnant.*
   Nothing affords more effectual relief to  patients troubled with
 this inquietude, than bleeding in small quantities, with the occa-
 sional use of cooling  and laxative medicines. Hoffman's anodyne
 liquor, to the quantity of thirty or forty drops, given in some com-
 mon emulsion,  or  in cold  water,  every  night at bed-time, has
 been found useful.   Preparations of opium have little effect, un-
less they are given in large  quantities, and often repeated ; but a
 persuasion that these are ultimately injurious to  the foetus, or to
 the parent, has  long deterred me from using them on these occa-
 sions.   A glass  of cold water drunk  at  bed-time, is not a con-
 temptible  remedy;  or a  towel dipped in cold water, and  wrap-
ped  round the hand, with one corner  hanging over the edge of
the bed, has many times been serviceable  in procuring sleep, by
lessening the general heat of the body  as a conductor.
   There is another cause of much  uneasiness during pregnancy,
which sometimes occurs in very irritable habits; that is, the pain-
  * [Our author's reasoning in this paragraph  is sufficiently hypo-
thetical.   F.j 
246          INTRODUCTION TO MIDWIFERY.
ful  and almost constant motion of the child.  For the relief of
this it is usual to rub gently over the whole abdomen some unc-
tuous  or sedative application, and to give  occasionally  a few
drops of spiritus aetheris vitriolici composit. or of tine, opii, in
any suitable vehicle.

                        SECTION XIX.
  Very few women, even those who are  on other occasions pa-
tient and resolute, pass through the time ofuterogestation, without
using expressions, which  indicate  some degree of apprehension
for their safety.   This solicitude or discomfort may proceed from
the  mere dread of what they expect to  suffer at the time of la-
bour,  or from reports inadvertently made of untoward accidents,
which  have happened to some of  their  friends or acquaintance,
who were in the same predicament with  themselves.   In some
cases  there seem to be strange impressions  made in the  mind,
from some affection of the  body,  not then obvious, but showing
itself at the time of labour, or after delivery.
  It is sufficient, in the first instance, to contrive  amusements for
them, or to  inspire them with confidence, by  pointing out  the
fortunate event of the generality of these  cases,  and to impress
them  with favourable  sentiments of the skill or good fortune of
the  person who is appointed to attend them.  This apprehension
of danger may  arise from another source,  and  be caused by un-
easy sensations, which they  feel, but cannot well describe.   Then
it is really a symptom of disease, and may be ranked with the
terror which attends the commencement of some dangerous dis-
eases, of which  it is one of  the worst indications.  Instead of con-
sidering it as an hysteric affection not worthy of regard, we shall
find,  on inquiry, that the patient  has some degree of fever; as
increased heat, a white tongue and a quick pulse, and frequently
a fixed pain in some  part  of the abdomen ; or  peripneumonic
symptoms ;  or some marks  of local or general disturbance in the
habit, though not in a degree sufficient to  denote any particular
disease.   By bleeding in small quantities, by cooling  or  appro-
priate medicines, by repose and a well-regulated  diet,  both  the
sensation and the apprehension may be removed before the time
of delivery, and a  happy  recovery from childbed insured.  If,
.however, the complaint be  not properly  considered, but slighted
or ridiculed merely as lowness of spirits, the event may prove un-
favourable ; and on the  recollection of the circumstances, there
may  be room to lament that it was misconstrued  or disregarded.

                        SECTION xx.
  The  functions of the brain are often  disturbed in the time of
pregnancy,  by which  headache, drowsiness, and vertiginous com-
plaints  are occasioned; and sometimes pregnant women  have  a 
SIGNS AND DISEASES OF PREGNANCY.
247
true hemiplegia,  as well as  many  other  nervous symptoms.
These have usually been ascribed to a fulness of blood in the ves-
sels of the brain, caused by an obstruction to its descent into the
inferior  extremities, by the compression  of  the enlarged uterus.
But these do not more commonly happen to those women, who
are of full habits of body, than to those who are of different con-
stitutions ; and if  that was the cause, the effect  must be pretty
generally produced, when women have arrived at a certain time
of pregnancy.  The palsy is always preceded by such symptoms
as indicate an uncommon degree of uterine irritation,  on which
it is reasonable to consider it  may depend ; more  especially as,
though  relieved, it is never cured during pregnancy, and scarcely
ever fails  to leave the patient perfectly free, within a few months
after delivery, as has been proved in a variety of cases.
   The blood of those women  who become  paralytic whilst they
are pregnant, is always found to have the same appearance as in
the most inflammatory diseases; and the other  symptoms indi-
cate the like disposition.  It  is  not,  therefore, surprising, that
heating and  stimulating medicines are observed to increase the
complaint; or that it should be relieved  by  bleeding,  by gentle
purging,  by  a cooling regimen, and by such means as  abate
uterine  irritation ; not regarding the palsy  as an idiopathic dis-
ease, but as a symptom occasioned by pregnancy.

                        SECTION XXI.
   It was before observed, that  anasarcous  swellings of the infe-
rior extremities often occurred in pregnancy,  and  that those
sometimes extended to the groins and sides of the abdomen, and
in some cases, to the external  parts of generation, which become
extremely painful, and tumefied to such a degree, that the patient
is unable to  walk or sit without much inconvenience; and that
it has been necessary to scarify them.  They appear to be occa-
sioned, in some instances, by too much, and in others  by too
little, exercise; but more frequently by the  pressure made  by the
uterus upon those lymphatic vessels,  which are intended to drain
the fluids from the inferior extremities.  They have sometimes
been unjustly supposed to indicate such a general  hydropic ten-
dency as might deter us from bleeding the patient, even  in cir-
cumstances which  would otherwise demand it;  but when there
is  a  general leucophlegmatic appearance, it  certainly  requires
attention.
   But  in many of those abdominal  complaints, which occur in
pregnancy, it has been observed, that the patient was sensible of
much relief when the legs began to swell:  so that, in some cases,
this swelling may be esteemed as a  critical deposition upon  the
 inferior extremities  of something superfluous or injurious to  the 
248
INTRODUCTION TO MIDWIFERY.
 constitution.   Of the particular treatment which this complaint
 may require we have before spoken.

                         SECTION XXII.
   There have been a  few  instances of women  with child  who
 have had a true ascites; and those who  have an ascites some-
 times become pregnant.  Some  cases are recorded,  and many
 reported, in  which the  mode  of treatment  enjoined  has been
 founded on an erroneous opinion of these two situations ; that is,
 of a dropsy being mistaken for pregnancy, and pregnancy for a
 dropsy.   The former is not productive of  mischief in any other
 way, than by  delaying the use of such means as might be consi-
 dered likely to cure the disease,  if administered in its  early state.
 But the consequences of the second error have been  deplorable.
 For, if  any active  remedies  are  used  on  the presumption  of a
 dropsy,  the child will, of necessity, be often  destroyed, and an
 abortion or premature labour  occasioned ; and when  the opera-
 tion of the paracentesis has been performed, it hath been known to
 prove fatal to the mother and child, always reflecting great dis-
 credit  both upon the  operator  and profession.  It, therefore,
 seems necessary, to establish this general  rule,  that no woman, at
 a time of life,  or under circumstances which, in the most  distant
 manner,  subject her to a suspicion of pregnancy, should ever be
 tapped, or otherwise treated  for  a dropsy,  till, by examination,
 per vaginam,  or by waiting a due time, we are convinced that
 she is not pregnant; even though she may have before  under-
 gone the operation.
  It has  been  said, but whether upon sufficient authority I know
 not, that a dropsy has  sometimes been cured  by pregnancy or
 parturition ; and certainly the quantity of limpid fluid dischar-
 ged after  delivery, is in some cases not to be explained by any
 idea of its being contained in,  or secreted by, the  uterus.*

                        SECTION XXIII.
  The manner in which the abdomen is distended, with the usual
degree of its distention at different periods of pregnancy,  has  al-
  * [The fluctuation which  characterizes ascites, will enable the
practitioner to distinguish that form of dropsy from pregnancy, ex-
cept only,  perhaps,  when the water is  encisted.   We must also
have in recollection the stage ofuterogestation.  Yet m;iny lament-
able cases are recorded of ascites combined with pregnancy, and in
which  paracentesis was unsuccessfully performed.  The few in-
stances in which a  happy result  has  attended the  operation when
both states co-existed, ought not to justify such practice.
  In the  American  Medical and Philosophical Register, vol. 2. Dr.
William Moore has given an interesting case of dropsy, suddenly
cured after parturition.   F.j 
          SIGNS AND DISEASES OF PREGNANCY.       249

ready been  described.   This generally  appears  to be uniform,
though often on  one side more than  the other;  and  sometimes
there are partial  distentions, which  are popularly attributed to
the  head, elbow,  or some  other  limb  of the child, originally
placed, or accidentally moved, out of the common situation.  It
appears, that this  opinion cannot possibly be true, unless we pre-
sume, that there is at the same  time a partial distention of the
uterus, which could  scarcely  happen without some   important
and dangerous consequences.   As this case  most  frequently hap-
pens when the abdomen is enormously distended, and as it has
all the appearance of a  ventral hernia, it  is more probable, that it
is occasioned by the  starting of some of the abdominal muscles,
or the partial yielding  of the integuments,  or by an occasional
spasm of the uterus inclosing the placenta.  But  the explanation
of the case is of less importance,  as  it neither requires nor ad-
mits of any  assistance, either before  or at the  time of labour,
and disappears  before,  or almost immediately after, delivery.
   From the great distention of the abdomen, especially in cor-
pulent women, an umbilical hernia is very frequently occasioned,
which, depending wholly upon the degree of distention, does not
admit of any relief before  the patient  is   delivered;  when the
elastic  truss, suited to  the size  and form of the  hernia, seems a
more easy and effectual remedy,  than  any  instrument of the
kind which  has hitherto  been recommended; though  some pre-
fer a piece of ivory, formed  like a section  of a globe, and fixed
upon the part by adhesive plaister or any of the  usual  bandages.
Cases of this kind deserve  more attention than  is usually  given
them.  This seems to  be the only kind  of hernia produced by,
or which remains during pregnancy ; for  unless the other kinds
adhere to the sac in  which they are contained,  temporary relief
is afforded  by that ascent and  support  of the intestines, which
necessarily follows the  rise  and enlargement of the uterus.

                        SECTION XXIV.
   In some cases, the whole abdomen is distended beyond what it is
able to  bear without inconvenience; the skin becomes inflamed,
and sometimes  cracks,  so  that  there  is  a  little oozing from
various parts.  The true skin also cracks when the  outside is
not  altered, by which there remains upon the integuments of the
abdomen of women, who have had children,  a number of small
cicatrices, as if the parts had been scarified,  or there had been
slight  longitudinal ulcerations.   The same effect is  also  occa-
sioned by extreme corpulence.
   For the  ease both of the distention and consequent soreness,
some unctuous applications should be rubbed over the abdomen,
every night at bed-time.  The ointment commonly recommended
32 
260
INTRODUCTION TO MIDWIFERY.
for this purpose is composed of rendered veal fat beaten up with
a small quantity of rose water.
  Bv the extreme distention of the muscles  of the  abdomen,
these  are often the seat of pain during pregnancy, especially at
their  insertions:  and it requires some  attention to  distinguish
this from the pain which may arise from  affections of the sym-
ph) sis of the ossa pubis.   When the weight of the abdomen in
pregnant women is  very great, and  weakly supported by the
integuments, it becomes pendulous, and occasions to the patient
much pain  and difficulty in walking, and many other inconveni-
ences at the time of labour.   It will then  be of service,  by a
napkin or broad  bandage, suited to the purpose,  passed round
the lower part and middle of the abdomen, to support it with a
moderate degree  of firmness, and  then  by a  scapulary to
sling  the depending weight over  the shoulders,-by which the
 fiatient will be enabled to move and walk  about with infinitely
 ess trouble, and any inconvenience thence  arising will  be less-
ened or removed.  Immediately after  the  birth of the child, the
application of a broad  band drawn tight over the abdomen is
very beneficial.

                        SECTION xxv.
   Instances sometimes occur of pregnant women being affected
with the venereal disease:  and  we have generally been  advised
to follow a mode of  treatment, by which the disease was not  in-
tended to be perfectly cured, but moderated and restrained from
further progress;  leaving  the  absolute cure to be completed,
when the patient was recovered from the state of child-bed.  This
method of proceeding has been recommended on the presump-
tion that dangerous  consequences would  result either to  the mo-
ther or child, if a quantity  of quicksilver was used, during  preg-
nancy, sufficient to root out the disease effectually from the con-
stitution.  If the patient has a gonorrhoea,  there is clearly no-
thing in the medicines prescribed, or in the treatment, which can
prove hurtful to either at the time of utero-gestation. But if there
should be a confirmed lues, as  frictions with unguentum  hydrar-
gyri properly instituted  and pursued, which, as it was one of the
first, is  yet acknowledged tp be the most efficacious remedy; or
if equal  or greater confidence is placed in  them than in any pre-
paration of quicksilver internally given ; it is reasonable to think,
and the  opinion is confirmed by experience,  that women might,
at any time of pregnancy,  go through a due course of them with
perfect  safety.   It is scarcely  necessary  to observe,  that medi-
cines composed of quicksilver, whether internally given, or exter-
nally applied, are  not at this time used with a view to  promote a
salivation,  or any other profuse  evacuation,  but with  the  in-
 tention of filling the  habit with that medicine, and retaining it as 
SIGNS AND DISEASES OF PREGNANCY.       251
long as it  is thought necessary  for the extinction of the disease.
The utility and propriety of this practice is  allowed by those,
who differ  widely in their explanations of the mode  in which
quicksilver is supposed  to operate.  I may be permitted to ob-
serve, that the principal causes of the failure of this medicine to
answer our purpose of  perfectly curing the lues,  are either the
hurry with which it is at first used, the negligence and misrepre-
sentation of patients, or a conclusion often, though erroneously
made, that the disappearance of the symptoms is a proof of a per-
fect cure of the disease; whereas  it  frequently happens,  that,  if
the frictions are not continued many  days, or even several weeks,
or, in some cases, perhaps, months,  after all the  symptoms are
gone, there will,  in a short time, be new appearances, which prove
the return or existence of the disease.
  It has been supposed, that a  child born of an infected parent
could not, at the time of birth, be exempt from infection, and that
the virus would  be  so intermixed with its frame, that there would
scarcely be a possibility of exterminating it.   This is at least a
very dubious point; because it  has happened  to every  person
engaged in practice in a city or large town, to attend patients of
this  description, who have, nevertheless,  brought forth children
which were perfectly healthy.   I do not recollect one  decisive
instance of a child born with any symptoms of the venereal  dis-
ease upon  it; and  the contrary, I am persuaded,  is often  sus-
pected from  a knowledge  of circumstances, which give rise to
the suspicion, exclusive  of the symptoms; though it must be al-
lowed, that a child  has a chance of receiving  the infection in
the act of parturition, by absorbing  the virus in its passage over
ulcerated surfaces.   But, with regard to the first opinion, it may
perhaps be justifiable to reason  in this manner.   If the infection
is received, it must  be at the time of conception, or afterwards.
If the  prolific particles, whether  in the male or  female,  were
mixed  with the venereal virus, the prolific properties would, pro-
bably, by  such  mixture, be destroyed; but  if conception were
previous to the infection, there  seems  to be no way in which the
latter could be  communicated to the child  already conceived,
all immediate intercourse being secluded by the perfect closure of
the os uteri.                          ./.,.,,
   Children brought forth by parents  infected  with the venereal
disease, will often be born dead; but  this event may commonly
be imputed with more  propriety to the severity  of the means
used for the  extirpation of the disease, than to the disease itself;
and the rank  eruptions about  the  podex,  to  which children in
very early life are  liable,  certainly  canuot be justly attributed to 
252
INTRODUCTION TO MIDWIFERY.
venereal affection, the infection  first  showing  its power on the
part which received it.*

                        SECTION XXVI.
  When pregnant women have  the small pox, there is much dif-
ference in the opinions  entertained of the possibility of the child
being infected.   Some  have contended  that,  if the mother  has
this  disease, the  child could not escape;  whilst others are per-
suaded, that the  child could not, according to the  laws  of the
animal economy,  receive this disease.  Cases are recorded  by
various writers, in confirmation  of both the opinions; and  many
  *  [It is remarkable that Dr.  Denman  never saw a decided in-
stance  of a child born with the venereal disease.   The communi-
cation  of the  syphilitic virus to the foetus in utero, is one of those
facts which rests upon the best evidence, and which the observation
of the latest and most accurate physicians puts beyond denial.  The
diseased mother  may affect the foetus  while  in utero, and the child
be born with the venereal disorder;  the  diseased infant may, by
sucking, infect the nurse ; the infected nurse may, in turn, commu-
nicate  the complaint to the infant suckling at her breast.   All this
has occurred, where the  organs of generation, both of the male and
female were  unaffected.   The disease may also be contracted du-
ring the act of parturition.  Several instances have occurred among
the patients of Mr. Hey, of Leeds, where  the mother, having been
once affected with the venereal disease, has communicated it to two,
three, or even four  children in succession ; each of them ha nig the
disease in  a milder form  than the preceding  one , and this  '-vithout
any ground of suspicion that the mother  had received fresh infec-
tion.   I have had under my care three cages of the venerea! dis-
ease communicated  to the foetus in  utero ; two of these cases occur-
red where the genital system appeared in a perfectly sound state :
in the other,  there  were ulcers of the labia,  and constitutional dis-
ease.
  The  treatment of cases of this nature will, I believe, be best con-
ducted by the internal use of the corrosive sublimate, either in so-
lution or in pills. The eighth of a grain  in  the last form,  two or
three times a day, may be given  with safety, both to the mother and
foetus.   To the  newly born infant,  we  may  most conveniently give
the solution.   In one of the instances to which I have alluded, 1 be-
gan  with five drops three times a day, and gradually increased the
number to fifteen each time.  This, though the most formidable case,
j ielded entirely  to the remedy.
   A valuable  paper on the effects of the venereal disease  on  the
foetus in utero, by the late Mr. Hey, may be found in the seventh vo-
lume of the Medico-Chirurgical Transactions.   See also Dr. Dyck-
man's  elaborate Dissertation on the Pathology of the Human Fluids. 
SIGNS AND DISEASES OF PREGNANCY.       253
instances have been communicated to me by men of integrity and
attention, with the view of deciding this point; but the cases are
contradictory to each other,  and therefore prevent  any  present
decision upon the subject.  When by the multiplication of well-
attested facts, our knowledge is extended and corrected, should it
be proved, that the variolous infection is  generally received by
the foetus in utero, if the parent has the disease when  she  is
pregnant, we may then consider whether the knowledge of the
fact can be turned to any practical advantage.  (Mauriceau says,
that he himself was born with the small-pox  upon  him,  but the
weight of this assertion  must depend on the opinion of others.)
By the discovery  of vaccination, the decision of this case be-
comes of little consequence.
   It is an opinion almost universally received, that, if a woman
with child should have the small-pox, and miscarry; or,  if at the
full time, her labour should  come on during the continuance of
the disease, it would necessarily prove fatal to the mother.   The
event has too often proved the truth of this  observation;  yet it
will probably stand upon more jnst ground, if it be stated in this
manner.   Should  the attack  of the disease  be violent, and  the
eruptive  fever run very high, patients may, and have often esca-
ped  the  danger,  at any period  of  utero-gestation, though  the
child were then expelled.  But if a woman passes the time of the
eruptive  fever, and  labour, or a tendency  to miscarry, should
come on toward the crisis of the disease, as  far as my observa-
tion enables me to speak, she will then certainly die.  She dies,
in truth, not because she  miscarries or brings forth  a child, but
she miscarries or  falls into labour  because she is already in  a
dying or very dangerous state, and by  those circumstances the
danger is infinitely increased.
   When other diseases occur in pregnancy,  the treatment to be
directed  must be such as the particular disease may require, ma-
king due allowances for that state, by not prescribing  any violent
means, unless  the immediate safety of the  patient  may render
them absolutely necessary.   Every morbid alteration of import-
ance which happens during pregnancy, supersedes, if we may be
allowed the expression, all the changes which depend upon that
state; and whoever aims to establish the character of a  success-
ful practitioner in midwifery, must pay attention to the health of
his patients when they are pregnant.  If there be no disease, or
disposition to it, the process  of a labour is generally uniform and
safe.  If any disposition to  disease should exist at that time, the
labour may be rendered irregular and dangerous, or the  imme-
diate cause of some disease peculiar  to  the child-bearing state,
not by  giving, but by diverting such disposition to  some part
rendered by parturition more susceptible of its influence. 
254          INTRODUCTION TO MIDWIFERY.
                     CHAPTER VIII.


                         SECTION I.

                   ON OTERO-GESTATION.

  It was formerly asserted and believed,  that the proper situa-
tion of the child in the uterus, in the early  months of pregnancy,
was sedentary; with the breech resting at the superior aperture
of the pelvis, and the fore-parts of the child turned exactly to the
abdomen of the mother.  At or towards the  time of parturition,
it was thought that the child,  partly by  the  increased weight of
the  head, but chiefly by its own instinct and powers, made a re-
volution, and turned with its head downwards, in such a manner
that the vertex was placed to the pubes, and the face  to the sa-
crum.   In  this position it was supposed to  pass  through the
pelvis.  This change was called presenting to the birth, of which
it was judged to be the  signal; and,  from the terms used in dif-
ferent languages  to express the change,  the  opinion seems to
have been  universal.   By the examination of women who have
died at different periods of utero-gestation, or in the act of child-
birth, it is now ascertained,  that such as is the situation of the
child in the early part of pregnancy, such it will be at the time of
labour,  unless, which  can very  rarely happen,  the position be
altered  by  some  accidental violence.  Perhaps this  opinion of
the ancients was not founded on observation, but on  the presump-
tion that fatal consequences would result from  the continuance
of  the  foetus with its head downwards for nine months.  They
did not know, that there was a circulation of the blood;  and of
course were ignorant  that an order of vessels existed in the body,
especially calculated, by preserving a particular communication
between different parts,  to prevent any injury to the foetus, either
from its confinement or  situation.
  The  natural position  of the fcetus in the  uterus  is such  as to oc-
cupy the least possible space,  so that  the  least possible  inconve-
nience  is occasioned to  the parent, yet with the utmost ease to its
own body and limbs.   (Quasi in  seipsum totus conglobatus.—
Fabric, ab Aquapend.)  In the positions which are esteemed na-
 tural there is an endless variety,  but  they are most  commonly
 after this  manner.*   The knees  are  drawn up  to the belly, the
* Adductis ad abdomen genibus, flexis retrorsum cruribus, pedibus 
ON UTERO-GESTATION.
255
legs are reflected backwards, the  feet crossed, and lying close to
the breech; the elbows  are in contact with its  sides, and the
hands turned up to its head, one of which is often  placed upon
the cheek or ear.  The spine is incurvated,  and the  neck being
bowed, the chin rests upon its knees.   There is that  inflexion of
the body into which we spontaneously fall, when we seek repose ;
and as  it is our position before we are  born,  it is  that also  to
which we have  an inclination in the decrepitude of old age.
  The situation of a  child, presenting naturally at the time  of
birth, is with the head downwards,  resting  upon the ossa pubis,
with one side of the head towards the abdomen of  the mother,
and the other toward  the sacrum, or in a small degree diagonally.
The bulk of the body of the child is not placed against the spine,
but on one side, most commonly  on the right,  and the  limbs
turned toward  the left, so  that the abdomen of a woman with
child  is,  in  general,  evidently  distended  more on  one side
than  the other.  When this  circumstance, though  a  necessary
consequence of the proper situation  of the child, is observed, a
suspicion, wholly  groundless, is often entertained, that its pre-
sentation at  the lime of birth will be unnatural.   A small de-
gree of permanent enlargement may  afterwards be perceived on
that side on which the child has rested, in which also, for some
time after  delivery, the mother  is subject  to  pains resembling
 those which are considered as rheumatic.

                          SECTION II.
   The term of utero-gestation is different  in every class of ani-
mals, and the diversity has been  attributed to  the nature and
properties  of the parents  or the offspring.   Those  who were of
 opinion that it depended upon the parent, sought for the reason
 in  the structure or constitution of the uterus, the heat or coldness,
 dryness or moisture of which, according to the doctrines of the
 old philosophy, were supposed to be the causes of the varieties :
 yet, if  the term depended  upon  these, it  would then remain to be
 proved, how it happened that one form or constitution was capa-
 ble of bearing distension  longer  than  the other.   Those, who
 imputed the time  of the event to  the offspring, assigned to them
 the same properties.  It seems to  have been  generally believed,
 that, by the long  or short continuance of the fcetus in  the uterus,
 the future size, duration, and qualities, of different animals were
decussatis, manibusque sursum ad caput sublatis, quarum alteram,
circa tempora vel auriculas, alteram ad genam detinet; spina in or-
bemflectitur, caput ad genua incurvato collo propendet ; tali mem-
brorum situ, qualem in somno per quietem quajrimus.—Harv. Exer-
citat. de Partu. 
25b'
INTRODUCTION TO MIDWIFERY.
influenced;  and that  these were most perfect and  permanent in
those animals which  had the longest period of utero-gestation.
It was also thought, and perhaps with truth, that the longer the
time of utero-gestation, the longer the animals were before they
came to full  growth ; and that on this depended their continuance
in the  mature state, without any natural tendency  to decay, one
period  of existence  regulating  another.   (See Lord  Bacon's
Histor. Natural.)  In  oviparous animals, the time of incubation
necessary for the production of their young is not altered by the
qualities of the bird by which it is incubated, but follows its genu-
ine nature;  as in a hen's egg incubated by a duck.   This favours
the opinion  that the  term is guided by the offspring, but it is by
no means decisive: but the circumstances relating to the birth of
oviparous and viviparous animals,  though they  may illustrate
each other, cannot,  with any intelligence, be compared,  before
the egg is expelled.
   If the time of utero-gestation be not interrupted by accidental
causes, it proceeds in all  animals  with great,  though not with
exact  regularity, as  is  proved by those who  are employed  in
breeding cattle, by whom a correct account is usually preserved.
But in the human species there was  supposed to be a considera-
ble  latitude in this  respect, and examples  have been  recorded
with great confidence, by grave writers, of children  born after a
term  much exceeding  the common, and  of others  after a term
 far  short  of  it,  which  were nevertheless  in  a perfect state.
 This opinion hath, also, been countenanced to a certain degree
 by  the laws or customs established in different countries.*
   The common time of utero-gestation in women is forty weeks,
 or ten lunar months, (See Wisd. of Solomon, Chap, vii.) and
 some  men  of ability and candour have been persuaded, that  it
 is possible  for them  to proceed as  far as ten calendar  months.
 By the laws of this country the term is not precisely limited ; so
 that if any case should  occur, in which  this matter might  be
 litigated, the decision would rather depend upon circumstances,
 or upon the confidence placed in the  testimonies of the medical
 witnesses,  than upon  any positive proof or conviction of the
 nature of the thing to be decided.
   There must, in general, be much difficulty in  determining,
 with absolute precision, the time of utero-gestation in individual
 women.  But I have met  with  several instances of those who,
 from  particular contingencies,  such  as the casual intercourse
 with their husbands, or their return to, or absence from them for
  * Spigelius Ulpianum juris consultum immerito reprehendit, quod
post decimum mensem editum  neminem ad legitimain hcereditalc*^
adtniserit.—Harv. Exercitat. de Partu. 
ON UTERO-GESTATION.
25?
a particular time, have  been able to tell exactly when they be-
came pregnant; and none of these have exceeded forty weeks.
I am therefore persuaded, that the term of utero-gestation is as
accurately limited in women as in animals.  I do  not mean that
it is completed to  a minute  or an  hour, as has been  surmised,
because the  birth  of the  child  may be delayed or accelerated
by a multiplicity of accidents.  But parturition will be accom-
plished, or the parturient disposition will take  place, before or
at the  expiration of forty weeks from  the  time of conception.
Nor does it seem reasonable that a law of nature, which is not
altered by the differences of age, by diet,  by  the extremes of
climates, by the  severities  of slavery or the indulgences of luxu-
ry, should be changed by circumstances of less  importance.
  But the examples of women who have brought forth their
children  apparently in  a perfect  state, and of a proper  size,
before the full time of pregnancy, are innumerable.  As there
is no mark in the external appearance, or internal conformation,
which enables us to determine  with precision  whether  a child
has remained  in the uterus its full time, this must continue doubt-
ful, except as far as we are able to judge by the general proba-
bility, or  by the size of the child.  So  many  accidents occur,
which may give to the uterus its disposition to expel  the child,
that its premature expulsion can never  be the  occasion of sur-
prize ; not to mention, that there is in particular  women a specific
time, as the thirty-seventh or thirty-eighth  week,  beyond which
they never pass  in  succeeding labours.
  Though it should be allowed that the natural term of pregnancy
in women is forty  weeks, there will be some difficulty in making
the  calculation.  The disappearance of the menses  is  usually
the first change, which occasions a suspicion of pregnancy ; and
might therefore be esteemed the era from which  we are to date
 its commencement. But, though women are more apt to conceive
soon after, than just before menstruation, they may become preg-
nant at  any  part of the time  between  the two  periods, when
they did, and when they were expected to menstruate.  In order
 to avoid any great error, it is  customary, therefore, to take the
 middle time, and to reckon forty-two weeks from the last act of
 menstruation, by  which  method, if we are  rightly instructed,
 we may avoid any egregious mistake.
   Women who  give suck, ajid  who do not menstruate, sometimes
 become  pregnant, and having no alteration by which they can
 make any reckoning at the time of their delivery,  all is left to
 conjecture.   But  there is  usually,  in these cases, a short and
 imperfect menstruation,  which denotes the  time when the uterus
 was in a state  fitted for conception.  Some women, also, have
 conceived, who never did menstruate regularly, or  in whom
 menstruation had  been  interrupted for many months.  We can
                              33 
258          INTRODUCTION TO MIDWIFERY.
then only judge of the time when they conceived, by such symp-
toms  and  appearances as  showed  that  they had acquired  the
disposition to  menstruate,  and  would have menstruated if they
had not conceived.  All calculations  founded  on the time of
quickening, the  size of the patient, and  the like circumstances,
amounting only to conjecture, must be very liable to mistake.
   Some inconveniences are produced by attempts to make exact
reckonings for pregnant women; for when  the time fixed  for
their delivery is past, the error  creates much solicitude and  im-
patince.  When, therefore,  it  is necessary to give an opinion on
this subject, it is better to mention some time beyond that which
we really suppose; or, on the whole, it would perhaps be better
that labour should always come on unexpectedly.*
   * Great diversity occurs, both in the decisions of judicial  tribu-
 nals and in the opinions of physiologists, in regard to the  duration
of legitimate utero-gestation.  One of the earliest  opinions we
meet with on  the subject is that of the father of medicine, who ad-
mitted that  pregnancy might continue  ten months, but not longer.
Haller wa9  willing to admit gestation in women  of  ten, eleven,
twelve, thirteen, and even fourteen months.  Smellie has recorded
the particulars of  two cases of gestation protracted  in the one to
" five or six weeks at least," and in the  other to eight weeks beyond
the usual term.  Dr.  William  Hunter has given the  following opi-
nion : The usual period of a woman's going with child is nine cal-
endar months ; but there is very commonly a  difference  of one,
two, or three weeks.  A child may be  born alive at any time  from
three months ; but we see none born  with powers  of coming to
manhood, or of being reared, before  seven  calendar months, or
near that time.  At six  months it cannot be.   I  have known, he
also says, a  woman bear a living child, in a perfectly  natural way,
fourteen  days later than nine calendar months, and believe two wo-
men to have been delivered of a child alive, in a natural way,  above
ten calendar months from the hour of conception.
  Aristotle says, unum pariendi tempus statutum omnibus est animali-
bus ; homini uni multiplex  datum est; to which Pliny and others as-
sent.  But the truth is, nature has not always limited herself to a
precise  period for the time of parturition either among  animals in
general, or in  the female  of the human species : Tessier, who for
forty years has been occupied with this investigation, ascertained
that the diversity in this respect, even  among inferior animals, is
considerable.
  The Roman law  granted ten months.   Prior to the revolution the
French courts allowed ten months.  The code Napoleon  hesitated
as to the legitimacy of a child born three hundred days after the
dissolution of the marriage.   Neither  the  English nor  American
Courts have  prescribed any particular time.  Their decision  is de
termined by  the opinion of the medical  witnesses : according to the
favourite law maxim : cuilibet in sua arte credendum est.  F.j 
ON UTERO-GESTATION.
259
                         SECTION III.
   At the expiration of forty weeks the process of labour com-
 menced!,  unless it  be hastened or retarded by some particular
 circumstance, and various opinions have been  given with a view
 of explaining its causes.  Of these  opinions,  which have been
 supposed to constitute a very important part of obstetric know-
 ledge, we should not be ignorant, as it appears that the practice
 of midwifery has really been very much influenced by  them.
   It was said by all the ancient writers, that  a child was  born
 by its own efforts, which it was incited to make by the necessity
 it felt  of  breathing cool air, for the purpose of moderating
 that heat which  was generated by its long confinement in the
 uterus; or by the  want of nourishment, the  sources  of which
 failed, or were become depraved;  or by the acrimony of the
 meconium  and humours of its own  body.   By some,  the cause
 assigned for  the exertions of the fcetus was the want of room for
 its further growth  and enlargement;  and  that by its  efforts  it
 escaped out of the uterus as out of a prison in  which it  had been
 constrained; by  others,  it was presumed that there was some
 analogy between the ripeness and falling of fruit, and the perfec-
 tion and birth of a child.  The peculiar cause was unimportant,
 but, from a general persuasion of the principle, it was presumed,
 that  ease  or difficulty with which   labours  were  completed,
 depended  upon the  strength or activity of the child.  Another
 conclusion certainly followed; when the child was feeble the
 labour must  necessarily be slow;  and in cases of unusual diffi-
 culty we might be assured, that the child was dead, or could not
 possibly be saved.   Of course, whenever the  assistance of art
 was required, there  was less occasion  to regard the child, the ex-
 istence of the difficulty proving the death or the impossibility of
 preserving the child.   If we had no  other  circumstance, by
 which the practice of the ancients would be  compared  with that
 of the moderns, this alone would decide in favour of the latter.
 Many expressions are, however, in use at the present time, which
are founded on this opinion of the ancients; and it is not clear,
that practice is not,  in some instances, yet influenced by it.
   No fact is more incontestibly proved, than that a dead child, even
 though it may have become putrid,  is commonly born after  a
labour as regular and natural in every part of the process as  a
living one; and  that children,  after  labours accomplished with
the most extreme  difficulty, will often be born not only living,
but in perfect health.  There must be then some other principle
 of birth  beside the efforts of the child, which  in fact appears to
be passive.
  It was by  later writers supposed,  that the child was expelled
by the action of the uterus, aided  by that of the diaphragm and 
260          INTRODUCTION TO MIDWIFERY.
abdominal muscles.   This doctrine,  which I believe was  first
advanced by Fabricius ab Aquapendente, (Simul expultrix uteri
facultas exemplo insurget, et excitatur.—See Cap. Ixxxvi.) is the
basis  of many modern  improvements in the  practice  of mid-.
wifery ; and it is so indisputably proved,  by the occurrences both
in natural and difficult labours, that its truth is almost universally
admitted.
  Ingenious  men were not satisfied  with the  observation of the
fact,  but they endeavoured to discover the principle of the ac-
tion of the uterus, and to assign reasons  for  its coming on at a
particular time.   It was surmised that this expulsatory action  of
the uterus depended  upon its form or structure, or its inability
to bear further distention;  or upon its heat or coldness, dryness
or moisture ; or upon the distinction of its muscular fibres, which
were said to be arranged in a peculiar direction; or to the effort
to menstruate when the vessels of the uterus were  incapable  of
containing a  greater quantity of  blood  than was already col-
lected in them.  Of these and many other opinions it would be
useless to debate ; but, as all viviparous animals bring forth their
young at regularly stated  times,  and  by processes  generally
alike, it would not be judging  according to any philosophical
rule,  to attribute  as the immediate  cause of parturition, or  of
parturition at any certain time,  a  circumstance  peculiar to any
individual class of animals.
   The  opinions of men upon the same  subject are often in di-
rect opposition to each other: and some, fearful that truth is not
to be found in either extreme, have steered a  middle course be-
tween the doctrines  of the ancients and  moderns.  These have
supposed that child-birth is not completed solely by the efforts
of  the child, or by those of the parent, but by the conjunction  of
their  efforts; and it may often  be perceived  that the  motion  of
the child  precedes the action of the uterus.  Of this  opinion,
which participates of the error  of the ancients, there have been
few supporters; and the arguments in its favour have been drawn
from observations made in the  first instance  on  vegetables and
oviparous animals.   How far  the dicovery of the  particular
cause of the birth of a child might  lead  to the improvement  of
practice, it is impossible to  determine.   The knowledge of the
fact,  that children are expelled,  has evidently  been productive of
much advantage; but the attempts to investigate  the  cause  do
not give us more satisfaction than old  Avicenna, who, with great
humility and devotion,  says, " At the appointed  time, labour
comes on by the  command of God."

                         SECTION IV.
    It  was before observed,  that pregnancy and parturition have
 usually  been mentioned as distinct operations of the constitution. 
ON UTERO-GESTATION.               261
But it seems better to consider every change in the animal eco-
nomy, from the time of conception to the birth of the child, as
forming a single process, consisting of several parts, each perfect
in itself, and at the same time a cause of some subsequent change
necessary for the completion of the whole; and  though there is
no precise line to the different parts of this process, they readily
admit of distinctions, by  which they are more easily compre-
hended, and more accurately described.   Thus,  previous to the
act of parturition, many changes take place in the  constitution,
which indicate its approach ;  and these have been called the pre-
disposing signs of labour.  The time of their appearance is dif-
ferent, being in some women several weeks, and in others only a
few days, before  the commencement of labour: but they univer-
sally take place, unless the labour be  precipitated by some acci-
dental influence: and the more perfectlj' these changes are made,
and the longer the time of their preceding the labour, the  more
natural and kindly  will the process generally be.
   There is, first, a gradual subsidence of the fundus of the uterus,
and whole abdomen, so that women often appear, and really are,
less in the ninth  than in the eighth  mouth of pregnancy ; and  the
form  of their size is different.  This is a good  indication, be-
cause it shows that  the fundus  and all the other parts of the ute-
rus are disposed to  act; and on the equality of this disposition,
the efficacy of its action will very much depend.   When there is
no subsidence of the abdomen, or but little, and the patient com-
plains, even in the time of labour, that the  child is very high, it is
always unfavourable;  being a proof that the fundus of the uterus
is in  an  inactive state, or acting improperly.
   There is, secondly,  a discharge  of mucus from the vagina,
which, in the beginning, is of the kind often observed in  the fluor
albus;  that is,  a mere augmentation of the secretion  from the
glands of the vagina and neighbouring parts ; but,  by a gradual
alteration in some instances, it becomes extremely viscid and te-
nacious, or that which  was originally of such texture is dischar-
ged.  This is very  remarkable in some  animals  whose  bodies
are exposed to view, especially in cows; and it is a sign that the
parts concerned in  parturition are in  a state disposed to dilate,
which disposition is farther improved by the discharge.
   Thirdly, in early pregnancy, the external parts of generation
are in a  natural state, or at some periods rather  more contracted
than  usual: but when the time of  labour  approaches, there is a
gradual enlargement and relaxation of them,  with some degree of
protrusion. This change, also, is to be observed in animals  only;
but, from their complaints,  and the representation of their feel-
ings  toward the conclusion  of pregnancy, there is  every reason
to believe, that a similar change usually takes place in women.
   Fourthly,  it was observed that  the breasts very readily and 
262          INTRODUCTION TO MIDWIFERY.
 generally sympathize with the uterus in all its affections, and par-
 ticularly that they are enlarged before, or immediately after con-
 ception.  There is also a gradual change in them from that time
 to the approach of labour, when they are perfectly  fitted for the
 secretion of milk ; which, when secreted in a more  mature state,
 or in an increased quantity, may be esteemed a sign  that the
 time of  labour  is drawing near.  Some animals, the  pecora for
 instance, though the quantity  of  milk has  gradually declined,
 have continued to give suck during pregnancy,  without any  ap-
 parent alteration in the quality of their milk, till they approached
 the time of parturition,  when it was found to be much changed in
 its consistence, colour, and  properties, a new mode of secretion
 being evidently established.
   Fifthly,  by the insertion and disposition of the  sacrosciatic
 ligaments,  the principal firmness is given  to the connexion of the
 bones of the pelvis.  In animals not with young these ligaments
 are very strong and rigid,  and make a resistance to  any external
 pressure almost as firmly as if they were ossified.  But when the
 time of parturition is at hand their strength and rigidity gradu-
 ally decline, and they feel scarcely more firm  than a duplicature
 of the skin.   In consequence of this relaxation of the ligaments,
 animals  change their  manner  of walking,  by projecting  the
 weight of the body on each side alternately, rather  than  by ad-
 vancing the feet.   There is such an appearance  as  justifies the
 use of the  popular expression;  for they literally seem falling in
pieces.  In women  these changes cannot be so well observed ; but
 there are many reasons  to be drawn from  their manner of walk-
 ing, and from their representations, which  would induce us  to
 believe,  that  similar ones take place in  them  as  well as  in
 animals.*
   Sixthly,  all animals, wild  or domesticated,  assiduously en-
 deavour to provide a safe and comfortable habitation for their
 young,  when the  time of bringing  them forth draws  near.f
 The actions of mankind are always  attributed  to, and  usually
 proceed from, more dignified  and  commendable  principles than
 those of animals.  But  in  many natural  actions, which are too
 powerful to be controlled, or not without great difficulty,  by in-
 structions,  manners, or  customs, they may often be observed  to
  * Sacri et pectinis ossium cum coxendice copula, quaa fit per syn-
chondrosis adeo  emollilur et solvitur, ut dicta ossa  facile  exeunti
foetui cedant,  et hiantia regionem totam hypogastricam ampliorem
reddant.—Harv. Exercitat. de Partu.
  t Accedente pariendi tempestate  ad solita  loca revertantur : ut
stabula vel nidos suos tuto extruant, ubi foetus, pariant,  foveant, al uni-
que,—Harv. eodem loco. 
ON UTERO-GESTATION.              263
act instictively; and this is  in no case more remarkable than in
such actions as relate to child-bearing and  to children.  From
instinct, therefore,  and not reason, it may be presumed, that the
chosen and favourite employments of pregnant women are those,
which  in  some way or degree  relate to the expected blessing ;
and an unusual solicitude about the  preparation  of such things
as may be necessary or convenient to the child, in the advanced
state of pregnancy, may be considered as a sign, that the time
of labour is approaching.

                         SECTION V.
  Before  we proceed to the history of labours,  it is  necessary
that we should speak  of the operation, if it deserves the name,
by which  we are to acquire our information.  This is  described
by  the term examination, or examination per vagii.am.  When
instituted  at the time of labour, it is popularly called taking a
pain, which explains  the operation  entertained of it by women.
Concerning this opinion two things are to be observed: first, the
manner in which patients are to be examined ; and, secondly, the
information to be gained by the examination.
   The position in which  women are placed, when it is thought
necessary to examine them, varies in different countries.  In some,
the examination is made when they  sit in a chair or stool con-
trived  for the purpose; in others, when they kneel by the side of
a bed ; and in others, in a recumbent position. But in this  coun-
try, at the present time, almost universally, women repose on a
couch  or bed, upon their left side, with their knees bent and drawn
toward the abdomen; and this is by far the most convenient as
well as decent  position.  It is not requisite, or possible, to enu-
merate every circumstance, to which it is necessary to pay atten-
tion ;  but it must be an  invariable   rule,  never  to propose  an
examination per vaginam but as a matter  of absolute necessity,
and in the presence of some attending person.  It is,  also,  to be
performed with the utmost care and  tenderness, and the strictest
regard to  decency; for, unimportant as the operation in  itself
really  is,  an opinion is formed by the manner of doing it, of the
skill and humanity of the practitioner, and of the propriety of
his conduct.
   An examination, per vaginam, may be needful to discover and
distinguish diseases of the uterus and  contiguous parts; to ascer-
tain whether a woman be pregnant, or how far she is  advanced
in  her pregnancy;  to determine whether she be in  labour, or
what progress that has made; if the presentation of the child be
natural;  if the pelvis be well formed or distorted; and on other
occasions.
   The state of the parts examined, under all the incidents before
recited, is different  from the natural; but of the deviations of 
264          INTRODUCTION TO MIDWIFERY.

every kind, and in every degree, it is impossible to form  a judg-
ment, unless we have previously  obtained  an accurate idea of
their  natural state.   This forms the true standard by which we
are to judge of every change, natural or morbid ; and  the faculty
of discriminating the various diseases or alterations can only be
acquired by frequent practice, no abstract  rule being sufficient
for the purpose.  It may indeed be  said, that, in some diseases
of the  uterus,  especially those disposed  to  become  cancerous,
the os  and cervix  uteri is enlarged, or elongated, indurated,
thickened,   fissured,   spongy, and  uncommonly  tender  when
touched ;  or patulous, or  with the  labia  somewhat reverted ;
lying too low in the vagina, disengaged or firmly attached to the
adjoining parts.  But in others, as  the  polypus, hydatids, in-
flammation, or  a glandular  enlargement of the uterus, the state
of the parts, (except the simple enlargement of the uterus)  or the
sensation they give, cannot be described by words, without au an-
tecedent agreement what those shall  be called which  we  before
felt or seen.  We are often able to  distinguish the changes made
in the  body of the uterus by an examination per  anura  more
perfectly than by any other  method,  but this is not to be  done
without giving  previous notice of our  intention.
  As it  is extremely difficult, if not impossible, to determine by
an examination  per vaginam  in the  early  part of pregnancy,
whether a woman be  with child, it is  then prudent to evade the
operation;  because it is always expected, that we should after-
wards speak with precision and confidence.   For the fundus of
the uterus being the part first distended  in consequence of con-
ception ; and the cervix,  which is the only part we can feel, not
beginning to shorten in any  distinguishable way before the termi-
nation  of the fourth  month of pregnancy ;  not to  mention the
natural  varieties in the structure and size of the parts in different
women, and the alterations which may be caused by the  attach-
ment of the placenta to different parts of the uterus, or by
those diseases which  resemble pregnancy, we shall see sufficient
reason for putting off this kind of inquiry.   A cautious practi-
tioner will  not, therefore,  on any account,  examine before  a
suitable time, because  he cannot gain information, to supply him
with proper ground on which to form the opinion required of him,
that will not be extremely subject to error.  Perhaps  this limita-
tion may not be sufficiently strict, and it is better to say, in gene-
ral terms, that the longer we defer the examination, the greater
probability there will be that we shall not be  deceived, or disap-
pointed  of the information we want.  In all cases,  likewise, of
doubtful prognostic, it is prudent to avail ourselves of every ad-
vantage, which  a knowledge of the collateral circumstances can
afford, before we give our opinion. 
ON UTERO-GESTATION.
265
  Nor is there less difficulty, when we are assured that a woman
is with child, in deciding, by an examination per vaginam, how
far  she is advanced in her pregnancy.  An opinion of this mint
be formed on the estimation we  make of that portion of the cer-
vix  uteri, which we suppose should remain undistended at any in-
dividual period of pregnancy.  But as the cervix  uteri naturally
varies  in  its length in  different women, of course the portion
which remains undistended at any precise time must vary; and
all that can be justly said upon this subject, will only deserve the
name of conjecture.  It is therefore more judicious not to hazard
an opinion singly upon the information  gained by an examina-
tion per vaginam, when any determination of importance is to be
made; but, as in the former statement respecting the existence of
pregnancy, to act with caution, and to collect all the information
we can get from other circumstances, before we presume to give a
decided opinion.
  When a woman is at or near the full period of utero-gestation,
it may be determined whether she is in labour by the state  of the
os uteri.   By the  dilatation of the os uteri  during the continu-
ance, and not by its relaxation in  the absence of a pain, we  are to
judge that the patient is in labour; for a considerable degree of
relaxation of the os uteri is sometimes found  to take place several
days,  or  even  weeks,  before the commencement  of  labour;
though it is generally in a contracted state, till it is distended in
consequence of the pressure made by some part of the ovum ur-
ged upon it by the acting uterus.  By the  time which has been
required to produce a certain degree of dilatation, we may guess
with tolerable exactness the general duration of a labour, provi-
ded the action of the uterus should continue with equal energy;
because  on this, as well as on the state of the parts, the progress
of a labour must depend.   But so many  unexpected circumstan-
ces occur, which may accelerate  or interrupt a labour in its pro-
gress, that it will usually be a proof of wisdom, to be silent upon
this subject;  at least,  not to advance our  opinions  with  confi-
dence, but to offer them, when demanded, with hesitation and re-
serve,  as the circumstances of the case  do not justify, or in fact
require, our giving a positive opinion.
   The manner in  which the child presents, may generally be dis-
covered  by  an examination in the beginning  of labour; for,
though we should not be able to  distinguish any part through the
membranes, in the intervals between the pains (when only the at-
tempt  for this purpose ought to be made,) if the head presents it
may  be perceived through the  anterior part of the cervix uteri,
resting upon the ossa pubis, in  some cases so early as  the fifth
month of pregnancy.  When any other part presents, we can in
general only discover  through the membranes that it is not the
head, by its smallness and the want of that resistance which is 
266
INTRODUCTION TO MIDWIFERY.
made by the head ; and if we can feel no part presenting, though
it does not certainly follow,  it is not amiss to conclude, that it is
not the head; and then in our report to the friends, we shall ex-
press ourselves with some doubt, and be prepared to give assist-
ance at the time when the membranes break, if the presentation
should be such as to require  it.
  After an examination per  vaginam, our opinion  is constantly
demanded as to  the prospect of an easy or difficult labour.   If
the presentation  of tire child be natural, the  pelvis well  formed,
the soft parts in a relaxed state, and the patient free  from  disease,
we may safely assure her friends that all the appearances are pro-
mising, and that the labour  will be finished, in all probability,
with perfect  safety both  to  the mother and child.   But of the
slowness or celerity of a labour, great experience and attention
can only give that maturity of judgment,  which enables us  to
form an opinion with tolerable precision; yet the  same expe-
rience having often shown the uncertainty of any determination,
will point out the propriety of leaning rather to the  side of doubt
than of confidence.   It is not a little extraordinary, how often we
may observe labours proceeding  in regular  circles of time, as
four, six, twelve, or twenty-four hours, from the first alarm or
token ;  or how frequently their progress is suspended in the  day
time, especially in very warm weather, as will be more particu-
larly observed. 
ON LABOUR.
267
                      CHAPTER IX.

                         SECTION I.

                         ON LABOUR.

  Having given a description of all the parts concerne d in par-
turition, and shown the peculiarities  of the female constitution ;
having enumerated the principal alterations produced in the con-
stitutions of women during pregnancy, and having farther taken
notice of all the previous changes,  we come in the next place to
the consideration of a Labour.  This term  is  generally used to
signify every act performed with difficulty or pain; but by long
established custom  it has been appropriated in this and many
other countries  to  parturition,  the circumstances of which it is
well suited to describe.
  Before we proceed to the  history of labours,  it is requisite that
we  should divide them into classes  or kinds ; and, though  objec-
tions might be made to very strict arrangement, some appears to
be  both convenient and necessary, for the purpose of enabling us
to convey our sentiments with perspicuity to others,  and for real
use in practice.
  With these intentions, labours  may be divided into the four
following classes:
   1.  Natural.
   2.  Difficult.
   3.  Preternatural.
  4.  Anomalous.
  Under one or other of these  distinctions, every kind of labour
which can occur, may be reduced.*
  * [Baudelocque has divided labour  into, 1st.  Natural or unassisted
labour : 2d. Preternatural labour ; that which requires  assistance,
but may be completed by the hand  alone : and 3dly, Laborious la-
bour ;  that which requires the use of instruments.
  Burns, in his disposition of labours, has made seven classes :  1st.
Natural labour:  2dly, Premature  labour: 3dly,  Preternatural la-
bour :  4thly, Tedious labour : 5thly, Laborious or Instrumental la-
bour :  6thly, Impracticable labour:  7thly, Complicated labour. It
is essential to his natural labour that it does not take place until the
end of the ninth month of pregnancy :  his premature labour taTies
place considerably before the completion of the usual period of m> 
268
INTRODUCTION  TO MIDWIFERY.
                         SECTION II.
  Natural labours,  which  have  had their  denomination  from
their frequency, or from  the shortness of the time required  for
their  completion; from the regularity of the manner  in  which
they proceed, or from their being accomplished by the unassisted
efforib of the constitution, form a standard by which we  are to
judge  of every other class.   It is therefore  necessary, that  we
should  obtain  as precise an  idea  of these as the subject will al-
low.  We will then say, that every labour shall be called natural,
if the head  of the  child present, if the labour be completed
within  twenty-four  hours,  and if  no  artificial assistance  be
required.
   Should any  of these three leading marks in the definition of a
natural labour be  wanting, it must come under some other de-
nomination.  Thus, if any other  part except the head should
present, the labour would be preternatural;  if it should be pro-
longed beyond twenty-four hours, it  would be difficult;  and if
the circumstances were such as to require assistance, though  the
labour  might be completed  within one hour, it would be anoma-
lous, or must be referred to some  other class.
   The  presentation of the  head of the  child constitutes an
essentia]  part of the definition of*  a natural labour ; yet this may
happen in  various  ways.  The  most common  position of  the
head, and that in which it is expelled with the greatest facility, is
when the hind-head is disposed to turn toward the pubis and the
face toward the hollow of the  sacrum.  But the  face  is some-
times inclined  toward the ossa pubis, and the hind-head toward
the hollow of the sacrum ; or there may be an original presenta-
tion of the face; or one or both arms may descend together
with the head.  These differences in the position of  the head do
 not constitute  labours of another class; but they are to be con-
ro-gestation, but yet not so early as to prevent the child from sur-
viving.
  Merriman divides labour into two classes : 1st.  Eutocia, or na-
tural  labour:  2dly. Dystocia,  or difficult labour.   There are in
this last class fifteen sub-divisions or orders.
  Hogben has  distinguished labour into four kinds.  1st. Natural;
2dly.  Difficult: 3dly.  Preternatural:  4thly. Complex.   The first
two are supposed to include all labours  where the head presents.
Preternatural labour is, when any other part than the head presents ;
or the head descending with one or both arms.  A complex labour is
attended with intervening anomalous circumstances,  meaning the dif-
ferent species  not  naturally  connected  with each other; such as
twin cases, (or more,) presentations of the funis umbilicalis, convul-
sions, floodings, rupture of the uterus, &c.  F.J 
QN LABOUR.
269
sidered  merely as varieties of  natural labours, provided  the
other circumstances correspond ;  experie||fe having fully proved,
that, in  any of these positions, the head may be expelled  by the
natural  efforts with perfect safety to the^bther ana child, though
not generally with such ease and expedition as  if the hind-head
was turned toward the pubis; unless the head be Very small.  It
must also be observed,  though another part of  the definition be
taken from time,  that it is possible  for  one woman  to make
greater  efforts, and to undergo more pain,  in  two  hours, than
another may in  twenty-four.   Then  the  definition will  be im-
perfect ; as almost all  general distinctions must be, when they
come to be examined and tried by individual cases.
  A natural labour  was the last  thing well understood   in the
practice of  midwifery; because scientific  men,  not being for-
merly employed in the  management of common labours,  had no
opportunity of making observations upon them.  Practitioners
were then engaged in qualifying themselves for the manual ex-
ercise of their art, whenever they might be called in to give as-
sistance, and not in  making  nice distinctions, or investigating
the particular cases, in which only it  might be necessary to ex-
ercise it.

                         SECTION III.
  We have before given an account of the changes which  pre-
cede labours, and are  now to give a detail of the  symptoms
which accompany them.
  The  first symptom which indicates a present  labour is anxiety,
or that  distress which  usually arises  from the  apprehension of
danger, or doubt of safety.  This does not seem to be confined
to the human species, but to be  common to all  creatures,  as they
universally show signs of dejection and misery at this time, though
they suffer in silence;  and even  those animals which are domes-
ticated, strive to conceal themselves, and  refuse all  offers of as-
sistance.   This anxiety, which  is probably occasioned  by the
first changes made upon the os uteri, and by the consent between
the vital organs, and that very irritable part, is often exceeding-
ly  increased by  an original  timidity of disposition,  especially
with first children; or by the  discovery  of untoward accidents
happening  to  other women under the same circumstances,  with
whom  a similarity of situation is  the  cause of  a very interesting
sympathy.   From motives of humanity,  as well as professional
propriety, it  is, therefore, at these times necessary, by steady
conduct, and by arguments suited to the patient's  own  notions,
or the  peculiar cause of her fear;-, to  remove her apprehensions;
 and, by soothing and encouraging language,  and by  uientiou
 to  her  complaints, though not  indicatory of any danger, to af-
 ford her every consolation in  our power.   This anxiety is great- 
270
INTRODUCTION TO MIDWIFERY.
est  in every woman  in the beginning  of labour, for the  sharp
pains which attend its .progress generally excite other sentiments
in her mind.  But we are at all times  to be on our guard, that
her fears or supplications for relief, do  not prevail with us to  at-
tempt to give assistance, when our interposition is not  reqaired,
and when it must necessarily be productive of mischief.
•  2. At the commencement of labour, and sometimes on the  re-
turn of every pain, women have frequently one or  more rigors,
with or  without  a sense of actual cold in their inferior extremi-
ties, or  of the whole  body.   These  are not  to be considered as
signs of the accession of disease, but as the effects of  an increased
irritability spread through the whole frame; or perhaps as proofs,
that all  the powers of the  constitution  are summoned  to contri-
bute toward the important process, which is carrying on.   These
rigors are void of danger, and they are most apt to occur when
the os uteri begins to dilate, and when it  is upon the point of be-
ing fully dilated.  But in  the course of a labour, perhaps in all
other respects  natural, but  more especially in those which  are
either difficult  or very lingering, when there is one strong and
distinct  rigor, it is often  followed  by some disease dangerous
either to the mother or child.
   3. When the head presents,  and scarcely in any  other posi-
tion of the child, women have generally some degree of strangury
in the latter part of pregnancy ;  and this symptom is increased
on the  approach of labour, by the pressure  of the descending
head upon the cervix of  the bladder.  Should the  pressure  be
very great, or of long continuance, a  suppression of urine may
be occasioned  before, or in the time of labour.  To prevent  the
inconveniences which might arise from a distention of the blad-
der, either to the part itself, or by obstructing the passage of the
head, it is necessary to urge the patient to void the urine fre-
quently ; and in case of a suppression, to give relief by introdu-
cing the catheter.  On the other hand, should the pressure of the
head be made upon the fundus of the  bladder, there will be  an
involuntary discharge of urine at the time by her enduring every
pain ; or, if there should  be any extraordinary agitation from a
cough, or any similar cause,  before delivery, there will  be  the
same consequence, which is  very disagreeable and troublesome,
but not dangerous.
  4. It is  not unusual for  patients  to  have a   tenesmus,  or
one or  two, or more loose  stools,  in the beginning or  course
of  a labour.   Both these  symptoms  may be occasioned  by
the consent between the os uteri and the sphincter of the anus, or
by the pressure made upon the rectum, as the head enters into, or
passeth through the pelvis.  There is in the minds of all women
a popular prejudice and unreasonable dread of complaints in  the
bowels through every stage of pregnancy, parturition, and  child- 
ON LABOUR.
271
bed ; and of course there is never any objection, but on the con-
trary, a willingness to use such means as are advised  to suppress
them, or restrain any disposition to a diarrhoea. The error has
arisen from their confounding the looseness, which often  accom-
panies the last stage of the puerperal fever, with that which pro-
ceeds from  any other cause.  But the diarrhoea which  attends
the beginning or course of a labour is so  far from occasioning,
or from indicating any danger, that the patient is evidently re-
lieved by it; a  greater freedom being given to the action of the
uterus, more room made for the passage of the child,  and any fe-
verish disposition thereby removed or  prevented.  If, therefore,
the patient should not at that time have stools spontaneously, it
is very sound practice to direct one  or more  emollient  clysters
for the before-mentioned purposes. Nor are these the only good
ends which are  answered by clysters;  for they sooth and give  a
proper bent to the parts when too much or improperly irritated ;
and serve also as a fomentation, which, by its  warmth and mois-
ture, may give or amend their disposition to dilate.  In very slow
labours, when the head of the child has dwelt  for a long time in
one position,  it is not unusual for  the patient to have  one or
more copious and loose stools, immediately before the advance-
ment of the head, after which the labour is soon concluded.
  5. The  uncoloured mucous discharge from the vagina, which
pretty generally occurs before labour,  on its accession is usually
tinged with blood, or a small quantity of pure blood is discharged.
This sanguineous discharge, which varies in quantity and  appear-
ance in different women, is popularly called a show, and it happens
more particularly at two periods of a labour; when  the os uteri
begins to dilate, and when it is finally dilated.  In the first instance
it is probably occasioned by the separation of a few of those vessels,
by  which the membrane, which connects the ovum to  the uterus,
was originally bound ;* and in the second by the effusion of some
blood before extravasated  in the  substance of the os uteri;  for
this part in some cases acquires an uncommon  thickness from
that cause, independent of any edematose or inflammatory tume-
faction.   In many cases there is no coloured  discharge in any
period of a labour, and  then the  dilatation generally proceeds
more slowly;  for the discharge is a sign, that the parts are in a
state disposed to dilate, but it also improves that state.  It is not
only in colour or quantity, that there is  found much difference,
either in the sanguineous or mucous discharge, but  also in the
consistence and  tenacity of the latter; it being  in  some cases
thin and  watery, and in others thick and extremely viscous.
  * [This discharge is owing to  a  partial detachment of the pla-
centa.  F.] 
272          INTRODUCTION TO MIDWIFERY.
  6. But all these symptoms are not positive proofs of the existence
of labour; for we cannot consider a woman as being in  actual
labour, unless she has the usual pains.   Nor does all pain in the
region of the uterus certainly  prove that a woman is in labour,
because  such pain  may be excited toward the  conclusion  of
pregnancy,  by various causes beside  the action  of  the uterus.
These pains are therefore distinguished into two kinds, true and
false; but the seat, the manner,  and the degree of these  pains,
often resemble each other so  nearly, that it is very difficult or im-
possible to distinguish them, unless by an examination per vagi-
nam, or by waiting for the event.
  The true pain of labour usually begins  in the loins or lower
part of the back, surrounds  the abdomen, and  terminates at  the
pubes, or upper part of the thighs; and  it  sometimes  observes a
quite contrary direction.  In some cases the pain  is  confined to
one particular  spot, as the  back,  abdomen,  thighs,   or  inferior
extremities: in others, the pain is seated in some part far distant
from the uterus, as in the knees, heels, or feet.   In some the sto-
mach is affected; in others,  though very rarely, the  brain ; and
then  convulsions, or  some derangement of  its  functions, are
brought  on.   In short, the varieties of pain, as  well as its effects,
are innumerable; and these have been explained by what we
really do know, or  fancy we  know, of the influence of the ner-
vous system.
  The pain  attending a labour is periodical,  with intervals  of
twenty, fifteen, ten,  or five minutes, according to its progress, and
as regular as the clock, but with a longer or shorter duration, ac-
cording  to the action of the  uterus, en which it depends ; and the
more the pains are multiplied, the better it is for  the patient.
For, if an effect of great importance to the constitution  is to be
produced, the  more slowly  it  is made,  provided the  slowness of
the progress does not depend on any morbid cause, the more gra-
dual will be the change, and of course the danger which sudden
violence might produce will be avoided or lessened ;  the division
of the pain being equal to the  diminution, nearly in the same pro-
portion  as rapidity  is an addition to force.  It is an old obser-
vation, confirmed by daily experience, that,  after the completion
of  slow  or  lingering  labours, patients usually recover  better,
than after those which are quick ; not  to mention, that they are less
liable to the untoward accidents which  precipitation  may imme-
diately produce.
   Those who endure any kind of pain, express their sufferings by
some peculiarity of manner, or by some tone of voice, which to a
nice observer will generally discover the  part affected, together
with the kind and degree of pain, and the change it is effecting.
Sharp pain is universally expressed by an interrupted and acute
tone of voice; obtuse pain,  by a continued and grave tone, un- 
ON LABOUR.                    273
 less the expressions are controlled  by an  acquired firmness of
 mind, which on particular occasions may enable it to rise above
 the infirmities of the body.   The expressions of pain  uttered by
 women in the act of parturition, may be considered as complete
 indications  of  the  state of  the  process,  so that an  experienced
 practitioner is often as fully master  of the state of his patient, if
 he hears her expressions, as by  any mode of examination.  He
 must, however, understand  and make allowances for  the peculi*
 arities of different patients, or he  will be deceived ; because, in
 tender  constitutions, the sensations  being quick, and the resolu-
 tion faint, the mode of expression will be according to the sense,
 and not in proportion to the degree  of absolute pain.
   In the first stage of a labour, the change consists in the dila-
 tation of the parts.   Forcible  or quick dilatation gives a sensa-
 tion similar to that produced by the infliction of a wound, and it
 is equally expressed  by an interrupted and acute tone of voice.
 These are popularly called cutting,  grinding, or rending pains,
 When the internal  parts are dilated, and the child or contents of
 the uterus begin to descend, the patient is, by her feelings, obli-
 ged to make an involuntary effort to expel; and the expressions
 are then made with a continued and grave tone of voice, or she is
 mute.   These  are called bearing  pains.   But there is an inter-
 mediate period of  a labour, in which there is, in the first in-
 stance,  some degree of dilatation,  and afterwards  an effort to
 expel; and  then there will be the expression which denotes sharp
 pain, combined, or immediately succeeded by  a graver  tone of
 voice.   When the child first begins to press upon, and to dilate
 the external parts, the expression  becomes again  acute  and ve-
 hement; and lastly, the expulsion of the child is often accompa-
 nied with an outcry of suffering beyond what human nature
 seems able to bear;  or the pain is  endured with silence.  The
 knowledge of these circumstances, though apparently trifling and
 contingent,  is really of some importance in practice; and they
 are permanent, as far, at least, as the freedom or restraint of the
 breathing can  operate.  If, for example, on any principle the
 patient  was  induced, in the beginning of labour, to retain her
 breath, and to make  strong efforts to expel, the order of  the la-
 bour would be inverted, as it would  also be when the parts were
 dilated, and the expulsatory power wanted, if she should exclaim.
   The pains of labour or childbirth, and the action of the uterus,
 are terms used synonimously; but they are not  exactly the same
 thing.   The action of the uterus, by which its contents are com-
 pressed  into  a  less  space, and  would be excluded  if there was
 any opening for their passage, first takes place as a cause; and
this does  not seem  to be attended  with pain.  When some part
resists  the passage of the contents of the uterus, the exclusion of
which is the  effect to be produced, there  will then be pain pro*
                              35 
274          INTRODUCTION TO  MIDWIFERY.
portionate to the action,  to  the  sensation of the resisting part,
and the resistance made.   There is no way by which we can es-
timate the degree of force but by the resistance; nor  the resist-
ance, but by the pain attending it; nor the pain, but by the ex-
pression.   Judging by induction of the force exerted, by the ex-
pression of the pain, we say in common language a weak pain, a
strong pain, or  a woman is delivered by her pains ; and the pur-
pose of conveying our meaning is answered,  though the expres-
sions are not strictly logical.   We may suppose the parts, through
which the child must pass, so  perfectly disposed to dilate,  that
they would  make  little or no resistance to the excluding force,
and  then a woman would be delivered with little or no pain.  This
observation will not only discover the reason of the great advan-
tage obtained by a labour being slow and lingering,  and why
some women are  delivered comparatively without pain; but,
with this perfect disposition to dilate, if the  patient  should be
asleep when  the action of the uterus came on, of the possibility
of her being delivered before  she was quite awake.
  In the conversation of those who   attend labours,  it  is often
surmised,  that women have much unprofitable pain.  This state-
ment is not only unfair as  to the fact, but the language is very
dispiriting, and it is often  assigned as a reason for an  interposi-
tion  altogether unnecessary, and often injurious to the mother or
child.   No person in labour ever had a pain,  depending on her
labour, which was in vain. It  may  not be equal to the accom-
plishment  of the effect we want, or at the time  we wish, but every
pain must have its use, as  preparatory to, or absolutely promo-
ting, the effect; and, as we are not  able  to comprehend every
possible cause of every state, by endeavouring to remove what
appears to be one slight ill, it  often  happens that  we occasion
many, and  those of greater  consequence.  Therefore, whether
the pains, which any woman in  labour  may have, produce an
immediate effect or not, it  is our duty to wait  with patience, pro-
vided there be no tokens of danger;  because  the natural order
of proceeding requires a succession  of  pains, and  artificial at-
tempts to  dilate the parts would be injurious.
   Though the  pains of labour return periodically, the intervals
between them are of different continuance.   In the beginning,
the pains  are usually slight in their degree, and have long inter-
vals ; but, as the labour  advances,  they become stronger,  and
the intervals  are shorter.   Sometimes the  pains are alternately
strong  and weak, or  two feeble and one  strong;  and there is
reason to  think, that every variety  has its advantage, by being
suited to the apparent or real internal state of every  individual
patient.   In every circumstance, which relates to natural partu-
rition, it is impossible not  to see, and not to admire,  the wisdom
and goodness of Providence,  in ordaining the power, and fitting 
ON LABOUR.
275
the exertion to the necessities of the situation, with a marked re-
spect to the safety both of the mother  and child.  This perfect
coincidence between the cause and  effect, should afford a lesson
of patience to those  persons,  who, when in labour, become in-
tractable, and, by losing their self-possession, add  to the una-
voidable evils of their situation; and to those practitioners, who,
being led away by popular errors,  aim to add to the strength of
the pains, or to quicken their returns, and act as if they thought
there was no other evil but that of a slow labour; an opinion
which, in its consequence, has done more mischief than the most
skilful practice ever did good.

                         SECTION  IV.
  Though it was said, that pain was, properly speaking, a con-
stituent part of a labour,  it was also observed, that all  pain in
the region of the uterus, near the full period of gestation, though
periodical in its returns,  was not a  positive proof of the  exist-
ence of a labour.  For, whatever  disturbance  is raised  in the
constitution, especially  in those parts connected or readily con-
senting with the uterus, or with which the uterus may recipro-
cally consent, toward  the conclusion of pregnancy, it is very apt
to induce the symptoms of labour,  in a manner which makes it
difficult to  distinguish  between true and  false pain.   Yet the
good of the patient, as far as relates to the proper conduct of the
ensuing labour, may  depend upon the justness of the  distinc-
tion ; for if the pain which is false be encouraged or permitted
to continue, the action of the uterus might follow, and premature
labour be occasioned.
  The causes of false pain are various; as fatigue of any kind,
especially too long standing;  sudden and violent motions of the
body ; costiveness, or a diarrhoea; general feverish disposition;
agitation of the mind, and a spasmodic action of the abdominal
muscles.  Very frequently, also, the irregular and strong move-
ments of the child, in irritable constitutions, occasion  pains like
those arising from the action of the uterus at the time of labour.
In some cases there is such a close  resemhlance between the true
and false pains, that they  cannot be distinguished without an ex-
amination  per vaginam.  If, during the continuance of a paiu,
no pressure upon, or dilatation of,  the os uteri can be perceived,
we may conclude that the pain is not the consequence of the ac-
tion of the uterus ; and  whatever likeness it may have, that it is
not true pain.  But if there  should be  pressure upon,  or dilata-
tion of, the os uteri during the  continuance of the  pain, we may
consider it as proceeding from the action of  the uterus, and be
persuaded that the patient is really in labour.  In a few  cases, I
have  known the action of the abdominal muscles so regular and 
276
INTRODUCTION TO MIDWIFERY.
 strong, that the whole volume of the uterus  has been heaved up
 and down  alternately,  in  such a  manner, that it was scarcely
 possible to distinguish between this  strange  succussion, and the
 proper action of the uterus;  yet, without any dilatation of the
 os uteri.
  The means to be used for the relief of false pain, must be gui-
 ded by the cause.   When it is occasioned by fatigue of any kind,
 immediate ease will often be gained by a short  confinement in a
 horizontal position.  In plethoric habits, or  with a feverish dis-
 position, it  will be  necessary to take away some blood;  and,
 when the patient is costive,  to procure  stools by emollient clys-
 ters, or gently  opening medicines.  In every case, when  means
 adapted to the  apparent cause have been used, it will be proper
 to give an opiate proportioned to the degree of pain, or to repeat
 it in small quantities at proper intervals, till the patient shall be
 composed.

                          section  v.
  It has been thought equally  incumbent upon the practitioner, to
 promote the power and effect  of true pain, as it was to quiet that
 which  was false.  This opinion is, perhaps,  more  universally
 popular than any other throughout medicine; and  if it have
 infected  the minds  of practitioners, as it often has those of the
patients, it would  be as  injurious as general.   From this source
may be traced  the  opinion of the necessity, and the abominable
custom of giving assistance, as it is  called, by dilating the inter-
nal and external parts artificially ; of giving hot and cordial nou-
rishment during labour, even in plethoric habits and feverish dis-
positions, by which the nature of the principle which should ac-
tuate the uterus is changed, the pains are rendered disorderly and
imperfect, and  the foundation  of future  mischief and difficulties,
in one  form  or  other, invariably  laid.   Hence,  also, was derived
the doctrine  of the necessity of patients helping themselves, as it
is called, by urging with all the voluntary force they are able to
exert beyond the dictates of nature;  as if a labour was a trick to
be learned, and not a regular  process of the constitution.   Wo-
men may be assured that the best state of mind they can be in at
the time of labour is, that of submission to the necessities of their
situation; that  those who  are most patient actually suffer the
least;  that,  if  they are resigned to  their pains, it  is impossible
for them to do wrong;  and that attention is  far more frequently
required to  prevent hurry,  than to forward a labour.  In every
 thing which  relates  to the  act of parturition,  Nature, not dis-
 turbed by disease,  or molested by interruption, is fully compe-
 tent to accomplish her own  purpose; she may be truly said to
 disdain and  to abhor assistance. Instead, therefore, of despairing,
 and thinking they are abandoned in the  hour of their distress, all 
ON LABOUR.
277
women should believe and find comfort in the reflection, that they
are at those times under the peculiar care  of Providence; and
that their safety  in childbirth is insured by  more numerous and
powerful resources, than under any other circumstances, though
to appearance less dangerous.*
   In order to give a full and distinct view of a natural labour,
it is expedient to divide the process into three periods or  stages.
In the first will be included all  the  circumstances which occur,
and  all  the changes made, from the commencement of the labour
to the complete dilatation of the os uteri, the rupture of the mem-
branes,  and  the discharge of the waters; in the second,  those
which occur  between that time and  the expulsion of the child;
and  in the third, all the circumstances which relate to the sepa-
ration and expulsion of the placenta.f
   In the beginning of labour the os  uteri is found in very differ-
ent states in different women.  In some it is extremely thin, and
in others of considerable thickness ; in some it is rigid and closely
contracted, but in others it is much relaxed, and somewhat open-
ed for several days, or even weeks,  previous to the accession  of
labour.   In some cases  the os uteri remains so  high,  that it can
with  difficulty be reached, in the centre of the  superior aperture
  * [It is greatly to be lamented, that the excellent principles in this
section are so often disregarded, and that even professional men fre-
quently countenance the popular error which our author so strongly
and so justly condemns.   F.]
  | [Mr. Hogben, in his  Obstetric Studies, has divided labour  into
five stages.   The first stage is  from  the  commencement of pains ;
the os uteri somewhat relaxed, open, and gradually  stretching by
the waters pressing on  the  membranes ; which,  being ruptured,
the child's head enters the brim of the pelvis, down into the cavity,
(or upper chamber ;) in its most favourable position, lying diagonally,
with  the occiput to one side of the symphysis pubis.   The second
stage  of labour is the time in which the face is passing into the lower
pelvis, the face turning into the cavity of the sacrum.  The third
stage  is the  further advance of the  head out of the hollow of the
sacrum, through the passage of the vagina and os  externum.  The
fourth stage comprehends the expulsion of the body of the child
and lower extremities.  The fifth stage is the discharge of the pla-
centa and membranes.                    #
  Labour has been divided by Dr. Hosack into tour stages, accord-
ing to the impediments to  be overcome : 1st.  All that may occur be-
fore the complete dilatation of the  os uteri :  2dly. The passage  of
the child's head  through the brim of  the  pelvis, until  it  has de-
scended so low as to press on the perinaeum : 3dly. The passage of
the child through the soft parts ; and, 4thly. The  delivery of the
placenta and membranes.   F.] 
278
INTRODUCTION TO MIDWIFERY.
 of the pelvis, projected backwards or on either side;  whilst in
 others it is spread thin, and pressed very low before it begins to
 dilate.   There is, in short, every variety of state and position,
 which a part constructed and connected like the os uteri can be
 thought capable of undergoing.
   The first part of the dilatation is generally made very slowly,
 the action of the uterus, on which it depends, being feeble in its
 power and slow in its returns; but the more perfect the  state of
 relaxation is, with the greater facility the dilatation will of course
 be made.  This at the commencement is effected by the simple
 pressure of the contents of the uterus upon the os uteri, which is a
 necessary consequence of the action or contraction of the uterus ;
 but when the dilatation is made to a certain degree, the membranes
 containing the waters of the ovum are insinuated within the cir-
 cle of the opening os uteri,  and form a soft pillow, which, at the
 time of every pain, acting upon the principle of a wedge, operates
 with increasing force according to the size it acquires; in conse-
 quence of which the latter part of the dilatation usually  proceeds
 with more expedition than the former,  unless the membrane con-
 taining the waters  be previously ruptured.
   There is no possibility of prognosticating  how long a time may
 be required for the complete dilatation  of the os uteri in any indi-
 vidual case ; yet a tolerable conjecture, subject however to many
 deviations,  may  be formed by a person who has had much expe-
 rience.   If, for example, after the  continuance  of the pains for
 three hours, the  os uteri should be dilated to the size of one inchT
 then two hours will be required for dilating it to two inches ;  and
 three hours  more will be necessary for dilating it completely, pro-
 vided the action of the uterus should proceed with regularity and
 with equivalent  strength.  But in  some cases the os uteri will
 abide in nearly  the same state for  several  hours; yet  when the
 dilatation begins,  it will  soon be perfected.  In  others,  after a
 certain  degree of  progress,  the action of  the uterus will be sus-
 pended for many  hours, and then  return  with great vigour; so
 that all  which could be said  on  this  subject would in fact be con-
jectural.
   With first children this stage often makes the most tedious and
 important  part of a labour, both on account of the longer time
 required for, and the greater difficulty in completing the dilata-
 tion of the  os uteri, and because the accompanying pain is more
 sharp and harder to  bear, than that which is attended with the
effort to expel; which never fails to inspire the  patient  with the
hope  of being soon  freed from  the misery which she endures.
When the parts are to our apprehension in  the same state, there
 will be a wonderful difference in the manner of,  and the time re-
quired  for,  their dilatation, in first  and subsequent children.
There might  be much difficulty in exploring and ascertaining the 
ON LABOUR.          f        279
cause of this difference : but we may presume that a part which
is accustomed to perform an office, or undergo a change, acquires
a readier disposition to the office or change, according to the
number of times it has performed that office, or undergone that
change.  Something of  the kind  may be observed in new-born
infants, in which there is often a tardiness in executing what may
be considered as the common functions of the body.
  As a labour advances, the intervals between the pains become
shorter, .and their force is  increased.  At the time of each pain
the  patient is restless, and  solicitous for  the event; but when it
ceases, by a happy oblivion she soon forgets it,  and is unmindful
of its return.  In some constitutions, the labour, instead of adding
to the irritability of the habit, and exciting its powers to action,
occasions a degree  of insensibility;  or the patient falls into  a
sound sleep the moment  the  pain begins to abate, from which
she is awakened by its return.  In others, the  power exerted by
the  uterus, aided by that of the abdominal muscles and diaphragm,
being insufficient for the purpose of dilating the os  uteri,  or that
part becoming unusually irritable by the  frequent impressions
made upon it; then, by its consent  with the  stomach,  extreme
sickness or vomiting is brought on,  sometimes after every  pain,
by which the labour is very much forwarded ; one fit of vomiting,
according to popular observation, doing more service than seve-
ral  pains, partly by the increased pressure, and partly  by the
succeeding relaxation.   But when theos uteri is dilated, patients
have very seldom  an inclination to vomit from any  natural cause.
Vomiting very often attends the passage  of a stone through the
ureters, or the gall-ducts, from the same cause, and  with the same
effect.
  By regular returns of pain, or with the  varieties before  men-
tioned,  with many others which it is  impossible  to enumerate, the
os uteri becomes at length wholly dilated.   Whether a short or a
long time be required for this purpose, it is the duty of the practi-
tioner to abstain from interfering in  this  part of the process.  It
may sometimes be necessary to pretend to assist, with the inten-
tion of giving confidence to the patient, or composing her mind.
But all artificial  interposition contributes to retard the event so
impatiently expected, by changing the nature  of  the irritation,
and the action thereon depending; or  does mischief by  infla-
ming the parts, aud rendering them  less disposed to dilate; in
short,  by  occasioning either present disorder  or future disease.
For these  reasons we must be firm,  and resolved to withstand
the entreaties which the distress of the patient  may urge her to
make, as we must also the dictates of vehemence and ignorance
in  the bystanders.  Others may  be  impatient,  but we must pos-
sess ourselves, and act upon principle.  The event will justify
our conduct; and, though there may be temporary dislike and 
280
£  I INTRODUCTION  TO MIDWIFERY.
 blame, if we do what is right, there will be permanent favour and
 reputation.
   During the continuance of a pain, the  membranes containing
 the waters are turgid, pressed upon, and within the circle of the
 os uteri,  according to the  strength of each pain, by  which the
 further dilatation is promoted ; but in the  absence of a pain, the
 membranes become flaccid, and seem to be empty.   These differ-
 ent states of the membranes  are readily explained  by  the obser-
 vations before made, by our knowing that when the uterus is  in
 action, its cavity is lessened,  and of course its contents  are coin-
 pressed ; but on the cessation  of the action, the  cavity of the
 uterus is again enlarged,  and the compression removed.  Hence
 it becomes necessary, when an examination per vaginam is made
 during the time of a  pain, that we should be cautious not to
 break the   membranes;  and if any accurate  investigation  be
 needful,  either of the state of the parts, or of the position  of the
 child, it  ought to  be made in the interval between the pains, or
 protracted till the pain has ceased.
   In a short time after the os uteri is wholly dilated,  the  mem-
 branes are  usually ruptured by the force of the pains,  and the
 waters of the ovum are discharged  in one large gush  or stream.
 But in many cases the membranes break spontaneously long be-
 fore this  period, without  any material  inconvenience.    In some
 they are  not ruptured  when the dilatation of the os uteri is com-
 pleted, but  are protruded by  each  successive pain lower down
 into the vagina, and  then within the os externum, which they
 also dilate ;  and at length a small bag of water is formed without
 the os externum, which can serve no farther purpose.
  It is a commonly  received opinion among the lower class of
people, that the child should be born speedily after the rupture
of the membranes and the discharge of the waters.  This opinion
 is not founded on prejudice,  but on  sound observation ; and was
 probably first entertained by those who were engaged in the care
 of breeding  cattle, in which this is  the order and usual course of
 parturition ; and I believe it would more frequently  happen in the
 human species, if the progress of the labour were  not  by some
means or other disturbed or interrupted.  But it  has been a cus-
 tom, which at the present time is not unfrequent with practitioners,
urged by the distress and suffering of those whom they are at-
tending,  or  by the concern of  friends,  or by a persuasion of its
propriety and advantage, and  sometimes perhaps by their own
impatience, to break  the membranes before the os uteri is dilated.
If these are  ruptured  spontaneonsly or  artificially before the og
uteri  is dilated, the child  cannot  possibly follow immediately;
and  all that  is gained is by bringing the head of  the  child,  in-
stead of the membranes containing the waters, into contact with
the os uteri.   This cannot be considered as any advantage, as it 
ON LABOUR.
281
changes a very soft  and  accommodating medium,  provided by
Nature for the purpose of preventing any  undue violence upon a
very tender part, for the hard and unaccommodating head of the
child.  Nor  is this  the only ill consequence which follows: by
such proceeding we occasion a general derangement of the order
of the labour, which  is never done with impunity, as  it may after-
wards become the cause of a laceration of the external parts, or
even of an unfavourable separation of the placenta.  Moreover,
by this premature rupture of the membranes, we often defeat our
own purpose; and, by disturbing,  protract instead of hasten the
labour.  We will therefore agree in establishing it  as a general
rule  for our own conduct, that  the membranes  should never be
ruptured artificially,  at least before the os uteri is  fully dilated,
and be persuaded that it is afterwards unnecessary, unless  there
should be some cause more important  than  the  mere delay of a
labour, or some  reason of more weight than  those which have
been commonly assigned.*

                         SECTION VII.
   In the second period or stage of a  labour will be included all
the circumstances attending the descent of the child ; the dilata-
tion of the external parts ; and the final expulsion of the child.
   Notwithstanding the definition of a natural  labour, which was
before  given, it is not to be considered as  a .process going  on in
one unvarying line, nor is every aberration to be thought of suf-
ficient importance to  constitute a labour of another class.  In this
respect, the definition of  a labour may be compared to that  of
health, which, however correct in general, would not correspond
in all points with the state  of any individual person, if submitted
to a  critical  examination.   In like manner, though a labour can-
not  come under the denomination of natural, without the three
distinguishing features, yet we may  probably never  meet with
  *  [Great deference is due to the opinion of our author concern-
ing the early rupturing of the membranes. The consequences which
ensue from the premature evacuation of the water, are such as fully
to justify the position  he maintains, as a rule of practice:  Never-
theless, the membranes may, in some few instances, be artificially
ruptured with advantage, previous to  the complete dilatation of the
os uteri: As in cases where we find the uterus makes long and inef-
fectual efforts to contract; while the pains are severe and not direct,
and the patient is expending her strength in vain.  By having thus
diminished the contents of the gravid womb, its power to contract ia
sometimes much augmented, and what might otherwise have been a
tedious and painful labour, is converted into one comparatively short
and easy. F.J
                             36 
282
INTRODUCTION TO MIDWIFERY.
any two labours in any respect exactly similar.  There are, per-
haps, more frequent deviations in the first stage of a labour, than
in any  other, both with regard to the time and the manner in
which the os uteri is  dilated.  Nor is the first stage concluded
either by the dilatation of the os uteri, or by the rupture of the
membranes, and the discharge of the waters, but by the concur-
rence of these circumstances; and  the farther  the labour is  ad-
vanced  before the membranes break, the  better it afterwards  ter-
minates.  For, before that event,  there is less violence done to
the mother,  and less  stress  upon  the parts; because,  without
much suffering, they every moment acquire a better disposition
to dilate; and till that has happened, whatever may be its posi-
tion,  the  child  undergoing  no  compression,  is  free  from all
chance of injury.
   When the  membranes break, if  the os uteri  be fully dilated,
the child, though resting at the superior aperture of the pelvis,
either sinks by its own gravity, if the patient be in an erect posi-
tion, or is propelled by a continuance of the same pain by which
they were broken;  or,  after a  short respite,  the action of the ute-
rus returns,  and the head of the child is  soon brought so  low
down as to press upon the external parts; properly speaking, upon
the internal  surface of the perinaeum.   In its  passage through
the pelvis, the head  of the child, which  at the superior aperture
was placed with one ear to the ossa pubis, and  the other to the
sacrum, or with different degrees of diagonal  direction, under-
goes various changes of position, by which  it  is adapted to the
form of each part of the pelvis, with more or  less readiness, ac-
cording to its size, the  degree of  its ossification, and the force of
the pains.  With all these changes, whether produced easily or
tediously, in one or in many hours,  the practitioner should on no
account interfere, provided the labour be natural.  If he attempts
to correct and to regulate every slight deviation, or uses any ar-
tificial means for hastening the process, the events of his practice
will convince him, that he has exercised  his art  on unnecessary
and improper occasions.   He will  moreover  be taught, though
he may acquire momentary approbation by endeavouring to re-
move every little present inconvenience, that diseases then far  dis-
tant  will  be attributed to his misconduct,  and sometimes  not
without reason.  In this state and  kind  of labour  he  may with
confidence rely upon  the powers and resources of the constitu-
tion, which will  produce their effect with less injury either to the
mother  or child, and  with more propriety than can be done by
the most dexterous  human skill.
   The external parts yield in a shorter or longer time, and with
more or less  ease, according to their natural  rigidity, the degree
of disposition to dilate which they have assumed during the la-
bour, the  force and frequency of the pains, and the number of 
ON LABOUR.
283
children which the patient has before had.  But the prevention
of any injury to the mother, when  the  child is passing  through
the external parts, being esteemed a circumstance wholly depend-
ing upon the care of the practitioner, this part  of our subject de-
serves a separate and  particular inquiry.

                        SECTION VIII.
  When the head  of the child first  begins to press upon and di-
late the external parts, every pain may be suffered to produce its
full and natural effect, without the hazard of mischief;  but when
a part of the head  is insinuated between them, and  the  anterior
edge of the perinaeum is upon the stretch, they are  liable to be
injured by the violence of the distention.   Any  of these parts may
be injured ;  but the perinaeum in particular is subject to a lacera-
tion, which  may not only extend so far as  to occasion much pre-
sent uneasiness; but  sometimes very  deplorable consequences
for the remainder of the patient's  life.  It is therefore our duty
to inquire into the merits of the different methods which have
been recommended for the prevention of this  accident, more es-
pecially as it admits of very imperfect relief  when it  has hap-
pened.
  Yet  it is  very remarkable, that none  of the ancient writers
either advise any method  by which  this  accident may  be pre-
vented, or any means to be used for its relief, excepting such as
were generally recommended for inflamed, ulcerated, or  fistulous
parts.  In  the  works of Eros, who lived in the thirteenth cen-
tury, and which  were  published by Spachius, this accident is in-
deed mentioned, and an awkward method of preventing it recom-
mended.   We  might therefore  presume, that  it is an  accident
which did not frequently occur in their  practice, or that it was
esteemed of too little consequence  to  engage their attention.
With respect to the former opinion, it  may be observed, that,
whatever event is  the consequence of any cause, it must at all
times have been produced whenever that  cause  and the same
circumstances exist.   But those who,  perhaps, had not perfec-
tion in view, and formed no very nice rule for their own conduct,
might not be sensible of,  or pay due attention  to, the deviations
or accidents which occurred, and  would not adjudge disagreea-
ble consequences to their  own error or  mismanagement.  They
did not, therefore, advise any  method  of preventing this acci-
dent, because  they were ignorant of the cause, or they underva-
lued it.
  It may be further observed, that the oldest writers in midwifery
lived before the Christian religion was established, and  in coun-
tries in which polygamy  was allowed ; when  the death or infir-
mity of one wife was comparatively of little importance to him
who had many, equally, or in some degree, dividing or  parta- 
284           INTRODUCTION TO MIDWIFERY.

king of his affection.   But on the establishment of the Christian
religion, by which the  selfish and bad  dispositions of the human
mind were intended  to be restrained or corrected,  and its better
qualities exalted, one  wife  only being allowed to one man, and
she being  supposed to possess  the entire  affections of  her hus-
band, every disease or infirmity, which might render her person
less agreeable to him, became  of infinite  consequence  to their
mutual  happiness.  Those only who in the present state of so-
ciety have had an opportunity  of seeing  the many evils which
flow from  this alienation of affection,  the  cause being  perhaps
unknown to the parties themselves, can be sufficiently aware of
the importance of this and many other accidents and diseases, to
which  women are subject;  and which are neglected and  disre-
garded, because they are not attended with immediate danger.
   Still the question remains to be decided,  whether women are by
any peculiarity  of construction, naturally  or necessarily subject
to a laceration  of the perinaeum; or  whether  this accident be
the consequence of erroneous opinions, and of alterations in the
frame, occasioned by the peculiar manners of society ;  or of any
adventitious  circumstance whatever, at the time of delivery.  It
was before observed,  (see chap.  2.  sect.  6.) that none of the
classes of animals are ever liable to a laceration of the perinaeum,
except when extraordinary assistance is given in cases of  other-
wise insuperable difficulty ;  and it is well known, that the lacera-
tion in  any important  degree does not universally, or  perhaps
generally, happen  to  those women who  are  delivered before
proper assistance can  be given.  It is  also to be remarked, that
as far as relates to the state of all the internal parts, the  changes
which they undergo at the time of parturition are not only effec-
tually, but most safely produced by the natural  disposition assu-
med by the parts, or the instinctive efforts of the parent.   From a
general survey of the  wisdom, order,  and benignity,  so clearly
apparent in all the designs of Providence, in every circumstance,
particularly, which  relates  to  the  propagation of the different
species of animals, and the coaptation,  as it were, of that wisdom
to the necessities of those  of every kind,  we  might perhaps be
justified in making this general  conclusion, that women, in every
circumstance  which relates \o their safety  and well-doing in na-
tural  parturition, are not left in  a more destitute state than ani-
mals ;  for though it were proved,  that  women are more liable to
natural evils and difficulties in parturition than animals,  the proofs
of these would equally satisfy our minds, that they are also pro-
vided by nature with irtfcmy  peculiar resources,  and with powers
which are, in  general,  limited only by  the  degree  of the  difficul-
ties which require their exertion.
  Nevertheless,  from the frequency of  some degree of laceration
of the perinaeum, when women  are delivered without assistance, 
ON LABOUR.
285
and from the  difficulty  with which  it is  sometimes prevented,
when the most judicious and skilful assistance is given, it is  be-
lieved bv  many, that women must often be  unavoidably subject
to it, and that the prevention 'must ever remain an object of  hu-
man skill.   Now, with respect to the first  statement, that of  the
laceration  happening when women are delivered  without assist-
ance, it does not follow that it is inevitable;  for even then it may
be the production of error in the patient herself, or  her friends.
Because, from the hurry and solicitude of their minds, and even
by their fears, she may have been encouraged to make great vo-
luntary efforts, when the head of the  child  was on the point of
coming into the world, merely because she was not  assisted; or,
after the expulsion of the head, instead  of waiting  for the body to
be expelled also,  some officious person presumed  to extract  it
without regard to time, or the  direction  of the vagina.   As to
the difficulty or impossibility of preventing the laceration m some
cases, we are  to consider,  that  what  may happen  in a state ot
society, might not have happened in a state  of nature; that the
foundation of the accident may have been  laid  by  something
done in the preceding  stage of the labour; and that it may be
very  much doubted,  whether some of the methods  practised lor
the prevention, may not in fact have been the cause  of the acci-

  eBut the  conduct of the practitioner is not to be guided by re-
flections on what his patients might do or  bear, with constitutions
healthy and firm, and with minds untainted  with prejudices; but
bv due  consideration of what they are now capable of doing or
bearing:  and he must  adapt his rules and his  practice to the
state in  which he actually finds them.   From some natural or
adventitious cause,  the  laceration of  the perinaeum in some de-
gree certainly does  often  unavoidably happen; but  as so much
of the future  happiness  of a woman may depend  upon  its  pre-
vention, we will grant, what in  many  cases  seems true  that it ts
always to  be prevented  by our skill and  care; as  no harm  can
arise from the opinion, though erroneous, if the  assistance we
 afford be judiciously given.                 #
   In the beginning  of  a labour, especially  with first children, it
 is not  unusual to find  the external  parts closely contracted, and
 void  of all  disposition to dilate;  yet in  the  course of a few
 hours  even  when  they have undergone no kind  of pressure or
 distention, but  merely by a disposition assumed from the-r con-
 sent with  the internal parts, they become relaxed and soft.  1 he
 lontrer  the time, therefore, which passes  between the commence-
 ment of a labour and  the birth of the child, the less liable to a
 laceration will  the  perinjeom be; for  it is scarcely  ever lacerated
 in  a very slow  labour,  whatever may be  the size of the child.
 But if it was possible to  hurry a labour  in such a manner, that 
286
INTRODUCTION TO MIDWIFERY.
the head of the child should be brought into contact  with,  and
pressed forcibly upon, the external parts, before they had acquired
this disposition to dilate, they woujd be universally torn,  unless
the accident were  prevented by art: and the chance of the acci-
dent would be according to  the degree of precipitation, and
perhaps many hours  after the act,  by which the labour  was
hurried, was forgotten.
  When the head of the child is insinuated  within the external
parts, if these do  not  easily  yield to the  occasion, it  has been
customary to dilate them artificially, under the idea of preparing
them, to allow of  the more speedy passage of the head.  During
every pain, it is obvious that the parts undergo  as  much dis-
tention as  they are capable of bearing without injury; and this
preparation, as it is called, lessening in fact the native disposition
to dilate,  irritating,  and causing,  also, an  additional stress upon
them, nothing is more clear than that this  method  of proceeding
contributes to their laceration.   All  artificial dilatation  of the
parts, all  attempts to  slide  the perinaeum over the  head of the
child speedily, are, therefore, to be forborne and avoided as per-
nicious.
   When the external  parts are very rigid, we have been taught,
that it is  of  great  service to anoint  them frequently  and un-
sparingly with some unctuous application,  with the  intention of
giving or improving that disposition to dilate, which is wanting.
If the parts are clothed with their proper mucus, as by  the use of
any application in the manner advised, that would be absterged,
we shall afterwards  find ointments of any kind very poor substi-
tutes for that mucus, and that there is little profit from their use,
under any circumstances.  But  if the parts, from  any cause,
should  become heated and dry, after the  application of flannels
wrung out of warm water, some  soft and  simple  ointment  may
be serviceable,  by abating their heat,  giving them a disposition
to  secrete their proper  mucus, and,  of course, favouring their
dilatation.
   In some constitutions, the different  parts  concerned are not
equally inclined to  dilate.   Sometimes the internal parts dilate
in the most kindly manner, when  the  external are in a contrary
state; and sometimes  the internal are very rigid,  when the ex-
ternal parts have  the  greatest aptitude to dilate, yielding to the
first  impulse of the head.   There is  in all  infinitely more diffi-
culty with the first than subsequent children, not  from  rigidity
only, but, if we may  be allowed the expression, from  ignorance
how to dilate;  and  from a certain degree of reaction evidently
perceived  in  the parts  during the continuance of every  pain, and
when it has ceased.   It is therefore often observed, that the head
of the child  advances more,  and  with greater safety, when  the
violence of a  pain  begins to abate,  because  the reaction  of the 
ON LABOUR.
287
parts is not then  so strong as while the pain continues in full
force.
   During a  pain there is  often reason to expect, that the head
of the child would be excluded ; but the moment the pain declines,
the head is retracted a considerable way into the vagina, and the
external parts close again.   No other inconvenience arises from
this cause than a  little prolongation of the labour,  which may
be  irksome, but cannot be injurious.   If the parts do not distend
favourably, should  the  head of the child abide within them in
the absence  of a pain, it may  sometimes be  expedient even to
repel it  in imitation of this natural occurrence,  for  the purpose
of preventing the laceration.
  When the  head of the child is every moment expected to pass
through the  external parts, we have been advised  by some, to
forward the emergence  of the  head from under the arch of the
pubes.   Others  have, on the contrary, assured us, that it is more
eligible to prevent,  for  a certain time, this emergence, by  which
means not only time is given for the parts to dilate, but the head of
the child is so disposed as to pass through them  in its smallest axis,
and less distension is thereby occasioned.   Whoever has reflected
upon  this subject would hesitate as much to believe, that  in the
general dispensation of Providence,  it should  have  been left to
human skill to guide the head of the child at the time of birth in
a direction different from that  in  which it most commonly pre-
sents, as that it could have  been  intended  for the generality of
children to have been brought  into the world by instruments, or
by  any human invention.   As  far as my experience enables me
to judge, neither of these methods  ought to be followed, nor any
other which requires a complication  of artifice;  for,  after  a trial
of them all, perhaps not always very justifiably,  I am convinced,
that the most  effectual method of preventing  a  laceration, or
any injury to the parts, is  to be founded on the single principle of
retarding, for a certain time,  the passage of the head of the child
through them.   This  retarding may depend on the composure
of  the  patient,  and  the  skill  of the practitioner; and   those
errors,  of which  the  former might  be  guilty,  the  latter must
endeavour to obviate  and  correct.   The greatest degree of
laceration, which ever occurred  to me, was occasioned by the
patient  suddenly withdrawing  herself out of  my reach, beyond
the possibility of my  giving any assistance, or supporting the
part at  the instant  when  the head of the child  passed over the
perinaeum; an accident against  which  I  ought to  have been
guarded.
   When the  head of the child is nearly born,  the effort, to expel
is made instinctively,  and it  is usually  vehement,  the  breath
being retained for the purpose of strengthening that effort.  The
patient may  also, from a  persuasion of its being  necessary and 
288
INTRODUCTION TO MIDWIFERY.
proper, or at the instance of her friends, strive with much voIun»
tarv exertion to add to the force of the pain, for the purpose of
expelling  the  child  more speedily.   If we  presume, that the
danger of injuring the parts depends chiefly upon the rapidity
with which  the head may be  expelled, and  that these are only
able to bear without injury so much distention as is occasioned
by the  instinctive efforts, then all the additional voluntary force is
beyond what is either needful  or safe (see chap. 2. sect 6.)  It
is, therefore, requisite that  we should do  away this voluntary
force,  by convincing the patient of its  impropriety, and  dis-
suading her from exerting herself; or lessen at least the volun-
tary effort, by urging her to talk or cry out during the time of
a pain, which will prevent her from retaining her breath ;  or, if
her  sufferings are  so great that she  cannot command her own
actions, then the efforts  she makes must be resisted on our part
by the application of some  equivalent force, in  the  manner we
shall soon consider.  When the patient has been outrageous,
and  the  danger of a laceration  very great, I have sometimes
gained a respite by telling her suddenly, in the height of a pain,
that the child was already born.
  Every thinking man will endeavour to carry the principles he
has considered and approved in his  remembrance, through the
whole  course  of  his  practice  ; but  the  methods by which  his
principles are pursued must be carefully suited to the particular
exigences of every individual   case.   Yet, when  principles are
acquired,  there will often  be considerable difficulty in applying
them to practice; for it is not unusual to see them at  variance in
medicine as well as  morality.   On  the subject of which we are
now speaking, there are a  number of little  circumstances, the
knowledge of which can only be learned by experience, yet for
these we should be prepared by reflection, when they occur in
practice.  But it  will generally be   sufficient for the operator
to  resist  the  progress  of the  head   of the child, during  the
time of a pain, by placing upon it   the fingers and  thumb  of
the right hand, so formed that they may bear upou many points;
or, to apply the balls of one or both of the thumbs in  such a
manner that they  shall at the same time  support the  fourchette,
or thin edge of the perinaeum.  But in the first children,  when,
from the  vehemence of  the patient,  the strength of the  pains,
and the rigid state of the parts, there is great  reason to appre-
hend a laceration of the  perinaeum, then, occasionally calling in
the other  means to  our  aid, we shall be able to give the most
powerful and effectual support, by applying the palm of the left
hand, covered with a soft cloth, over the whole temporary  (see
chap. 2. sect. 6.)  and natural perinaeum, and the right hand em-
ployed as was before mentioned, with a force competent to resist
the exertions of the patient during the violence of the pain.   In 
ON LABOUR.                     289
 this way we are to proceed, till the parts are sufficiently dilated,
 when the head may be permitted to slide through  them  in the
 slowest  and gentlest manner; and we are never to quit our at-
 tention, till  it  is perfectly cleared  of  the perinaeum.  Should
 there be any delay or awkwardness when the perinaeum  slides
 over the face, the fore finger of the  right hand mast be passed
 under its lateral edge, by which it may  be cleared of  the mouth
 or chin, before the support given by  the left hand is withdrawn.
 When the pains are exceedingly strong, and the patient restless
 in her efforts, the head will sometimes be expelled with wonder-
 ful velocity, in opposition to all  the  resistance  we are able  to
 make ;  but by this calm  and steady proceeding we may be as-
 sured that we  shall, under all circumstances,  wholly prevent,  or
 greatly lessen, all the  evils to which she would have been liable,
 if our conduct had been different.
   It is necessary to observe, that these  attempts to prevent the
 laceration of the perinaeum  produce  some effect upon the head
 of the child, and upon the parts of the mother.  In the applica-
 tion,  therefore,  of the  resisting force, we must  not only be care-
 ful, that the  position  of the  patient  is proper, and such as will
 allow  us to act with advantage, but  that we do not make any
 injurious or  partial pressure; because, if a partial support be
 given to the perinaeum, the head  of the child is projected against
 an unsupported part, and the danger of a laceration is increased.
 The support  must be  equally applied, and  uniformly exerted,
 during the time of every pain ; and then there will be no greater
 prejudice done to the child by the pressure we make, than what
 might have been occasioned by the mere rigidity of the parts.
   When the  head of the child is expelled,  perhaps the conse-
 quences  of an  instant transition from  extreme misery to total
 freedom  from pain, and to positive joy, are in  no case, to which
 human  nature  is subject, more  conspicuous  and  interesting,
 though the delivery be not completed. It was formerly supposed
 necessary for the practitioner to extract the body of the  child, im-
 mediately  after the expulsion of the head, lest  it should  be des-
 troyed by confinement in this  untoward  position.   But  expe-
 rience has not only proved, that  the child is not on that account
 in any particular danger, but that it is really safer and better,
 both for the mother and child, to wait for the return of the pains,
 by which it will soon be expelled ; and a more  favourable exclu-
 sion of  the placenta will  also  by this means  be obtained.  In
 the course of a few minutes  after the expulsion of the head, the
 action of the uterus returning, the shoulders of the child advance,
 and the external parts  of the mother being again brought upon
 the stretch, the  practitioner  must place the  fingers of his right
hand  on each  side of the neck, and at the same time with the
left, support the perinaeum  with as much  circumspection as  when 
290
INTRODUCTION TO MIDWIFERY.
the head was expelled; he must then conduct the body slowly in
the direction of the vagina, till it is wholly extricated, though two
or three pains  are  sometimes required for the expulsion of the
shoulders of the child, after the head is born.*
   The child is to be placed in such  a situation, that the external
air may have free access to its mouth, its head being covered; care
being then taken of the mother, we must proceed to tie the navel-
string in  the manner recommended in the  next  section.

                         SECTION  IX.
   The operation of tying and cutting  the navel-string when the
child is born, though in itself of no  great importance, was for-
merly thought to require so much skill  and judgment, as to give
a professional name to those, who are now called practitioners in
midwifery. But every thing which relates  to the treatment  of the
mother or child is of some consequence ; and even in trifling mat-
ters there is a propriety of manner, the want of which may les-
sen the estimation of every person's  character.
   It seems to have been a practice with the ancients, to wait for
a certain time after the birth of the child  for the exclusion of the
placenta, before the navel-string was tied  or divided; and if the
child  was  born  apparently dead, or in a very feeble state, the
placenta, when expelled,  was laid upon its belly, as a restoring,
or comforting application.   When the  child revived but slowly,
or when  the signs of life declined, it became a custom  to lay the
placenta on hot embers,f or to immerse it in hot wine; and the
heat thereby conveyed was supposed to stimulate the weak or de-
caying powers of life to more vigorous action.  It has since been
the practice, to divide the funis immediately  after the birth  of the
child ; and  the  weaker  this  was,  the more expedition  it was
thought necessary to use; for, the child being supposed to be in
a state similar to that of an apoplectic patient, a certain portion
of blood might by this means be discharged from the divided
funis, and  the  imminent danger instantly  removed.  There is
another method which I have seen practised, the very reverse of
the preceding; for in this, the loss of any quantity of blood being
considered as injurious, the navel-string was not divided, but the
blood  contained in its vessels was repeatedly  stroked from the
placenta toward the body  of the child.   In all these different
  *  [To guard against a laceration  of the perinaeum, is among the
most essential duties of the accoucheur in a natural labour : and after
all our attention, to prevent this serious  occurrence is sometimes
impossible.  Occasionally, though very rarely, the laceration takes
place in the centre of the perinaeum.  F.]
  t See Peu Pratique des Accouchements, Livre I.  Chap. xii. 18. 
ON LABOUR.
291
methods, and many others founded on  caprice, or on  directly
contrary principles, children have been treated in different times
and countries, and yet  they have generally done well; the ope-
rations of Nature being very stubborn, and happily admitting of
considerable deviation and interruption, without the prevention
of her ends.
  There is yet in  all things a perfectly right as well  as a wrong
method; and, though the advantage  or disadvantage of either
may be overlooked, the propriety and  advantage of the right me-
thod must be evidently proved by individual cases,  and of course
by the general result of  practice.   In this,  as well as in many
other points, we have been too fond of interfering  with  art, and
have consigned too little to nature, as if the human  race had been
destined to wretchedness and disaster,  from the moment  of birth,
beyond the allotment of other creatures.
   Perhaps the changes which take place in the body of the child,
immediately after  its birth, at least the manner  in which  they are
produced,  are not perfectly understood at this  time.*   But we
know if the child  is in a healthy state, that it usually cries lustily
and continually,  when the air  rushes into its lungs, which are
thereby expanded.  This cry,  which does  not seem  to  be occa-
sioned by pain, but surprise, is in its consequences extremely im-
portant, as it is the cause of an exertion of all  the  powers of the
child,  and enables it to acquire a new manner of  living, incon-
sistent with, and very different from, that  which it possessed be-
fore it was born.  But the change from uterine life, as it may be
called, to breathing life, is not  instantaneous,  but gradual; and
the uterine  life  continues till the breathing life is perfected, as is
proved by the continuance of the  circulation  between the child
and placenta for some time after it has cried.  As  the breathing
life becomes perfected, the uterine life gradually declines, and the
manner of its declension may be proved by attending to the pul-
sation of the navel-string, which first ceases at the part nearest the
placenta,  and then,  by slow  degrees, nearer and  nearer to the
child, till at length it entirely ceases; so that the whole  of the
circulating blood  ultimately resides in the  body of the child, and
the navel-string which was before turgid  becomes quite flaccid.
It seems reasonable to believe, that the continuance of uterine life
after  the birth of  the child was designed for its preservation from
the accidents of its state at that time,  should the acquisition of its
breathing fife be by any cause retarded or hindered.  If,  then, the
  * See Peu Pratique des Accouchements, Livre I. Chap. xii. 18.;
and an Essay on the Treatment of Women in Childbed,  written by
my very ingenious and indefatigable  friend,  the  late Mr.  Charles
White. 
292          INTRODUCTION TO MIDWIFERY.
practice of tying or dividing the navel-string the instant the child
is born  be followed,  though it were before vigorous, it will  in
some  cases immediately decline, and never acquiring  its perfect
breathing life, may in a short time die: or, if the child were in a
feeble or a dubious state,  possessing only that life which it had
during its residence in the uterus^ as by tying and dividing the
navel-string that life is destroyed before the breathing life is ac-
quired, it must inevitably perish.   We may therefore  safely con-
clude, that the navel-string of a new-born infant ought not to  be
tied or divided, till the circulation  in it has ceased spontaneously;
nor would the child suffer, though the funis was never tied, if it
was not divided.
  With respect to the manner of tying the navel-string there has
also been much difference of opinion, whether there should be one
or two ligatures,  and in what part these should be fixed.   Two
ligatures were advised, on the presumption, that by the end of the
funis next the placenta the maternal blood might be discharged,
and the parent brought into  great danger,  as if there were two
currents  of blood circulating in the vessels;  and by some it was
also supposed proper to use two ligatures, for the purpose of  re-
taining the blood, presuming that the placenta would be cast  off
more commodiously, in the manner  of a gorged leech.  On  the
contrary, one ligature has been recommended, that we might have
an opportunity of draining away  as much blood as possible from
the placenta, by the divided end of the funis, which was supposed
to produce an advantage equal to the diminution of the bulk of
the placenta,  and to favour its expulsion.   But, if the custom of
deferring to make  the ligatures   till the circulation in the  funis
ceases to be established, all this reasoning in favour of one or two
ligatures will fall to the ground.   Yet, as there is a possibility in
the case of twins, with a single  or  communicating placenta, of the
child yet unborn,  losing its blood by the divided funis  of that
which is born, and from  the habit of using them, on the whole, I
prefer two ligatures,  more especially as no harm can  arise from
them,  even if one should be useless.  As  to the part where  the
ligature ought to be fixed, it is of no  real consequence;  because
the future separation of the funis will not be made at the ligature,
wherever that is fixed, but at a line evidently marked at the time
of birth, and close to the belly of the child ; and as to the mate-
rials used, provided they  are not so thick as to be cumbersome,
nor so thin as to cut the funis, it is all that is required.
   In the course of ten or twenty minutes,  and sometimes lon-
 ger,  after  the  birth  of  the  child,  the circulation in the funis
having ceased,  and the  funis itself become empty and flaccid,
 one ligature is to be fixed upon it about three inches from  the
 belly  of the child, and another  at twice that distance, with so
 much force as to repress the circulation which may happen to 
ON LABOUR.
293
 return, and yet not so firmly as to divide it.   The naval string
 may  then be  cut with a pair of scissors between the two liga-
 tures, and the child given to a careful assistant.  It was former-
 ly the custom to divide the funis under the bed-clothe6; but,
 having once known a very deplorable accident happen from this
 cause, I make it  a general rule decently to withdraw the child,
 that 1 may  have an opportunity of seeing when I tie or divide
 the funis.*
                         SECTION X.
   Soonf after the birth of the child, it is  proper to apply the
 hand upon  the abdomen of  the mother, to  ascertain  whether
 there  be  another child ;  or whether the uterus be contracting
 in a manner favourable to the separation and  exclusion of the
 placenta.   Both the doctrines and customs of practice, regard-
 ing the management  of  the placenta, have been exceedingly
 different, even  in common cases ;  and though one method of
 proceeding may be more generally preferred and followed than
 the rest,  there is,  in  the  management of the placenta, much
 diversity in the conduct of individual practitioners, who may be
 suspected to act sometimes in a manner contrary to their own
 judgment, in  compliance with the prejudices of those by whom
 they are employed.  The minds of all women are full of soli-
 citous  fears till  the placenta is brought away; and the sooner
 this is done, after the child is born,  the more they are gratified.
 But though the discovery of truth,  and the  fidelity  of practice
"founded thereon, may not always be acceptable ; yet in all prac-
 titioners, however desirous of obliging, there must be some firm-
 ness  of mind, some determination to act upon principle, or they
 will be perpetually involved in error, and led to do what may
 be productive of immediate or distant mischief, in order to avoid
 the evil of present censure.
   In the history which has been given of the former stages of
 a natural labour, it appears that all the passive changes which
 the parts undergo,  and all the active powers exerted fcr pro-
 ducing these  changes, are not only  entirely  independent of the
 will  of the patient, but  are fully  equal to the end which they
 were designed to accomplish,  without any assistance ;  which is
  * [After the child shall have manifested life, by its respiration,
crying, &c. we may apply the ligature to the chord.  I do not see the
necessity of waiting until all pulsation of the funis has ceased. On the
other hand, the premature tying the chord has destroyed life.  A
case of this kind came under my observation several years ago. The
first ligature ought to be applied about an inch and  a half from the
navel; the second, about two inches beyond the first.  F.J
   t  [immediately. F.] 
294         INTRODUCTION TO MIDWIFERY.
no more wanted for the purpose of forwarding a natural labour
than for any of the ordinary functions of the body.  When we
have seen a child safely  expelled by a process beautiful, and
regulated by the greatest wisdom, there seems to be no reason
why we should be  apprehensive of error or inability in those
powers for the separation or exclusion  of  the  placenta, which
is but an inferior or secondary  part  of the same process; or
why we should not in this, as in all other cases of medicine, be
first convinced of the necessity of using art, before we attempt
to give  assistance.   On the proper management of the placenta
the life of  the patient  may  depend;  and it is  therefore fitting
and necessary, that our conduct should be guided not by preju-
dice, but by the dictates  of reason and experience.
  After a natural labour, especially  with a first child, the pain
which the patient has suffered, and the exertions by which the
expulsion of the child was effected, will have occasioned a pro-
portionate degree of temporary fever,  and she will be in the
same situation as if she had undergone  some excessive fatigue.
By the  birth  of the child she is freed from her suffering, and it
must be our first employment to restore tranquillity to her mind,
to calm the hurried circulation of the blood,  to recover her from
her fatigue,  and to bring her as soon as we can into a natural
state; and  this is to be done by keeping her perfectly quiet,
affording her  at the same time some refreshment, suitable to the
circumstances to which she may be reduced.  In the course often,
and not often more  than twenty minutes, the action of the ute-
rus is again excited for the purpose of  expelling the  placenta,
which is indicated by pain, less in degree, but in other respects
like that of which she complained when the child was expelled.
It seldom happens that the placenta  is either wholly separated
or expelled by the first pain;  but when that has ceased for a
few minutes,  it is again renewed ; and, on examination, the pla-
centa is often found descended, or descending,  into the vagina,
where it may with safety and propriety be suffered to abide, till
it is wholly expelled by a repetition of the pains.  But if the
placenta should descend  very slowly,  or the patient be much
disturbed, the practitioner may take hold of the funis,* and by
gently pulling in the time of a pain, and in a proper direction,
by the  most moderate action, favour  its operation and descent.
  * When the young has been a short time  expelled,  carnivorous
animals, apparently feeling pain, lay hold of the naval-string with
their teeth, in  order to extract the placenta.  It is probable that a
woman in a state of nature, would, with her own hands, give some-
thing like the same assistance ; and in the force I use to bringdown
the placenta, I generally bear in mind this circumstance. 
ON LABOUR.                    295
But whether the placenta should descend into the vagina spon-
taneously, or be brought down by the gentle assistance  given,
it should be  suffered to remain there till it is excluded by the
pains ; at least it should not be extracted before the hurry oc-
casioned by the labour is wholly composed,  and the  uterus has
had sufficient time to contract  in such a manner, as to prevent
any undue, or alarming loss of blood.   The  placenta seldom
remains more than one hour in this situation;  but if it should
not be excluded at the end  of that time, we  may again  take
hold of the funis, and, aiding the force of a  pain, in the gent-
lest and slowest manner, bring the placenta  through the os ex-
ternum.   We must even then  be cautious to bring  down the
membranes very slowly, and as perfectly as we can, that any
coagula formed in the cavity of the uterus may be  enveloped in
them, and one principal cause of after-pain be removed.  Then
the patient, being put in a comfortable state, and as little dis-
turbed as possible,  may be left to her repose.
  In this  third stage of a labour many inconveniences and many
impediments  to the exclusion of the placenta may occur; the
generality of which require a longer time to be given,  and some
the assistance of art,  for the removal  or prevention of danger.
But of all these  difficulties, and the means of giving relief, we
shall speak more fully when we come to the treatment of Uterine
Hemorrhages.
  I take this opportunity of speaking of a point  upon which we
may be called to give an opinion in a court of judicature;  that
is, whether a child be born living or dead.  What is now consi-
dered as a legal proof of a living child 1 cannot ascertain.  When
a child cries aloud, there can be no doubt of its being born alive,
however speedily it might afterwards die.   But a child has been
often known to breathe, which could never be excited to cry ;  and
though a  child may neither cry nor breathe, the circulation  of
the blood may be distinctly perceived both in the  funis and heart,
yet not be recoverable; and we can scarcely be allowed to say
that a child which breathes is still born,  nor one in which the
blood circulates.  Of both these circumstances any person with-
out medical knowledge may judge, and  any corrupt  evidence
frustrated  as  readily as in other cases subjected to the inquiry  of
the  laws.*
  * [In the whole extent of medical jurisprudence there is no point
more  frequently agitated, or one  in which more serious consequen-
ces may be involved, than the  subject  of infanticide.   The law,
departing  from  its usual  lenity, presumes the child  to  have been
born alive, and renders it necessary that the contrary be made out
by strict evidence.  Of the numerous authors on forensic medicine 
296          INTRODUCTION TO MIDWIFERY.
 I know of no one who has treated  this part  of it with equal ability
 and satisfaction as Dr. John B. Beck of this city, in an Inaugural Dis-
 sertation  for  the  doctorate in medicine in the University  of New-
 York, published in 1817.  The value of  the information will justify
 the extent of the extracts which I have made : for further views I
 refer the  reader to the  Dissertation itself.
   " In cases of Infanticide,'''' says  Dr. Beck, " it is only from the
 circulation and respiration that any thing is to be learned: the brain
 and nerves leave no trace of their influence behind them.
   '* Of the blood having circulated  after birth.—There are two cir-
 cumstances from which a conclusion on this point may be drawn ;—
 the appearance of the blood itself,  and the ecchymoses on the body
 of  the child.
   " 1. The difference  between the  blood of the foetus,  and  the
 child  after birth, has  been  particularly noticed  by Bichat   He
 made  numerous  dissections of young guinea  pigs while yet in the
 womb of their mother,  and he uniformly found the blood of the ar-
 teries and veins presenting  the same  appearance, resembling the
 venous blood of  the adult.   He  made the  same  observations in
 three experiments of a similar nature which  he made upon pups.
 He  also frequently dissected human  foetuses who had died in the
 womb, and found the same uniformity in the arterial and  venous
 blood.  From these experiments,  he concludes, that no difference
 exists between the arterial and  venous blood  of the fcetus, at least
 in external appearance.    The chemical constitntion of the blood of
 the  fcetus appears, also, to differ from that of  the child after birth,
 or the adult.  Fourcroy, in analyzing it, found it destitute of fibrous
 matter, as well as  of the phosphoric salts which are always detected
 in the blood of the adult.   He also  discovered, that it was incapable
 of becoming florid by exposure to the influence  of  atmospheric
 air."
  " 2  Ecchymoses or extravasations of blood on the body of the child,
 produced  by blows or other injuries, prove that it enjoyed  vitality
 at the time they were inflicted ;  for in a dead child, as the blood has
 ceased to circulate, it could not flow to the injured part, and, there-
 fore,  there would be no appearance of  extravasation.  Professor
 Mahon  mentions  another possible cause of such extravasations,
 which should not  be overlooked.   He says it may  result from
 putrefaction, which,  by means of  the air  that is generated,  bursts
 the veins,  and then blood from very distant  parts  of the body is
 insensibly carried  along to this outlet, so  as to form a considerable
 extravasation.  It  could not certainly be  very difficult to discrimi-
nate in a case  of this kind, yet it teaches us a practical caution of
 some consequence, which is, to pay particular attention to those
 circumstances which tend to favour the process of putrefaction, as
 the climate, season of the year, and place where the body is found.
  " Of the child having respired after birth.—The act of respiration
constitutes  the great distinguishing feature between adult and foetal
life.  Its commencement is succeeded by  revolutions in the  animal
economy,  the most wonderful  and interesting.   The pulmonary
system is,  however,  principally affected by it, and it  is there that 
ON LABOUR.
297
 the medico-legal inquirer must search for those changes, which are
 indicative of the exercise of that function.
    " In examining a child which has never breathed, its thorax is found
 flattened,  or, as it were,  compressed ;  the lungs  are dense, of a
 reddish brown colour, and in a collapsed state ;  they are compara-
 tively small in size,  occupying only the upper part of the chest,
 and  hence they leave the  heart and percardium uncovered ; on ex-
 amining the pulmonary vessels, they are found to contain little or  no
 blood.   If the lungs be taken out of the thorax and put into water,
 they will sink to the bottom, and if their weight be compared with
 the weight of  the  whole  body of the child, they  will  be  found to
 be to each other as 1 is to 67 or 70.  The reverse  of all this is met
 with in a child that has respired.   The thorax is more  arched, and
 its size augmented in every respect; the lungs are dilated; they
 fill up the cavity of the thorax, and cover the lateral parts  of the
 pericardium ; their colour is less  deep,  and the pulmonary vessels
 are moreover distended with blood.   1 heir specific, as well as abso-
 lute weight, is  also changed, and accordingly, when put into water,
 they will float upon its surface, and when compared with the whole
 weight of the  body,  they will be as 2 is to 67 or 70 ; or in  other
 words, the absolute weight of the lungs in a child which has breathed,
 will double that of the fcetus  previous  to respiration.   In addition
 to this, they have an elastic feeling, and on cutting  into  them, there
 is a crepitus caused by the extrication of the air from the pulmonary
 cells.   Beside the effects thus produced upon  the lungs themselves
 by the admission of air into them, there are other changes effected
 in the neighbouring organs.  The shape of the diaphragm is altered
 by the expansion of the lungs, pressing it down and diminishing its
 arch  ;  and from  the same  cause, the  situation of the  liver and
 stomach will be lower."
   " Of the floating of the lungs in water, as a test of previous vitality."—
 Dr. Beck  first states  the  test and then considers the principal ob-
jections which may be brought against it.
   " It is observed," says Dr.  Beck, " that  upon putting into water
the lungs of a child which has never breathed,  they will sink to the
bottom ; but that if it has once respired, they will float.   The rea-
son of this is so  obvious, that it needs no  explanation.   Now from
these  facts the general conclusion necessarily  follows,  that where
the lungs of a child float in  water, it must have  respired, and there-
fore must have  been born alive. And, on the other hand, when they
are found to  sink,  it is an evidence that the child has not breathed,
and therefore was not born alive.   Such  are  the general  proposi-
tions.  Let us now see if it is safe to trust to them  in all cases, by
considering the different objections which  have been urged against

   «« Objection 1. Dr.  W. Hunter says, that« a child will very com-
monly breathe as soon as its mouth is born, or protruded from its
mother; and in that case, may lose its life before its body be born,
especially when there happens to be a considerable interval of time
                              38 
298           INTRODUCTION TO  MIDWIFERY.
between what we may call the birth of the child's head, and the
protrusion of its  body.*
  " Morgagni and Haller appear to be  of a similar opinion,  and
Mahon does not  deny its possibility, although he considers its occur-
rence as not very probable.  Hebenstreit, on the contrary, accord-
ing to Mahon, boldly denies that it ever can  take place.   Notwith-
standing this diversity of sentiment, the objection has obtained cur-
rency, and,  therefore, deserves  to  be examined.   It involves  two
cases:  1st.  The mouth may be applied to the os externum, and  res-
piration be  effected without the delivery of any part of the body.
2d. The head may protrude while the rest of the body is detained,
and in this  position  air may be inspired.  In both  these cases, the
objection supposes that the child  may die before  it is delivered ;
and therefore, the evidence afforded by  the floating  of the lungs
would be fallacious.
   " With regard to  the first of these, it may be remarked, that it is
a case extremely improbable.   The mouth may present in the man-
ner just stated,  but any efforts  at breathing,  so prematurely  and un-
naturally, must necessarily be very imperfect, and quite insufficient
to dilate the lungs.  Besides, if the child dies between the time  of
 the presentation of the mouth, and the expulsion of the whole body,
 it must be  caused by natural debility, or some accident during  deli-
 very, the most  common of which is pressure on the cord, so as to in-
 terrupt the circulation.   That the former cannot occasion it, is pro-
 ved by the very fact of respiration having  taken place ; for the ex-
 ercise of that function so prematurely, necessarily implies a degree
 of vitality  and vigour inconsistent with the supposition of such ori-
 ginal feebleness.  Nor can pressure on the cord be the  cause, for it
 is wholly immaterial whether the circulation in it be stopped or not,
 after respiration has  commenced, as  the foetal circulation  has then
 become unnecessary.   The second case  supposes the head of the
 child to be protruded while the body is detained,  and in this situa-
 tion, death to  ensue after respiration has  been effected.   That a
  child may  breathe in this position is  granted ; but is it likely that it
  will die under these circumstances ? The remarks made before, on
  the child dying from debility,  or from interrupted circulation in the
  cord, apply with equal.,  if not greater force, in the present instance,
  and they  prove that  the child cannot suffer from either of those
  causes.  Besides,  it is wholly incredible that the body  should  not
  shortly follow the protrusion of the head ;  because if that,  being
  the largest part of the child, had once passed, the rest would present
  no  obstacle to speedy delivery.   But granting for  a moment, that
  after the  protrusion of the head, the body is retained by the firm
  contraction of the  female organs around it, then  it is wholly incon-
  ceivable  how  respiration should ever have  taken place, for this very
  contraction would prevent that dilatation of the thorax which is ne-
  cessary for the performance of that function.   Practical writers  re-
  mark, that there is  no danger attending a child  in this situation.
     " Objection  2. The child may have been born dead, and yet the 
ON LABOUR.
299
 lungs will float when put into water, either from artificial inflation or
 putrefaction.
   " The facts here stated are true; but unless it can be proved, that
 there are no means of discriminating between the floating of the lungs
 as occasioned by these causes,  and natural respiration, the objec-
 tion cannot be admitted  as of any weight.  Let us examine each in
 order :
   "Artificial inflation of the  lungs.—It has  been doubted by some,
 whether this could ever be effected.  Heister states, that he proved,
 by actual experiments,  that air blown into the lungs cannot dilate
 them.   Hebenstreit and  Roederer maintain the same doctrine.  The
 majority of writers,  however, assent to its possibility, and admit that
 the lungs will float in consequence of it; at any rate, there can be no
 question, but that a part of the lungs, at least, may be inflated artifi-
 cially.  And there are not wanting occasions when this might be  at-
 tempted.   It is not incredible that it might  be the  result of malice
 designed to injure the innocent mother,  or of maternal tenderness
 endeavouring to resuscitate a lifeless child.  It becomes, then, a ques-
 tion of great interest, to determine  whether the existence of air in
 the lungs be the product of nature or of art.   And it is fortunate for
 the cause of justice, as  well as humanity,  that this  can be done.
 Buttner appears  to have been the first who  proposed a test for this
 purpose, both certain and obvious,  founded upon the difference be-
 tween  the  foetal  and  adult circulation.   In  the former, it is well
 known, the blood does not pass through the lungs, whereas, as soon
 as respiration commences, the old passages are closed, and the whole
 mass is forced through those organs.   If, therefore, a child has been
 born dead, the arteries and veins of the lungs are found destitute of
blood,  and in a collapsed state, notwithstanding any artificial inflation
 that may have been practised upon them.  On the contrary, the vas-
 cular distention of the pulmonary  organs, proves that the  child has
 breathed, for nothing but natural respiration can produce this effect.
   "Another method of determining this question, is by taking the ab-
 solute  weight of the lungs, according  to the test of M. Ploucquet,
 which  shall  be noticed more particularly hereafter.
   "A third test for this purpose  has been suggested by  M. Marc.  He
 considers that art can  never completely inflate the lungs ;  and from
 the greater  difficulty which attends  the admission of air into the left
 lun<»-, he is induced to believe, that the inferior extremity of that lung
 will remain in a collapsed state, and float but imperfectly,  or not at
 all.  The truth of this position, though extremely probable, does not
 appear to be supported by a sufficient number of experiments to al-
 low its  adoption as a general and infallible rule.  With  regard to the
 two first, they are founded on principles so just and immutable, and
 their practical application is so certain, that fhey appear to have re-
 moved all the doubt which previously existed.
  "The putrefaction of the lungs.—It has been a question of much dis-
 pute, what the effects of putrefaction are upon lungs that have never
 respired : some  asserting  that  it renders them specifically heavier
 than water, and consequently they will sink when thrown  into that 
300
INTRODUCTION TO MIDWIFERY.
fluid, while others, of equal respectability, maintain a contrary opi-
nion.  Both parties adduce eKperiment9 in proof of their particular
doctrines.  The only solution that can be given to these contradic-
tory results, is by  admitting that all the experiments have not been
performed with sufficient care, so as to lead to conclusions uniformly
just.   Every thing depends upon the manner in  which they  are con-
ducted.  The most accurate experiments, I believe, were those per-
formed by Mayer, as related by Mahon.   From his observations  it
appears, that in the incipient stage of putrefaction, lungs that have
never respired will float in water, whereas they will sink, if it has
continued long enough to completely destroy their  organization, and
thus extricate all the air.  These results  have been corroborated by
the  observations and experiments of others, and their truth cannot
be doubted.   It seems  singular, indeed, that they should ever have
been quettioned,  when a case perfectly  analogous is witnessed  in
every person that  is  drowned.  The body at first sinks,  afterwards
rises to the surface, when putrefaction has generated air sufficient to
render it specifically lighter than water, and finally descends again
upon the extrication of that air.
  " Such being the effect of putrefaction, it becomes a question of con-
sequence, to determine in what way we can distinguish between the
floating of the lungs as caused by natural  respiration, and that which
is the  consequence of decomposition.  Haller directs, that in a doubt-
ful  case of this kind, the other viscera of the body should be put into
water as well as the  lungs, and if they also float, it is a proof of pu-
trefaction.  '  Id si viderit, non aer in pulmonem per respirationem
receptus causa erit natandi, sed aer ex humoribus carnibusque per
communem legem putredinis expeditus.'
  " This rule is not strictly correct,  for it is found that the lungs,
from the peculiarity of their constitution, resist putrefaction  much
longer than other parts of the body.   Faissole and Champeau, in ex-
periments which they  made on drowned persons,  observed that the
lungs  remained sound  after the whole body had become putrified,
and Mahon noticed the  same fact in his dissections  of dead bodies.
   " Dr. William Hunter lays down the following rule, which appears
to  be founded in truth, and accordingly  it has  been adopted by Fo-
dere\  Marc, and other writers.  «If the air which is in the lungs be
that of respiration, the air bubbles will hardly be visible to the naked
eye ;  but if the air bubbles be large, or if they run in lines along the
fissures,  between the component lobuli of the lungs, the air is cer-
tainly emphysematous, and not air which had been taken in by breath-
ing.'
   " Two facts, then,  appear to be evident, viz. that the lungs are
less in danger of putrefaction than  any other organ  in the human sys-
tem, except the bones, and therefore,  that it is perfectly safe to make
experiments upon them, even after decomposition has commeuced in
other parts of the body; and that when  putrefaction has  attacked
them, it is possible  to distinguish  its  effects  from  those of respira-
 tion.
   «* But suppose the lungs are found to be actually in a state of pu- 
ON LABOUR.
301
trefaction, is the physician then justified in drawing any conclusions,
or in giving any opinion ?  Mahon  directs in  such a case, that it is
better for the medical witness to be  silent, and to leave to the magis-
trates the task of finding out other grounds of accusation.   Marc,
however, a writer who throws light  upon every  subject that he
touches, answers this question  in the affirmative, and proposes two
characteristics to enable him to make a positive decision. The first
is, that lungs which have respired,  notwithstanding they have beep
attacked by putrefaction,  always  have a crepitus  when cut into ;
whereas those  which  have never  respired, although they float in
water, are  destitute of this  peculiarity.  The second, and which he
considers the most decisive and certain, is this ; that upon squeezing
out from a  section of the lungs the matter  developed by putrefac-
tion, they will sink if they are from a child born dead ; but on the
contrary, if they are the lungs of a child born alive, they will, not-
withstanding, continue to float.
  " Objection 3. The child may have breathed, and yet the lungs  in
some cases sink, as  when  affected  by certain  diseases which shall
increase their specific gravity, or when the respiration  has  been so
imperfect,  as not to dilate them sufficiently to cause them to float in
water.
   "The first part of this objection has been deduced principally from
analogy.  It has been observed, that various morbid affections of the
pulmonary organs of adults, as calculi, schirri, peripneumony, hy-
drothorax, ulcers, &c.  will cause  their subsidence  in water; and
hence it has been inferred, that the same  might take  place in the
fcetus.   It  cannot be admitted, however, that  these  morbid condi-
tions will frequently occur in the foetus, for it  is not exposed to the
influence of the  causes which usually produce them.  Haller, not-
withstanding his great experience and extensive learning, relates no
instance of it, and expressly asserts, that they  are very rarely found
in the foetal state.   * In adulto homine aliquando, in foetu ranssime,
ut pulmo calculis, schirris,  aliave materie morbose  gravis in aqua
subsideat,  etsi quam respiraverit.'   Brendelius, in speaking on this
subject, relates  only a single case of  an abortive fcetus  which had
schirrous lungs, and considers it a singular occurrence.  It appears,
then, as well from reason as from facts, that the objection is founded
upon the existence of circumstances barely possible, and by no means
probable.   As such, however, it  demands consideration ;  and it is
necessary  to suggest the means by which a false judgment may be

P " To any one who has been accustomed to the examination of the
 human body in its different states of health and  disease, it cannot be
 very difficult to decide whether the lungs are in a sound  or  morbid
 condition.   It would  appear, therefore, at first view, that m such
 cases no difficulties  could occur, which a sound judgment, aided by
 anatomical knowledge, could not remove.  But admitting that these
 are not always sufficient, there is still  a resort left in the very test
 aeainst which this objection is adduced.  The objection takes it for
 granted that  the child has breathed;  whether feebly or vigorously 
302           INTRODUCTION  TO MIDWIFERY.
is a matter of no consequence.  Some part,  therefore, of the lungs
must contain air, and although the quantity of it may be too  small to
cause the whole organ to float, yet if it be divided into a  number of
pieces, and any one of them remain on the surface, there cannot be
a moment's hesitation about  the conclusion  to be  drawn.  Fodere
states, that be frequently made experiments  upon lungs that were
schirrous, or had congestions  of blood, and he  uniformly found,  that
although they  sunk when put into water entire, yet when  cut  into
pieces, some of them always floated.
  " With  regard to the  second  part of the objection,  it is admitted,
that the child when born may be so feeble, as only to  be  able to in-
hale* a small quantity of air, and therefore that the whole lung will
not float in water.  Heister, indeed, relates the case of a very  fee-
ble infant, whose lungs sunk in  water, though it lived nine hours af-
ter birth.
  " The same method must here be adopted, as in cases  where the
lungs are diseased ; they must be  cut into several parts, and experi-
ments must be  instituted upon each.  However imperfect the inspi-
ration has been, some portion must be  inflated, and therefore  will
float.
  *' Objection 4.  Granting that the floating of the lungs  is an  evi-
dence that the child has  respired,  their sinking by no  means proves
that the child was born dead.
  " This proposition is  undoubtedly true.  But does it constitute a
solid objection ?  It is well known that children may  be  born  alive
without breathing.  The causes which occasion this may  be divided
into three classes : 1st.  Those which depend upon some  malforma-
tion of the thorax or  abdomen, which prevents respiration.  2d.  Me-
chanical obstructions, as mucus in the trachoa, doubling back of the
tongue, &c.  3d.  Causes connected with delivery, as long detention
in the pelvis, compression of the cord, or the head of the child being
covered with the  membranes.  Now, in most of these cases it is ob-
vious, that the cause of death  may be detected by a careful exami-
nation of the body.  But even  where  this cannot  be done, are we
not justifiable  in considering as dead, every child that has  not breath-
ed ?  Governed by such a rule, any error that might be committed
would always  be on the side of mercy.  It is  true,  that certainty is
as desirable here, as in any other case ;  for the destruction  of a fee-
ble child is a crime as enormous as that of a  vigorous and healthy
one, and the punishment of the murderer of the one,  is eqaully an
object of public concern, with that of the other.  But in the language
of a  distinguished writer on this subject, ' pour le punir,  il faut le
constater ; et  lorsque les limites de Part nous refusent le degre' de
certitude  que  nous ambitionnons,  la clemence, que dis je, la crainte
d'immoler Tinnocence devra l'emporter sur toute autre considera-
tion.'
   "This objection, so far from  showing the inconclusiveness of this
test,  serves only to establish more clearly its absolute necessity. It
 is by resorting to it alone,  that the sacrifice of innocence can be
prevented ; for who would  assume the responsibility of  deciding 
ON LABOUR.
303
that a child had been born alive, when this evidence of vitality was
absent ?
  " If the writer has been fortunate enough to obviate the difficulties
which have been raised against the test, which has just been consi-
dered,  then  it  may  be  esteemed as  settled, that this method of
judging whether a child has been born alive  or not, is not merely
unattended with danger, but is founded on principles as favourable
to humanity, as they are  to rigid  justice.   It cannot, however, be
otherwise than plain, that a conclusion ought never to be drawn from
a superficial inspection  of the lungs.  The reputation of the profes-
sional witness,  as well  as the fate of the accused, are  too deeply
interested to admit of this.  It may. therefore, be proper to present
a summary of practical  rules, for the guidance  of the physician when
called to the  examination of a case, which,  of all others, demands a
combination of the exercise of the soundest  judgment, and  the most
profound knowledge.
   «' 1.  After having examined the general  shape of the thorax, and
noticed the position and colour of the lungs  in its cavity,  they should
be taken out, together with the heart.   They should then be sub-
jected to a careful inspection, to determine  if they are sound or dis-
eased, and if they are stall affected by putrefaction.
   " 2.  Particular attention should be paid to the temperature of the
water,  in which the lungs are to be immersed.   The reason of this
is obvious,  when it is recollected, that the  specific gravity of water
varies with its  temperature ; thus, for instance, water at 100°,  is
lighter than water  at 60Q, and still lighter than  at 40°.  Besides, if
the  water  be too hot, it will have the effect of expanding the lungs,
and thus favour their floating, especially when there already exists a
slight  tendency to putrefaction.   If, on the  contrary,  its tempera-
 ture be too low, the air cells will  be  contracted, and much of the ait-
 will be thus expelled.  The temperature of the water, should, there-
 fore, be regulated by that of the surrounding air.  Another precau-
 tion relative to the water is,  that it  should not  be impregnated with
 salt; for in consequence of the greater specific gravity of saline wa-
 ter, a body might float in it which would sink in fresh water.  3. The
 lungs, together with the heart, should then  be placed in the water,
 and if they both float,  it is a proof of  complete and  effectual respi-
 ration.  4.  If the lungs sink  with the heart, or  if the floating is only
 partial, it is then proper to separate  them, and repeat the experi-
 ment upon  the lungs alone ; observing whether the whole float, or
 if they sink, whether any part  shows a tendency to float; if so, 5.
  The two lobes should then be separated, and the experiment repeat-
  ed upon each, noticing  the  difference,  if any,  between them.  If
  only one floats, see if it is the right one.   6.  If both lobes sink, or
  float but imperfectly,  they should be  cut  into  a number  of pieces,
  taking care not to confound  the  fragments of one lobe  with those of
  the other ; and upon  each of these the same experiment should be
  instituted.  7.  While cutting the lungs, it  should be  marked if there
  be any crepitation; if the vessels  are  charged with blood;  and if
  there be any traces of disease. 
304
INTRODUCTION TO MIDWIFERY.
   " After having performed these different processes, the conclusions
to be  drawn from them are evident.   If the entire lungs, as well as
all the divisions, remain on the surface of the fluid, it is a proof that
the infant enjoyed  perfect respiration ; if only the right lung  or ita
pieces float, the respiration must have  been  less perfect; if some
pieces only float, whilst the greater number sink, it proves that the
child  lived with pain, or that its lungs were diseased, or that the par-
tial floating was owing to artificial inflation ;  if all the pieces sink, the
inference is decisive,  that the child never respired.
   " Having thus noticed,  at sufficient length, the various circum-
stances relating to  the floating of the lungs, I shall next consider,
  " The test of M. Ploucquet, founded on the absolute weightofthe lungs.
—From the peculiarity of the vascular system in the fcetus,  only a
very  small portion of the blood  goes the  round of the pulmonary
circulation.   As soon as respiration commences, a change is effected,
and the whole mass of the blood passes  through the  lungs, in order
to undergo the necessary process of oxygenation.  From this  it ap-
pears that the foetal lungs must be considerably inferior in weight
to the same organs after respiration has been established.  It is upon
this fact that M. Ploucquet founded his celebrated test for determin-
ing whether a child had been born dead or alive, by comparing the
weight of the lungs with the weight of the whole body.  From the
experiments which he made to ascertain  their proportional gravity,
he drew the general conclusion, that the weight of the lungs previ-
ously to respiration, is one seventieth of the weight of the whole
body, whilst after that process,  it amounts to one thirty-fifth ;  or, in
other words, that the  blood introduced into the lungs in consequence
of respiration, doubles their absolute weight."
   Before I dismiss this subject, 1 cannot but declare  my belief in
the opinion  of Dr. Hunter of the practicability of the child respiring
before delivery, after the rupture of the membranes, and the escape
of the liquor amnii, while its mouth presents at the dilated orifice of
the uterus ; and yet that it may lose  life before its entire  exirtrom
the womb.  See Schmitld, in Dictionnaire  des Sciences Medicates,
torn. x.  I am aware that the reasoning of Dr. Beck  is supported
by high authority,  and that he might have still further strengthened
his views by other names.
   At  a trial of two young women for child  murder, at the Warwick
assizes, England, which took place  some few years ago,  their de-
fence, which proved successful, rested upon the principle that the
human fcetus may respire as soon as the head is expelled in delivery.
The  medical  witness expressed  himself most anxious that  "the
minds of the  jury should  be  duly impressed with  the important
truth, that a child  may breathe and even cry audibly as soon as the
head  is delivered,  and yet subsequently perish before the  whole
body  is expelled."  See London Medical Repository, vol. xi.
   In further corroboration of the opinions of Dr. Beck, concern-
ing the putrefaction of the lungs, the following quotation  is taken
from  Camper :  " In order to  ascertain to what degree  purtefaction
would advance in an infant before its lungs would float  in water, I 
ON LABOUR.
305
made different experiments at Amsterdam on this  subject;  and I
have found  that in those who  had died  before birth, the head may
be so far decomposed  by putrefaction, that the slightest  force was
sufficient to detach the bones  from each other, as well as those of
the arms and legs, before the lungs, which now began to participate
in the putrefaction, would float in water."  See also Hutchinson on
Infanticide.
   Ploucquet's test, depending upon the absolute weight of the  lungs,
is liable, I think, to several obvious and powerful objections.   F.] 
306
INTRODUCTION  TO  MIDWIFERY.
CHAPTER X.
CLASS  SECOND.
                         SECTION I.

                   ON DIFFICULT  LABOURS.

  From the foregoing history of a natural labour, and from the
tenour of  what has been on different occasions advanced in the
preceding chapters, it  appears, that parturition is a  process of
the constitution, which, generally, does not require any assist-
ance ;  and that when it is natural, it should be suffered to have
its own course without interruption, for the very same reasons
which render  all  interposition with other  natural  operations
unnecessary,  improper,  and  frequently prejudicial.   Whence
then arises the necessity or expediency of establishing midwifery
as an art for the relief of the human  species ? or in what respects
has society profited by the establishment ?  Certainly not on the
presumption that women are by nature destitute of those powers,
which at  the time of parturition are in  all  other  creatures ge-
nerally equal  to  the  exigences  of  their situation; nor  when
those powers   are  fairly exerted,  every cause   producing  its
effect, in  the order  and   in  the manner  which  the  parts
by their construction were framed to perform and undergo ; nor,
when  there exist  no  uncommon  impediments, by  which the
effects to  be  produced by the natural  causes are, or may be,
obstructed ; and when  no circumstances threatening  danger in-
tervene.   But as the aid of medicine becomes necessary,  when
from some defective, or irregular exertion of the native powers  of
the  constitution; or,  from  some  adventitious cause of obstruc-
tion;  or from some infirmity in the constituent parts of  any of
the  organs of the body, the functions of any part are suppressed,
impeded, or in some way rendered irregular or imperfect,  to the
detriment  of  that part, or of the  constitution, or  to the preven-
tion of any effect necessary to be produced : for the same reasons,
 and in like manner, the assistance of the art of midwifery,  scien-
 tific or manual, may be required for the relief of such  irregula-
 rities or  difficulties as may  occur  in the act of parturition.   It
 must however be acknowledged, that all the  errors of practice  do
 not proceed from ignorance  of the art.   Some  of them may  justly
 be imputed to our entertaining too high  an opinion of the art, or
 its application in practice, when it is not absolutely required, and 
ON DIFFICULT LABOURS.
307
when its application is prejudicial;  to too much confidence in our
own dexterity, and too little dependance on the natural efforts and
resources of the constitution.
  In all creatures in which there is a difference of structure, there
must be  a  difference  in the conduct or  manner in  which every
function  of the constitution will  be performed, which is at  all
connected  with,  or dependent upon,  such  variety in  structure;
and a difference in the process of any function, especially if  this
should be rendered more complex, and of course more liable to
aberration,  may become  the predisposing  cause of such devia-
tions  from the natural course of that function, as  may  require
the assistance of art:  though the very same function, proceeding
or being performed in a natural way, might be void of danger,
and require no assistance whatever.  The knowledge  of the
peculiarities in  the structure  of the  human species, or of the
specific circumstances in which the constitutions of  women differ
from those of  all other female creatures, may therefore be con-
sidered as affording the only just and true basis on which both
the theory  and practice of midwifery ought to be founded.   Be-
fore we proceed, then, to an  inquiry into the particular cases,
which  may demand the assistance of  art, or determine upon the
manner  in  which that art can be exercised with  the  greatest
propriety and  advantage, a short  review of those peculiarities
will be necessary and useful; that we may be cautioned to avoid
the abuse of the art, or the exercise of it, except in .those cases in
which  that assistance which  art can afford  is  absolutely  re-
quired.
  The first and  most obvious circumstance,  in  which  women
differ from all  other female creatures,  is  the erect position of the
body; of  the  consequence of  which, with regard  to  the pelvis,
and some diseases to  which women are particularly  liable, notice
has been already taken.   (See chap. 1.  sect. 5.  and chap. 4.
sect. 1.)   In the original construction of the pelvis in quadrupeds,
with a view to parturition, there seems to be a necessity for re-
garding  its capaciousness alone;  because if even more  than
sufficient space were provided for the passage  of their young, no
attitude  into which they put themselves, or into which they can
be  compelled  by any  accident,  during uterogestation,  would
subject them to difficulty or danger on this account.  But from
the erect position of the human body, if the cavity  of the pelvis
had borne  the  same relative situation and proportion to  the size
of the  fcetus as in quadrupeds,  women would have been liable to
many and  great inconveniences.   For the weight  of the ovum
and enlarged  uterus  must, in  advanced pregnancy,  have been
occasionally sustained only by the soft  parts, which becoming
thinner and less equal to that  office according to  the advance-
ment,  premature labour,  as well as many  other inconveniences, 
308          INTRODUCTION TO MIDWIFERY.
 must often have  been occasioned; with some  degrees of  which
 we often meet in practice.  For this,  and perhaps several other
 less obvious,  though probably equally important, reasons, all of
 which it  would be difficult to investigate, there undoubtedly  is
 in human  beings a greater difference  between  the dimensions of
 the cavity  of the pelvis, and the head of the fcetus, at the time of
 birth, than in  animals; and this difference, consisting chiefly in
 a greater proportionate and relative size of the head, may even-
 tually become the cause of more painful  and  difficult  parturi-
 tion.
  As there is no effect throughout nature without some adequate
 cause, as well as some wise end, perhaps the  most satisfactory
 proof of the existence of  this  disproportion may  be drawn from
 the construction of the head of the human  fcetus, which being in-
 completely ossified at the time of birth, is capable of having its
 form changed, and its size diminished, without any injury from
 the compression.   These effects are produced in some degree in
 almost all labours, but very remarkably in those which are com-
 pleted with difficulty; for in  such, the sutures  not only accede,
 but the  edges of the bones will ride over each other in a very ex-
 traordinary manner, yet  generally without any apparent preju-
 dice to  the child.  From  this  original and comparative  relation
 between the cavity of the  pelvis, and the head of the firtus, wo-
 men therefore seem to be naturally more  liable to difficulties in
 parturition than animals;  which difficulties may be  esteemed as
 an allay for the advantages obtained by  the erect position ; or
 because their offspring were so framed as to be capable of greater
 excellences than animals; which  excellences may  depend upon
 this construction and  size of  the  head. Independent of this in-
 complete ossification and  its  consequences, great  numbers of
 children must have been inevitably destroyed at the time of birth,
 or the parents must have died undelivered.   Nor is this provision
 only sufficient to answer  the  end of mitigating  those evils, to
 which women are, by their structure,  naturally and necessarily
 liable, in common labours; but it is generally  equal to  the re-
 lief of those, which are rendered difficult by morbid alterations in
 the  size  of the cavity of the pelvis.
  2. The intercourse between   the  parent and fcetus, while it
 abides in the  uterus,  though   generally alike in  all viviparous
 animals, has some variation in each class.  The  ovum is in  all
 constructed for a temporary use. but in a very beautiful and per-
 fect manner for the purposes for which it  was  ordHmed.  The
variations may exist either in the uterus or ovum.
  In  the uterus of the different classes of animals,  the most ob-
vious variety is in the  form.  Animals might, perhaps,  be nearly
as well arranged, and the  class to which they belong as well de-
termined, by the form of the uterus, as by any  external or  other 
ON DIFFICULT LABOURS.             309
 internal mark.  Such as are the form and structure of the uterus,
 such will  be the properties; and of course, in every animal in
 which there  is a difference  in  form, structure, or of properties
 thereon depending, there will be some corresponding difference
 in the circumstances of parturition ; so that if an inquiry was at-
 tentively made, it is probable we should not find an  exact like-
 ness in the parturition of any animals, which vary either in genus
 or species.
   The uterus in  all animals may be  considered as  the bed or
 soil, in which the foetus  is conceived, nourished,  preserved,  and
 accommodated, till  it arrives at a state of perfection, and the
 part by which it  is  ultimately expelled.  For the completion of
 these ends, there must be a  perfect coincidence, at least a  cor-
 respondence,  between  the nature of the fcetus to be thus con-
 ceived, nourished, preserved, and accommodated,  and  the form
 and properties of the uterus, by which those offices are to be dis-
 charged, as is proved by hybrids; and if the case were otherwise,
 though there might be a forcible sexual intercourse, there  would
 be no conception ;  and this clears us of an old but wholly unsnp-
 ported opinion of the cause of monsters.   The  varieties in the
 form of the uteri  in  different animals  are progressive, from those
 of the lowest tribe, which are horned or convoluted,  to the hu-
 man, which, when unimpregnated, is pyramidal, becoming more
 oviform, according to the degree of its distention.   On  the form
 of the uterus not only the accommodation  of the foetus  may  de-
 pend,  but  the term of uterogestation  also; or the  power which
 every individual uterus of any given form, has of bearing disten-
 tion only for a specific time.  Yet if this were allowed,  it would
 still remain to be proved, why a uterus of one form became capa-
 ble of bearing distention for a longer time than that of another.
  Complicated with, or  dependent on  form,  is the substance or
 thickness of the uterus;  and on this again the power which the
 uterus is capable of exerting at the  time of parturition.  The
 uterus in women  is of greater thickness, and of a firmer texture
 in the unimpregnated state, than in animals  of an equal size;
 and  in these it is said to become somewhat thinner, in  proportion
 to its distention ;  whereas in women it retains its thickness,  if it
 does  not become rather thicker during pregnancy.  It appears
 that by this thickness is gained  the medium of that power, which
 is exerted by the human uterus in the act of parturition, and with-
 out which women could  not in  many cases have been delivered.
 But if there had been occasion in animals for the exertion of an
equal degree of power,  they probably could not have  been de-
livered ; as  there does not  seem to be in them  a  medium, by
 which such power could have been exerted, and the form  of the
uterus would also have  been less favourable for its operation,
had it existed. 
310
INTRODUCTION TO MIDWIFERY.
  This thickness of the uterus, notwithstanding its  distention, is
chiefly preserved  by the  gradual enlargement of the arteries,
veins, and  lymphatics; and their enlargement is  most  conspi-
cuous  about that  part to which the placenta adheres.   The
quantity of blood circulating in the human uterus  and the adja-
cent parts, during pregnancy, is very great;  and it probably un-
dergoes in  the uterus itself some preparatory change, before it is
conveyed  to the placenta, where it may  probably be subject  to
farther alteration ; so that it may be presumed, that  the  uterus
performs the office of a gland, altering and  preparing the blood,
before any part of it, or  any  thing secreted from it, is absorbed
or  taken  up by the vessels of the placenta, for the use  of the
foetus, as well as that  of the containing part of the ovum.  On
the quantity of blood circulating in the uterus may also  depend
its action at the time of labour;  for  if the placenta be loosened
before the child  is bom,  and  the  blood has  a free  discharge,
there is seldom any efficacious  action till the discharge is abated,
though  the uterus  may  be, in all other respects,  in a  state  of
perfect health.
  In our present inquiry, the  principal part of the ovum which
deserves attention,  is the placenta, and of this there is  an endless
variety in  the different kinds of animals, according to the  nature
and properties of each parent and the offspring.  In the belluae,
the office  of the placenta  is performed  by the whole membrane
of  the  ovum being thickened,  and  becoming proportionably
vascular;  in the pecora, the placenta is divided into many lo-
bules, composed of long  and  vascular fibres, called  cotyledons
or cnps,  affixed  to as  many temporary eminences of the internal
surface of the uterus;  in  the ferae it surrounds the  uterus like an
internal belt;  and  so  on,  with great variety, in  the  different
classes of animals.   But in the human species, the placenta,  as
the word implies, is in one flattened  mass, commonly of a circu-
lar  form, becoming gradually thinner toward the edge,  and ad-
hering to the uterus with  a broad surface.   When any portion
of this is separated, the orifices of many of the large vessels  of
the uterus  are opened, and a  considerable quantity of blood  is
immediately discharged,  far beyond what could possibly  be lost
in any animal, though of a much larger size; and if the uterus
were to continue distended, the  orifices  remaining open, there
would be a dangerous or a fatal hemorrhage.   For, not only the
blood  circulating  in  the uterus  would  be immediately poured
out of its vessels, but all which is contained in  the body might  be
drained, and the patient speedily perish, if she were not relieved
by  art; and yet no animal (I believe)  ever  was or  could  be
destroyed, or brought into danger, by this circumstance.  From
the same cause also, the  uterine  discharges continue  a  longer
time, after delivery,  in women  than in animals;  the irregula- 
ON DIFFICULT LABOURS.              311
rities and interruption of which may  become  the  causes of dis-
ease, and are proofs that, independent of fashion or custom, there
exists in their construction  a necessity that women  should for
their own safety be separated from society for a certain time after
delivery; or guarded  against  such conduct or  accidents,  as
might cause a suppression of those discharges.  On account also
of the form of the uterus, and the peculiarities of  its action, of
the bulk, unity, and form of the placenta, and the manner of its
connexion, it is more likely to be retained or untowardly expel-
led in women than in animals; and its retention or disorderly ex-
pulsion  may be followed by worse consequences.
   3. In the consideration of this subject, the passions of the mind
are of too evident importance to escape attention.   On a variety
of occasions,  these, in  human  beings  to  a certain degree in a
natural state, and much more when heightened by all the refine-
ments  and perversions  of society, are found to be  capable of
producing  the most  extraordinary  effects;  by suppressing  or
suspending for a certain time the action of any, or of all  the pow-
ers of the constitution ; by occasioning them to act with irregu-
larity and at improper times ; and in some cases also by exciting
them to act with  too great energy and force.  But animals pro-
bably suffer neither from the recollection of the past, rtor dread of
the future; and acting  according to their nature,  the  good or
evil of  the present moment in them appears to be the principal
part of their existence.   In the  passions we may then  discover
sources of danger and  disturbance in the pregnancy and partu-
rition of women,  from which animals are wholly  exempt;  and
the observation is so  general, that care is universally taken to
prevent the communication of any intelligence to  pregnant wo-
men, or to those who are in or about to be in labour, which can
either distress, or much agitate them.  To this principle or cause
may also be referred  the many nervous affections, to which wo-
men are subject in the  state of childbed, and for  some time after
they are delivered, when the animal powers are reduced,  and
the sensations quickened. But it must be allowed, that the greater
degrees of these evils,   which are many and great,  are not to
be attributed to physical infirmities, but to moral errors.
   A consideration of their unimpaired constitutions and less ex-
quisite  feelings will likewise  discover to us the reasons, why  the
lower  orders of women have more easy and favourable births,
than those who live in affluence ;  the frame of whose bodies, and
the sensibility of whose minds are altered,  and often depraved,
by the  indulgence and  mistaken opinions  of parents, when they
are infants, and by their own luxury and improper conduct, when
they are adult.   The constitutions  of  those who are hardy  are
better able to sustain the common accidents of child-bearing, and
they suffer less  because they are stronger and have less feeling 
312          INTRODUCTION TO MIDWIFERY.
and apprehension.  When the Egyptian midwives were charged
before Pharaoh  with  disobedience  to his orders,  because they
preserved the lives of the Hebrew children, they pleaded in their
excuse,  that the Hebrew women were not like  the Egyptian,
" they were lively, and were delivered before they (the midwives)
could come to them."  Beside  other motives,  the  Hebrew wo-
men were slaves, accustomed to  labour and hard living, yet they
had more children and easier labours than the Egyptian, who, we
may presume,  suffered  all the  evils arising from indolence and
habits of indulgence.*  The same  observation will  also explain
the reason of many  of those evils which  women in the  higher
ranks of life suffer; particularly why fewer women die in child-
bed in the country than in cities, where even those  of the lower
class are often compelled to live in  unwholesome situations,  and,
too often plunging into  gross indulgences, therefore suffer the
same  or a worse fate  than the delicately luxurious.
  4. We are lastly to consider,  that women are by constitution,
and  by habits of education  and living,  subject to diseases,  to
which animals  are not liable;  which  diseases  may create new
causes of difficult parturition, by increasing natural  evils,  or by
weakening those powers, by  the operation of which  these should
be overcome.   Every such disease, it is unnecessary, and per-
haps hardly possible,  to enumerate; but that, which  by affecting
the bones in general, and those of the pelvis in particular, has the
greatest influence on labours, is deserving of especial notice.
  By the rachitis is not only understood the disease of children,
properly so called, but the osteosarcosis,  or mollities ossium also;
this being the only difference between them, that, in the former
the bones in the infantile state are prevented from acquiring  such
a degree of firmness, as will enable them to sustain the weight of
the incumbent body,  without yielding and becoming distorted;
which distortion may remain to adult age, even though greater
  * Among many wise observations and judicious inferences, made
by Adam Smith in his Wealth of Nations, there is one taken from the
state of population in the northern parts of Scotland.   He supposes,
that women in the lower orders of society breed the greatest number
of children ; but that those in the higher  rear more of those which
are bred.  The same observation has been  made of the Russians.
It has been  attributed to the scantiness of provisions ;  but I believe
it is very much owing to the coldness of the  climate, as, with equal
difficult}' of procuring the means of subsistence, in Ireland and many
parts of England, for instance, children born in health seldom die.
Mr. Gildemester, who was for many  years the Dutch Consul in Por-
tugal, assured me, that the children  of the lower orders of the Por-
tuguese, who live very miserably, which are  born in  winter, gene-
rally die, but suqh as are born in summer are as commonly  reared. 
ON DIFFICULT LABOURS.              3l3
 strength may have  been afterward acquired.  But in the latter,
 the bones having been properly formed and ossified, become soft
 again, at any period of life, inconsequence of the absorption  of
 the ossific matter, by which the most extreme degrees and fright-
 ful kinds of deformity have been sometimes occasioned;  the pro-
 gress of the disease being sometimes indicated  by the increasing
 difficulties of successive labours.  (See Chap. 1. Sect, x.) From
 distortion produced by either of these causes,  the cavity of the
 pelvis,  which in a natural state should measure upwards of four
 inches in its narrowest limits, may be reduced to two, or even  to
 less than one inch; by which the reciprocal proportion between
 it and the bead  of the foetus is perverted or destroyed,  and it is
 absolutely  impossible for the latter to  pass  through the pelvis.
 This  softness and consequent distortion of the bones, from either
 of those  causes,  being peculiar to * or infinitely more frequent in
 the human species, occasions difficulties at the time of parturi-
 tion,  from  which animals are  almost universally  free.   Even if
 animals were liable to it, from  their position, and the diminished
 weight which the pelvis supports in  quadrupeds, it  could not pro-
 duce  the same kind or degree of effect.   From  the frequency  of
 the rachitis in cold and  unwholesome climates, in crowded cities,
 extensive manufactories,  and  wherever the employments  and
 manners of the human race weaken  the constitutions of the inha-
 bitants, especially in early life;  and from its rarity in warm and
 healthy situations, or with rustic employments and simple man-
 ners, we  may conclude,  though we  retain and act upon the same
 principles,  that the events resulting from the practice of midwife-
 ry must be different in different places, and that the authority  of
 the best writers must in  some measure be local.
  On account of the original smallness of the cavity of the pelvis
 relatively to the  head of the child, of the structure of the uterus
 and placenta, of the passions,  and of the diseases to which man-
kind are by nature, or by the customs of society, rendered pecu-
liarly liable, the causes of many difficulties and dangers, which
attend parturition, will  be evident; and  of course, the necessity
of establishing midwifery as an art for  the  occasional relief of
women will be evinced.
  But to render these observations, with others diffused through
this work, of greater utility, I shall endeavour to reduce them into
 propositions in the following order,  submitting them  at the same
time with all deference to future consideration :
  1st. All  viviparous animals bring forth their young with pain.
  2d. The degree  of pain which they suffer, will depend upon
  * I think the late John  Hunter informed me that one of the old
lions in the Tower had  the osteosarcosis.
                             40 
314
INTRODUCTION TO MIDWIFERY.
the degree of their sensibility, natural or acquired, and upon the
difficulty with which they bring forth their young.
  3d. The difficulty with which they in general bring forth their
young, depends upon their construction.
  4th. By their construction, they are also endued with powers
capable of overcoming  all the difficulties, to which such construc-
tion generally renders them liable.
  5th. The process of parturition in animals is therefore to be
esteemed a natural process, requiring no other assistance,  than
the uninterrupted exertion of those powers,  which depend upon
their construction.
  And 6th. From  the very nature of  their construction, and
from their modes of living, unless they are  perverted by domes-
tication, they will not in  general be liable to any material devia-
tion from the ordinary  process of their parturition.
  Tth. The construction  of the females  of  the human species is
different from that of the females of any  order of animals.
  8th. The construction  of the females  of the human  species is
such,  as  to render  them unavoidably  subject, in general,  to
greater pain and difficulty in parturition, than the females of any
order of animals.
  9th. But by the construction of the females  of the human
species, and by the original formation of the head of the human
fcetus, provision  is  made for overcoming  all the difficulties, to
which the  peculiarities of their construction may render them
liable.
   10th. With regard to  the act of  parturition,  when natural,
women are therefore to he esteemed on a similar footing with
animals.
   11th. But as  women  are by their construction, and by the
customs of society, rendered subject to diseases and accidents,
which increase the  natural difficulties, and  produce  new causes
of danger attending their parturition, from  which the females  of
every order of animals  are free :
   12th. It will follow,  that the occasions   which  require  assis-
tance at the time of parturition, do and  must, of necessity, occur
more  frequently in women than in the  females of any order of
animals.
   From  these premises, the expediency and necessity of esta-
blishing midwifery  as an art for the relief of the human species
will appear, and the art be directed to its proper object.

                        SECTION II.
   Many general circumstances  and appearances have been men-
tioned, and considered  as presumptive signs of difficult labours;
and it will not be improper to enumerate these, though I appre-
hend, that  much stress  cannot  be laid upon them with  a view to 
ON DIFFICULT LABOURS.
315
practice, or even to prognostic.   If they were certain and in-
variable, or commonly just, it  would be incumbent upon us to
understand the degree and extent of their influence, and to apply
ourselves to the discovery of some means, by  which we  might
prevent or  remedy the evils which are threatened.
   1st.  The kind of labour which any particular woman will
probably have, has been supposed to  be indicated,  in some de-
gree, by her complexion.  Women with very fair, or  very dark
complexions, have been supposed  equally subject to  difficulties
or inconveniences in parturition : whilst those of the intermediate
shades were  considered as having advantages in their favour.
Now, as far as any particular complexion can indicate a general
state of health,  this observation  is reasonable and  true,  with
respect to labours; those who have the best health, usually pass-
ing through that process in  the best and safest manner.   But as
those who are of complexions in either extreme may  have  perfect
health, and easy labours, any inference drawn from this principle
must be liable to many exceptions.
   2d.  By the general size of the  body, it has been  conjectured
that we might foresee whether an ensuing labour  would be easy
or difficult.   This observation will  stand upon the same ground
with the foregoing; that is, it may hold good, as  far as any
particular  size  may be  found best suited for performing all the
functions of  the  body,  and for  the  general  purposes of life.
Those who are very tall or of a larger make than ordinary, are
not often very active, or capable  of bearing much fatigue; and
those who  are very short, may have been cramped, or become
deformed, in consequence of ill health in the early part of their
lives :  those,  on the contrary, who are of a middle size, or rather
below  it, being presumed to be more generally healthy, and best
adapted to the common occasions  of life,  may be expected to
have the best labours, as they have sufficient power, and a rea-
dier disposition to act.
   3d.  The habits of life, and the  dispositions of patients,  have
been supposed to have some influence in forwarding or retarding
labour.  Those women, who  are indolent in  their tempers and
habits, perform  all the functions of the constitution in  a slow
and indolent manner,  and of course  may be expected to have
tedious labours, as far  as depends upon the necessary action of
the body at  the time of labour.   But those  who are of lively
dispositions and active habits, being in the constant exercise of
their  powers,  have not only these  powers  strengthened and
improved,  but a readier disposition to act,  and greater energy;
and the activity of the parts concerned in parturition will partake
of that of the body in  general.
   4th. The regularity,  together with the ease or difficulty of a
labour, may in some measure depend upon the strength or weak- 
316          INTRODUCTION TO MIDWIFERY.
 ness of the faculties of the mind, or their disturbance by slight
 excitations.   But this must be a very general  observation, and
 can only  hold good in that extensive way, in which it is admit-
 ted in other occurrences of life, in which weakness of judgment
 may pervert  regularity  into  disorder,  fancy  evils that do  not
 exist, or add  to the weight of those which are unavoidable.
   5th.  Labours are generally affected by the climate, in which
 women are born and reside.  In hot climates, all natural Labours
 are said to be more easy, than in those that are cold; probably,
 because the disposition to  relax and  dilate is sooner assumed,
 and more perfectly accomplished.   But in  cold climates, from
 the native or acquired rigidity and firmness of all the parts  of
 the body, there will be occasion  for greater  exertion,  though
 there may be  greater power ;  yet if the labours are slower, per-
 haps the feelings are less, so that they may terminate with equal
 safety,  and probably, on  the whole,  without  greater  suffering.
 In the same climate there will generally be some variations  in
 labour at different seasons; and I  believe it is  true, that in this
 country women  have easier labours, and that they are less liable
 to diseases in  the state of child-bed, in summer  than in winter.
   Such observations might be extended  to a greater length, and
 discussed  with more nicety ; but  they can hardly escape the no-
 tice of an attentive man, and he  that  is prudent will  no esteem
 them of too much value.

                        SECTION III.
  Without some settled form of distinction, it will not be possi-
 ble for us to comprehend such a knowledge of Difficult Labours,
 as will enable us to conduct women safely and properly through
them ; or to communicate our knowledge to  another person.  It
is therefore necessary, in  the first  place, that we  should define
what is meant by the term ; and we will say, that every labour
in which the head of the child presents,  which   is protracted be-
yond twenty-four hours, shall be called Difficult.*
  * Fit partus difficilis et laboriosus, quod nee modo neque ordine
debit© res  peragatur, aut  pravis aliquibus symptomatibus impedia-
tur—Harv. Exercit. de Partu.
  Dicitur autem partus ille difficilis, qui cum fcetus  vel matris peri-
culo accidit; vel quia cum gravissimis fit symptomatibus,  vel tardiua
procedit, ita  ut longo tempore prematur.—Roderic. a Castro Lusi-
tan.
  Partus difficilis  appellator, qui debitas utque ordinarias  naturae
leges non servat, sed longius tempus insumit, et dolores subito vehe-
mentiores, aliaque symptomata graviora  comitantia  habet—Keverii
Prax. Medic. De Partu difficili.
  Foetus maturi enixus laboriosissimus.—Linnati Nosologia. 
ON DIFFICULT LABOURS.
317
  This  definition, which is chjefly taken from time, is liable to
some  objections, as there may be  more pain endured, and grea-
ter difficulties  surmounted by one woman in six hours, than by
another in twenty-four; not to mention the uncertainty in deter-
mining when a labour  does really commence; but on the whole,
it will be  found to apply to practice in an  advantageous, and
often  in an unexceptionable  manner.   It will, in  particular,
afford  a remedy for  impatience, and guard  the practitioner, in
some measure, from premature attempts  to give assistance, with-
out incurring the  danger of those evils which  might be appre-
hended  from too long delay.
  Of those  labours, which come under  the denomination of
Difficult,  there is an almost  endless  variety in their causes or
degrees.  Some  are occasioned by one cause  alone, but more
frequently by a combination of various  causes, though one may
be more obvious and important than the rest.*   For the uses and
purposes  of practice, it  is not sufficient to say, that  all  labours
are rendered difficult,  either from the greatness of the obstruc-
tion, or by  the insufficiency or debility of the power by which
the obstruction should  be overcome; or, that some  depend upon
the mother, and others  upon  the child.   Such distinctions or
references are too  general.  The  particular causes of every in-
dividual difficult labour  should be pointed out,  as  well  as the
conduct  which each specific  cause may require.  These are to
be stated by every person who teaches  the art,  and  received for
the present  by the student.  But when  students have gained ex-
perience,  they will, of course, by that try and judge the  doc-
trines which they  have learned, and  without some practical
knowledge  of a subject,  we cannot fully or well understand  the
merit of any doctrine.   For  there are  advantages accruing to
every man's own mind from his individual experience, of which
no doctrine or words  can convey an adequate idea; and those
who are  in possession of such  experience, seldom bend  to, or
submit  to be guided  by,  the  rules or admonitions of  others.
Nor  indeed is this to  be expected, except  in a very limited de-
gree.  It  is, therefore,  of the greatest consequence to those, who
have  not  yet attained  experience, that they should gain it, and
exercise themselves in  the custom  of registering and arranging
the particular knowledge they may have  an opportunity of ac-
  * As many causes concur in the  production of compound effects,
we are likely to mistake the predominant cause, unless we can mea-
sure the quantity of the effects to be produced, compare  them with
and distinguish them from each other, and find  out  the  adequate
cause of each  single effect, and what must be the result of their
joint action.—See Dr. Desaguliers'  Preface. 
318          INTRODUCTION TO MIDWIFERY.
quiring, in regular and  systematic order, or they will lose  the
benefit of it; for it will otherwise either be forgotten, or recollected
with difficulty, when they want to apply an observation made in
one^case to the exigencies of another.   It is, also, very possible,
that rules  may be too refined for  general practice; and it may
not be proper or expedient for any writer on this subject, to  de-
scribe every individual circumstance, to which he in the course of
his  practice may have found it  expedient to recur;  though the
true foundation on which the rules of practice should  be formed
is the result of a number of individual cases.  To lessen these
deficiencies at the commencement of  practice, and to point out a
better  method of preserving the advantages of experience,  as
well as to record,  in  the  clearest  manner,  what my own  had
taught me, we will divide all difficult labours into four orders or
kinds,  and  then enumerate the principal causes of each order.
As  the knowledge of causes, and the management or removal of
effects  or difficulties,  should accompany or  immediately follow
each other, the methods to be used for the relief of these will, at
the same  time, be pointed out.
  In the  First order will  be included all those  labours  which
are rendered  difficult  from the inert or irregular action of  the
uterus, by whatever cause produced :
  In the  Second,, those which are occasioned by the rigidity of
the parts  to be dilated
  In  the  Third,  those which are occasioned by disproportion
between the dimensions of the cavity of the pelvis of the mother
and the head of the child:
  In  the  Fourth, those which are  rendered  difficult by diseases
of  the soft parts.
  Under  one or other of these  Orders  may be arranged every
labour which can properly be called Difficult.
  This kind of labour has by many  writers been subdivided into
slow or lingering and difficult; but as by the former appellation,
a less degree of difficulty only is meant, both  with  regard  to
cause and effect, the subdivision seems to be unnecessary.*

                         SECTION IV.
On the First Order, or, those labours which are rendered difficult
         from the inert or irregular action of the uterus.
  The action of the uterus, by which every child must be expelled,
is generally accompanied with  pain proportionate to the force,
  * [The reader will find many valuable observations and practical
suggestions on difficult labour in a late  publication by Dr. Dewees,
of Philadelphia, entitled  an Essay on the Means of lessening Pain,
and facilitating certain cases of Difficult Parturition.  Second edi-
tion.  Philadelphia, 1819.   F.J 
ON DIFFICULT LABOURS.
319
and to the resistance made.   But as this action may become im-
perfect, irregular,  or insufficient for the purpose of expelling twe
child, it is needful that we should be acquainted with the causes of
such imperfection,  irregularity, or insufficiency.  Of these causes
there  is,

           1.  The too great distention of the uterus.
  It was formerly believed, that the uterus was distended mecha-
nically, by the increase of  the ovum contained in  it.   With this
opinion, it  was concluded,  that either from the size of the child,
or the quantity of water, the uterus might be brought into a state
similar to that which takes place in  the bladder, which, when dis-
tended beyond a certain degree,  loses all power of action.  But
later  observations  have proved, that the impregnated uterus is
never completely distended; nor in any  degree by its contents,
but by the  operation of a principle, which it acquires in conse-
quence of pregnancy; which principle ceases to act at the con-
clusion of the  term of utero-gestation,  and is immediately suc-
ceeded by  another directly contrary, that of expulsion. (See chap.
5. sect. 11.)   But though  the uterus,  when in a healthy state,
cannot be distended beyond its  power of  action, occasion has
been  before taken to observe, that,  from the  slowness and small-
ness of the effect of the first pains  of labour, the power exerted by
the uterus  is generally suited to  the state of the  parts,  and the
parts to that of the uterus,  with a wonderful coincidence, and in
some measure, according to  the quantity of  its contents.  Yet,
as every principle in nature may,  in particular cases,  alter or
fail, so that of the distention of the  uterus may prevail to such a
degree, or  may continue so long a time, that its possible  expulsa-
tory  force  shall be weakened, its energy lessened, and, of course,
the progress of the labour  be for the present retarded.  This
seems to be proved, not only by  the slackness and feebleness of
the pains in the beginning of all labours, especially in those cases
in which there are two or more  children, but by  the increase of
that action, when part of its contents are evacuated.   It is how-
ever  to be recollected, that the  uterus  cannot be distended be-
yond its power of action, though  when greatly  distended,  it is
capable only  of slow and feeble action, which is nevertheless then
suited  to the general state of the parts, and preparatory to  that
which  is stronger.  This slow or  feeble action, from distention,
is not therefore an object  of art; and it is  perhaps  beyond the
influence of any earthly power, to  give to the uterus its native or
genuine disposition to act, before it is disposed to assume it; to
add  to its power; or in any  material  degree  to increase its
energy ; though many applications and medicines have been re-
 commended and tried for  this  purpose.   Human  art may put or
preserve the constitution in a state best fitted for  such action, or
it may remove any impediments  to its effect; but  the principle is 
320          INTRODUCTION TO MIDWIFERY.

wholly independent of the will of the patient, or the skill of the
practitioner.   When,  therefore, the pains  of labour  are in the
beginning feeble and slow, as  no harm can arise from this cause,
either to the mother or child, except that the former is under the
necessity of bearing them for a longer time, though on the whole,
perhaps, not in an increased  degree; and as some of the methods
advised, and usually  practised, for  the  purpose of accelerating
labours rendered  tedious from this cause,  are either immediately
injurious, or may lay the foundation of future mischief to one or
both, it becomes our duty, under such circumstances, to wait w ith
patience, leaving the business  entirely to its own course without
any interposition.  Even when a labour has made considerable
progress, and there  was reason to expect,  that it would have
been concluded in a short time, there may be a suspension of the
action  of the uterus for many hours,  without any mischief or ha-
zard, as  experience has often shown, though the cause of such
suspension may not be obvious to, or explicable by, us.
   With the ancients  it was a custom in  these cases, to introduce
a stimulating pessary into the vagina; and lately with a physician
in France, to apply a mixture of the berries of the Bay tree and
oil to the navel, in the time of labour, by which he was supposed
to do  some  good, and certainly gained credit.  It would not,
however, be unreasonable to try the effect of various applications
to the abdomen for this purpose. A dossil of lint, moistened with
tinct. opii, applied to the navel, docs certainly, in some cases, ap-
pease uterine pain.
   Immediately on the cessation of labour, it has been the custom
to confine women to their beds, or to some particular  position,
on the presumption that it would be thereby rendered more easy
than in any other.   By such  conduct,  expectations of a speedy
delivery are often raised; and  when these are baulked, the mind
of the patient will be disturbed, and the process become irregular.
But it  will always be found more comfortable and useful, to leave
the patient to her own choice in these matters, and her inclination
will be her best guide.   Time  is the safest, and generally the on-
ly remedy, for lingering and tedious labours occasioned by the
U>o great distention of the uterus, as well as by many other causes;
and the patient will often find  relief, either by walking  or stand-
ing, pursuing some amusement, or choosing that position which
she herself prefers, because she will  instinctively  seek that which
is  proper. Under such circumstances, it would sometimes be well
to persuade the patient that  she is  not yet in actual labour; or,
that  no speedy change is to  be expected.  However, in many
situations of this kind,  the repeated  exhibition of emollient clys-
ters will be of service;  and  when the labour is far*advanced, in
some cases in which  the action of  the uterus is  very feeble and
slow in its returns, as if it were unwilling to come on, a clyster 
ON DIFFICULT  LABOURS.
321
rendered stimulating by the addition of one ounce of culinary or
cathartic salt will often rouse the dormant powers into action, and
the labour will be much sooner yet  safely completed,* the  very
conclusion of these putting her into the most favourable position.t

                 2.  Partial action of the uterus.
   It was observed,  that previous to  labour the uterus commonly
subsided  lower into the abdomen, and that the more perfect this
subsidence was, the more kindly would the labour probably be ;
because the uterus would act with more advantage.   But in  some
cases, the fundus of the uterus does not subside before or even in
the time of labour, the patient herself being sensible of, and  com-
plaining that the child is then very high in the stomach.   Some-
times she  will also complain of vehement and cramp-like pains in
various parts of the abdomen,  producing  no good or  adequate
effect,  which  are afterwards proved to have been occasioned by
the irregular contraction of the uterus.  This irregular and  par-
tial action, which  is  properly called  spasmodic, is capable of
throwing  the uterus into various forms ; sometimes the longitudi-
nal, and at others the  hour-glass,  with  all their  varieties and de-
grees, and such contractions may take place at the commence-
ment of a labour and continue through the course of it, and even
become the cause of retaining the placenta at the conclusion.  Eve-
ry change in the form of the cavity of the uterus, from the genuinex
will be productive of inconvenience,  according to the peculiarity
and degree of alteration ; and  it  is to be wished, that we could
discover the means of altering  the form of the uterus when thus
irregularly  contracted, of suppressing its action when too vehe-
ment or disorderly, and of strengthening  it when  too feeble, ac-
cording to the necessities of each case, as they may arise.  But as
these things are beyond our power, at least any method of pro-
ducing them is at present unknown,  all that we  can generally do
must depend, not on commanding what we choose, but on making
  * Clysteres injiciantur, quorum irritatione expultrix uteri facultas
excitatur, et depleta intestina ampliorem locum utero relinquant.—
Riverii Prax. Medic. De Partu. Difficilis.
  t [Much has been written in  favour of the efficacious powers of
the ergot or spurred rye ; and after a proper dilatation of the os uteri,
it doubtless may occasionally be given with advantage.   It is a vigo-
rous remedy, and requires to be administered with much caution, and
with great regard to circumstances.  Lately I saw the child destroyed
by its premature and injudicious employment.  Its dose  is fifteen or
twenty grains, in powder, mixed with syrup, or given in  infusion :
sometimes it  may be repeated  after an interval of twenty minutes.
We are indebted to Dr. Stearns, for the introduction of this potent
article into the American materia medica.   F.]
41 
322
INTRODUCTION TO MIDWIFERY.,
the best of such  circumstances  as do really occur ;  and it is ne-
cessary to consider, whether by any  previous management it be
possible to prevent this irregularity of action, or remedy its effects,
when it is in such a degree as to be very painful or troublesome
before, or productive of inconvenience at the time of labour. When
there is any  unusual kind of pain in the region of the uterus,
greater than, or different from, that which may be considered as
one of the common effects of pregnancy or labour, there is gene-
rally an increase of that feverish disposition, which  in a certain
degree is,  perhaps, natural to all women with child ; and it will
then be necessary to take away  small quantities of blood, to give
cooling medicines, to be very attentive that the regular course of
the bowels  be procured or preserved, and I think I have seen much
good done by gently rubbing the whole abdomen with warm oil.
At the time of labour the same means may also be necessary and
proper, on account of this irregular or insufficient action of the
uterus and of the concomitant pains, which most frequently  hap-
pen  to those who are naturally too irritable, or who  lead inactive
lives.  To such women should be pointed out the necessity of ac-
quiring a composure of mind, and of using exercise  in the  open
air as far as their unwieldiness will with propriety allow; even in
the time of labour, if rendered  tedious from this cause, in which
the pains are very sharp yet ineffectual,  it is of use to bear  them
when in an erect position, and to walk about as long and as  often
as they are able in the  intervals, even  till the labour is far ad-
vanced, or on the point of  being  concluded.  The chief part
of what can be further done is, to impress upon their minds the
necessity of  exercising that patience, which we  on our  parts
ought never to want.   In some cases of this kind, when the pa-
tient has suffered much, and for a long time after  bleeding, if
judged to be necessary,  and the  administration of a clyster, I
have directed twenty drops of tinct. opii  to be given, with the
intention of suppressing the present pain, which was irregular,
and  with the hope  that, when it returned, it would be with re-
gularity and efficacy.  But in general,  1 have great objections
to opiates  on slight occasions for women in labour  ; being per-
suaded that by disturbing the order of  labour, they frequently
produce very untoward symptoms, and make that which was in
itself  natural,  become  difficult or dangerous to the mother  or
child,  as evidently as any other kind of unseasonable interposi-
tion.*
  * [Opium given in the small quantity recommended by our author,
will prove of little service.   After venesection, if it be indicated, the
irritations of the system may be calmed by a dose of sixty or eighty
drops of laudanum: when the parturient efforts of the patient return, 
ON DIFFICULT LABOURS.
323
                3. Rigidity of the membranes.
  This has been mentioned by the generality of writers, as a
cause of difficult labours;  and I have observed, when a labour
proceeds slowly, the membranes being unbroken, that their ri-
gidity is usually  assigned as the cause of the difficulty or delay.
This subject has already been considered in the history of na-
tural labours; but we cannot too often inculcate, as the obser-
vation is of the greatest importance, that neither the mother or
child is  ever in any danger, (excepting cases of hemorrhage and
convulsion,) on account of the labour, before the membranes
are broken : and that there is infinitely more caution required,
to avoid breaking  them too early, than there is difficulty in
breaking them when necessary.  The true cause also, why the
membranes do not break at the usual or proper time,  is not in
truth from the rigidity of the membranes,  so commonly as from
the weak action of  the uterus:  because the membranes are
scarcely ever so rigid as  to withstand  the force of very strong
pains, and if they  were, the whole ovum  might be expelled at
the same time, a  circumstance not  unfrequent in  premature
births.  More than one case has occurred in  my own practice,
to which particular attention has been paid, for the  purpose of
registering the observation, in which the labour has commenced
properly, and proceeded   with much  activity, till the os uteri
was fully dilated, and then ceased altogether for many hours or
several  days :  at the end of that time the membranes breaking,
the action of the uterus has instantly returned, and the labour
been finished  speedily, with  perfect safety to  the mother and
child.  (When the  head of the child is born with the membranes
unbroken, it is said  to be born with a  cawl  or sillyhow.   To
this cawl imaginary virtues have been attributed, and a fancied
value has been set upon it.  It was esteemed the perquisite of
the midwife, and  perhaps  the whole  was the contrivance of
some intelligent man, to prevent her from interfering with any
labour,  which was going on in a natural way.)
   The circumstances of labours are, however,  sometimes, though
very  seldom,  such as make it not only justifiable, but  eligible,
or perhaps necessary, to break the membranes artificially.  Yet
before this is attempted, we ought first to be assured  of the state
of the  os uteri,  because this will sometimes be spread over the
head  of the child, so thinly and uniformly, before it is in any
they will come on with greater regularity  and efficacy ;  sometimes
opiates immediately expedite the labour.   I see no substantial rea-
son for concurring in the popular  opinion, that opium is detrimen-
tal to the foetus in utero.  F.] 
324          INTRODUCTION TO  MIDWIFERY.
degree or very little dilated, as to resemble the membranes.  But
when the os uteri is wholly dilated, and we have determined upon
the propriety of breaking  the membrane, no instrument is re-
quired for that purpose.   If they be confined with the end of the
fore finger  upon  the head of the child,  during the  time  of a
pain, they  generally give way; or if this be insufficient,  they
may be rubbed with the end of the finger, on one particular  spot,
till they are worn  through; or they may  be scratched with the
nail of the finger,  cut and slightly turned up for  that purpose.
I am persuaded, that no person, who is capable of judging when
the membranes ought to be broken, will ever meet with any real
difficulty in breaking them.

       4. Imperfect discharge or dribbling of the waters.
   This circumstance is  a cause, or at least a frequent attendant
on difficult labours, especially when  the  membranes have  been
broken designedly, or spontaneously,  before the  os uteri was di-
lated, though far more frequently in the former case.   For if the
membranes do not break, or be not broken, before the complete
dilatation of the os uteri, the whole quantity of the water is gene-
rally  discharged at once,  and the  head of the child is speedily
advanced by the  succeeding  pains.   Sometimes,  indeed, the
head  of the child is so placed, as to lock up a great portion of
the water, which cannot escape till the head is expelled.  Should
the water be imperfectly discharged, a further  small portion of
it  is usually evacuated whenever there is a pain,  and the pain is
not immediately efficacious, or entirely ceases after the discharge.
   In  this situation  there are only two methods to be pursued ;
we must either wait till all the water is drained  away by these
repeated small discharges, or we must contrive some method, by
which their evacuation may be hastened.   If there be no particu-
lar reason against  our waiting, it is better not to  interfere, but to
leave the business  entirely to  nature, explaining  the state of the
case  to the patient or her friends, taking care to prevent their
apprehension of danger from  the delay of the labour,  and not
by our solicitude to raise their expectations  or their fears unne-
cessarily.  But when  the water dribbles away in the advanced
state of a labour, or there is  reason for our wishing a speedy
conclusion of it, either on account of the mother or child, it will be
expedient to forward the discharge of the water, by raising the
head of the child a little higher into the pelvis; by the intro-
duction of the fingers and thumb of the right hand, which may be
done without prejudice either to the mother or child, during the
continuance of the pains;  or by pressing the  head toward the
hollow of the sacrum, by which means more room will be made
for the water to escape.  However, the dribbling  of the water is
not a circumstance of much importance, when it is not combined 
ON DIFFICULT LABOURS.             325
 with other causes  of difficulty ;  and it may be again mentioned,
 that it is generally occasioned by the artificial or premature rup-
 ture of the membranes.

             5.  Shortness of the funis umbilicalis.
   The funis umbilicalis seems to admit of a greater variety, both
 in thickness and in length, than any other part of the ovum when
 at its full growth, being in one subject several times thicker than in
 another, or perhaps three or four times as long in one, as it is found
 in another.  It may be naturally very short, or it may be rendered
 so accidentally, by its  circumvolution round  the neck,  body, or
 limbs of the child.   Whichsoever of these is the case, the  incon-
 venience produced at the time of labour is  the same, that is, the
 labour  may be retarded; or perhaps  the placenta  may be loos-
 ened prematurely; or the child may, in  a tedious labour, be in-
jured or in danger of being destroyed by the tightness of the liga-
 ture drawn  round  its neck; or  by the mere  stretching of it, as
 this must necessarily lessen the diameter of the vessels, if not per-
 fectly close  their cavity.  But the two latter consequences very
 seldom follow.
   The shortness of the funis is always to be suspected, when the
head of the  child is retracted upon the declension  of the  pain ;
and it may sometimes  be discovered, that  it is more than once
twisted round  the neck of the child, long before it  is born.  It
has been thought that far the greater number of  children are
born with one or more convolutions of the funis round the neck.
   Various methods  have formerly been  recommended for  pre-
venting this retraction  of the head, some of which are insufficient,
and others unsafe ;*  and the inconvenience is  usually overcome,
by giving the  patient more time.  But if  the  child should not
be born, when we have waited as long as we believe to be proper
or consistent with  its safety, or that  of the parent,  it will  be re-
quisite to  change  her position,  and instead of suffering  her to
remain in a recumbent one, to take her out of bed, and  raise her
upright, to permit her to bear her pains in that situation;  or ac-
cording to the ancient custom of this country, to  let her kneel
before  the bed, and lean forwards upon the edge  of it; or, as is
now practised in many places, to set her  upon the lap of one of
her assistants.   By any of these methods the retraction of the
head of the child is not only prevented by  its own gravitation,
but the weight of the child will be added  to the power of the
pain ;  and it will likewise be expelled upon an inclined plane, in-
stead of a level.  In the course of practice, I can with infinite sa-
  * Nocet obstetricis digitus ano imraissus, item nimia festinatio.—
Ruysch. 
326          INTRODUCTION TO MIDWIFERY.
tisfaction recollect a great number of cases,  in which, by advert-
ing to the benefits gained by an  erect position,  labours have not
only  been accelerated,  but the use of instruments,  which  were
before thought necessary, has been  avoided.
  When the head of the child is  expelled,  if the funis be twisted
round its neck, there is sometimes  a little delay and difficulty,
before the body  can be protruded or extracted.   We are, in the
first place, taught, that  it is proper  to bring this over the head
forwards,  lest the  placenta should be separated, or the body of
the child be hindered from advancing till it suffers detriment, or
is brought into absolute danger.   But it is in some cases drawn
so tight round the  neck, that  this cannot be done, without increa-
sing the hazard of the mischief we wish  to avoid.  We have then
been advised to slide the fun's back over the shoulders, but this
may be equally impracticable with the former method.  If either
of these intentions can be accomplished without violence,  they
are to be attempted, otherwise they must be omitted.   The child
will, nevertheless,  be usually expelled, if we wait for  the return of
a few pains, whi< h we may very safely do, and without any other
inconvenience tiian some increased  distention of the perinaeum;
the body making a shorter bend  or  doubling, on account of the
confinement of the neck by the funis.
  Instances have occurred,  in  which,  though  the  head of the
child  was expelled, and  the pains  continued,  the body has re-
mained, not perhaps always from this cause, and could not  even
be extracted with all the force which could be exerted, for a  long
time,  perhaps for several hours.   Two things are then to be con-
sidered : first, whether the child be  living; secondly,  whether it
be hindered merely by the shortness of the funis.  If a child in
this position should show any signs of life, if the pulsation in the
naval-string  should be  vigorous,  or  the  child should breathe,
though imperfectly, we  have no occasion to be in  a hurry, it
being only requisite that we should  keep its mouth open, to allow
of the free access of the air, till it is expelled, or can be more rea-
dily extracted; for the internal  organs will accommodate them-
selves to that stale, and the child  will possess a species of life half
uterine, and half breathing.   Bat when it has remained in this
situation as long as we  think consistent with its  safety,  and it
cannot without great violence  be  extracted;  should it then be
hindered by the shortness of the funis only, we have been taught,*
that it is advisable to divide the funis,   before the body is expel-
led.  Previous to  our doing this, it will however be expedient to
tie  the funis with  two ligatures,  and  then to divide it between
them,  otherwise the child may be instantly destroyed by the sud-
* See Chapman—p. 63. and 85. 
                 ON DIFFICULT LABOURS.              OAI

den gush of blood ; as happened  in  an unfortunate case under
my own care, though it was living when I divided the funis, and
was afterwards very soon expelled.*
   When the child is dead, and the total exclusion of it is preven-
ted by the tumefaction of the body, by the size or awkward posi-
tion of the shoulders, or any other cause,  by passing a napkin
or handkerchief roun>! its neck,  and taking both the ends in our
hands, we shall be able conveniently to exert much force; and if
we pull steadily and in a proper  direction, we shall usually suc-
ceed  in extracting  it.   But if we be  yet foiled in our attempts,
by turning the  head  on one side, we must endeavour to bring
down one or  both  arms,  which being included in the handker-
chief, will allow us to  pull with  yet more force, and facilitate the
passage of the body, by lessening its bulk.  The greatest difficul-
ty of this kind 1 ever saw, was in consequence of the inflation of
the whole surface of the body from its putrefaction, and there was
occasion for all the dexterity  and force I could exert for several
hours.   But in other  cases I  have succeeded better, by availing
myself of the changes produced, by wailing and giving  more
time, rather than  by the exertion of much force.   The case of one
woman, who absolutely died under these circumstances, was re-
lated to me; bul I  could not satisfy my mind, that her death was
to be attributed merely to  the situation and retention of the child.f

              . 6.  Weakness of the constitution.
   The health of women at the time of parturition is often impair-
ed,  either by some general indisposition,  which may have con-
tinued through pregnancy, though not altogether dependent upon
it; or, by some disease with which they are attacked, when they
are perhaps  in  daily expectation  of falling into labour.  The
more  perfect their health is,  the  better fitted they are for child-
bearing, as the process wiil not only go on with more regularity,
but they  will also recover more favourably, as is well known  to
 those who are engaged in practice.  Because though it be allow-
ed, that the state of childbearing  is not a state of disease, yet ex-
perience  has shown, that women are then more liable to be infect-
 ed with contagious diseases than at any other time;  and that all
  * [We are not to conclude that the retraction of the head is always
caused  by the shortness of the funis.   How is the accoucheur to
reach the chord, when the head only of the child has protruded be-
yond the os externum ?   When the shortness of the funis is the cause
of protracted labour, by changing the position of the patient, we may
often expedite  the delivery.  F.]
  | [The mere death of the child neither protracts nor facilitates la-
bour ; by putrefaction and distention its delivery may be retarded, F.] 
32ft            INTRODUCTION TO MIDWIFERY.
diseases  with which they are then affected, are not only apt to
fall upon those parts which  are left in  a more irritable state, in
consequence of the changes they have so lately undergone, but
the progress of disease is also then more violent,  and the event
far more dangerous.*
   But the case of which we are now speaking is, when the ge-
neral health of women is reduced below its proper standard, by
some previous or  accompanying disease, not absolutely  con-
nected with a state of pregnancy; of which a consumption is a
very fair example, as consumptive persons seem, of all others, to
be in the most hopeless state.   Yet though such are  often in
their own minds, and in the opinion of their friends, not able to
go through  the fatigue and other unavoidable consequences  of
childbearing, I do not recollect one instance  of any woman, in
that situation,  being  unequal to her delivery, or having  her
fate hastened by it.   If such women have  little strength,  they
have little   difficulty to  overcome ;  the  state  of  the parts,
which in a common way might require the exertion of much
force to dilate,  corresponding with the force which they are able
to  exert; and  more time only  is required.  When  a prog-
nostic, however,  is  made of the probable event of such la-
bours, it is to be  presumed, that  no particularly  untoward cir-
cumstance shall occur; for if there should, it cannot be expected,
that with extreme debility there should  be the  same power or
resources, as in great strength and good  spirits.
   In constitutions much reduced by a consumption, or a disease
of any part  not immediately affected by childbearing, there is
usually not only sufficient strength for perfecting the business of
a common labour,  but the patient appears  to  be relieved for a
certain time after her delivery; and then,  if the  diseases were
not dependent on pregnancy, or were incurable, they return, and
make their wonted progress.
   The effect of diseases seems also, in many cases, to be sus-
  * Hence at the time of any epidemic disease,  women more fre-
quently  fail in child-bed, though they are managed with equal skill
and care.  In the history of the different plagues in London, there
are sometimes two or three hundred women who are put down as
dying in child-birth in one month.   Procopius has also told us in his
account  of the  plague  at Constantinople—Tres  saltern  puerperal
convaluere;  that is, 1 presume, of those who actually had the plague
in child-bed.  On this subject we shall speak again in the chapter on
the puerperal fever.
  [Observations of a similar kind have been made by several writers
of other epidemical  or malignant diseases.  Dr.  Rush, in his account
of the yellow fever of Philadelphia in 1793, states that, "pregnancy
seemed to expose women to it."  F.] 
ON DIFFICULT LABOURS.
329
 pended during pregnancy.   Of the distinctions  to be made in
 the opinion we may be called upon to give of the event of acute
 diseases, during which a patient  may either be delivered at her
 full time, or suffer  abortion,  we shall speak when we come to the
 subject of uterine  hemorrhages.

                 7.  Fever, or local inflammation.
   On the  accession of labour, there is usually some increase of
 heat, of the quickness of the pulse, thirst, flushed cheeks, and a
 general feverish disposition  ; and commonly these continue in
 proportion  to the exertions required or made for the completion
 of the labour, with respect to which they are, properly speaking,
 merely symptomatic.  But, in some cases, the excitement is too
 great,  and  instead  of helping the action of the parts concerned
 in parturition, it prevents their acting with regularity or energy.
 Whenever the pains of labour are feeble, it is a vulgar custom,
 without regard to the case, to give cordials very freely, with the
 view of accelerating their returns, or  of strengthening  them;
 though under many circumstanees by such proceeding* we evi-
 dently add to the evils we mean to remove.  In some cases, also,
 from the acuteness and constancy of the pain  which the patient
 endures  with  little  proportionate  effect,  and from its  situation
 also, it may be readily distinguished from that which is occasion-
 ed by the proper action of the uterus, giving us too much reason
 to suspect,  that  the uterus, or some of the  contents of the abdo-
 men, are already in a state of inflammation, which  may require
 immediate attention.
  It does not seem necessary to bleed every patient on the ac-
 cession  of labour.  For some it must be highly improper.   But
 whenever the feverish symptoms  become violent, it  is, I believe,
 universally  proper,  the  quantity  of  blood taken  away  being
 suited to the degree of fever, and to the constitution of the patient;
 and  much service will  also be done by the frequent  exhibition of
emollient clysters, or even a common purging draught, by keeping
the room cool and well aired, by giving cooling  drinks  and  me-
dicines, and by keeping,the patient in a quiet state, without com-
pany or any other cause of disturbance.  When the fever is re-
moved,  the natural  pains will come on, and perform their office
with  propriety and success.  Independently of fever, when the
  * Lord  Bacon seems to have had a clear idea of this, though, by
the manner of expression,  his meaning is rendered somewhat ob-
scure : " To  procure easy  travails of  women, the intention  is to
brins down the child, whereunto they  say the loadstone helpeth ;
but the best help is to stay the coming down  too fast."—Nat. Hist,
cent. x. 968.
                            42 
330         INTRODUCTION TO MIDWIFERY.
exertions which the patient makes are vehement, if she be pletho-
ric, there is  on that  account sometimes a  necessity of taking
away some blood;  for during  these vehement exertions, if the
blood vessels be distended, some of them may give way, and the
patient be  brought into the  most imminent danger, before the
delivery, then at  hand, is completed.  Of one instance I  have
been informed by the  medical attendant, in  which a patient, thus
circumstanced, burst a blood-vessel in the lungs, and died imme-
diately, in the exertions of the very pain  by which the child was
expelled.

           8. Want of irritability in the Constitution
  Under many circumstances which occur in the practice of me-
dicine, as in some  kinds  of  fever, it  has been observed,  that
when a cause of pain  exists, it is found  to produce an effect quite
contrary to what might be expected : that is, instead of exciting
the  powt-rs of any one part, or of the  whole frame,  to action, it
oporcssetli  all the powers  of  the constitution, and creates a par-
tial f>r universal insensibility, or a disproportionate  action.  In
some  cases, on  the accession  of labour, the cause, instead of
raising a disposition to act,  or a power of acting with  energy,
in the part., concerned, seems to lessen both the disposition and
power to aci, and sometimes  even to deprive them, for a certain
time, of all power, as effectually as if they  were become paraly-
tic.   Inconveniences of this kind are  most  frequently observed
to take place in  fat and inactive women, or  in those  who are
extremely timid ; and such, in  spite of all  the means which can
be safely used, will  necessarily often have very slow and linger-
ing labours; and though they may at length be  delivered by
their pains, feeble as they are, when there is  no material cause
of obstruction, much  time will  be required  for every part of the
process, and  in some  of these cases, artificial assistance may be
required.   I  have  often  suspected,  that the foundation of this
imperfect action, or total  inaction, in  the advanced state of la-
bour, may  have  been laid by some error or  accident in the be-
ginning,  perhaps by exciting the action prematurely, which will,
of  course, cea^e when the  artificial  cause  is  removed,  (see
chapter vi. sect. xi. ;)  but sometimes  these imperfections  have
evidently been occasioned by some specific affection  or action of
the constitution.
  The circumstances  attending labours are generally alike, yet
in many women  they are marked  with some peculiarity,  most
frequently  in  the time required for  their  completion.  When
there has been an  opportunity of observing  the progress  of a
labour in two or three instances, we shall be  able  to tell  what
will be  the probable  termination of  any future labours in the 
ON DIFFICULT LABOURS.            331
 same person, and at  what time it will take place; but we can
 no more control the order of a labour in one woman, so  as  to
 make it correspond  with or exactly resemble that of another,
 than we can judge of the quantity of food which one person may
 require by that which is necessary or sufficient for another,  or
 regulate  any other function.   One woman  may require  twelve
 hours for the production of the same effects in the time of labour,
 that another  may finish in four hours, or even in less  time; and
 it would be  in vain  to attempt  to make an alteration by art,
 because the reason exists in some essential property of the con-
 stitution, beyond  the power of  medicine, or of any method,  to
 alter.

                   9. Passions of the Mind.
   As the infirmities and  particular state of the  body have a
 powerful influence upon the mind, and  as  the affections of the
 mind have, on various occasions, a reciprocal  effect upon the
 body, it  might be reasonably expected,  that the progress of a
 labour should sometimes be forwarded or hindered by the pas-
 sions.   It is  constantly found,  that the fear of a labour, or the
 same impression from any other cause at  the  time  of labour,
 often lessens the  energy of all  the powers of the constitution,
 and diminishes,  or wholly suppresses for a time, the action of
 the parts concerned in parturition.   It is also observed  that a
 cheerful  flow of  the  spirits,  which  arises  from the  hope of a
 happy event, inspires women  with an activity  and resolution,
 which are  extremely useful and favourable in that situation.
 In the time of a  labour proceeding very slowly or irregularly,
 doubts and  fears in the  mind of the patient having an evident
 and great influence upon the pains ; when  those  are removed,
 and her resolution confirmed, she will go on with courage, and
 effects will be produced, which would have been impossible if
 she had remained  in a  state  of depression.  The  intelligent
 practitioner,  who should be the last person to despond, will avail
 himself of the knowledge of these things, and by his  discretion
 will inspire his patient with sentiments which will  enable her
 to go through difficulties, that to her feelings,  and perhaps to
 his own judgment, appeared insurmountable.   He will also re-
 gulate the conduct of all her  attendants and friends, and lead
 them step by step  to   co-operate  in his   views and  inten-
 tions, which  will  at length terminate to  the real  advantage of
 his patient, the satisfaction of  her friends,  and  the increase of
 his own reputation.

                   10. General Deformity.
  Many women, who are gibbous or distorted in the course of
the spine, have the pelvis well formed;  and there are a  few in 
332          INTRODUCTION TO MIDWIFERY.

general appearance perfectly straight, who have yet some defect
in the pelvis.  Of the ease or difficulty of labours,  depending
simply upon the capacity or form of the pelvis, we are to speak
in another place. Those who are gibbous, are not unfrequently
asthmatic, or have some infirmity which prevents their breath-
ing freely, or retaining their breath ; and such must suffer some
inconvenience at the time of labour, though the action of the
uterus may be proper, and all the parts concerned in  parturition
in a natural state.  For as both the instinctive and voluntary
force, especially the latter, are affected by the manner of breath-
ing, and duly exerted only when the breath is retained, and this
not being  under such circumstances possible, of course the pro-
gress of a labour must be retarded. Should there be  any reason
to suspect inflammation about the thorax, particular attention
must be paid to  it, otherwise we have  only to give  more time
for the completion of the labour, and to wait for that effect from
a repetition of feeble pains, which, without this inconvenience,
would have been produced by a smaller number.  I have known
one instance of a patient  labouring under a fit of spasmodic
asthma, who was immediately freed from the asthmatic symp-
toms on the accession of the pains of labour; but the contrary
effect is more generally to be expected.  Should there be, in
such cases,  an appearance of real danger, the labour must be
accelerated  or completed,  by giving such assistance  as  the cir-
cumstances of any case may require.

                        section  v.

On the second order ; or, those Labours which are rendered dif-
       ficult by the Rigidity of the Parts to be  dilated.

                       1. First  Child.
   Every woman is expected to suffer  greater pain and to have
a more tedious labour with her first, than with subsequent chil-
dren, and the  difference is  not  unusually in proportion to the
number which she has had.   (/ have heard a voice as of a 700-
man in travail, and the anguish as of her that bringeth forth her
first child.  Jeremiah, chap, iv.)   Thus, if a woman  were to be
twenty-four hours in labour with her first child, she might be
six with her second,  and  with the rest four, or perhaps two;
but  from  any general estimate of this kind there will be many
deviations.  It was before observed, that when women have had
several children, the practitioner is often able to form a tolera-
bly precise opinion of the  kind of labour which they will in fu-
ture be likely to have, and which may  be as peculiar to their
constitutions, in  manner and time, as any other function of the
body. It is no more in our power to change this constitutional 
                ON DIFFICULT LABOURS.            «**J

labour, as it may be called, than it is to alter the frame of the
body, or any of the functions thereon depending.
  The  difficulty with which first labours are often completed,
not only depends upon the greater rigidity of the parts, or upon
their reaction, but on the imperfection or irregularity of the ac-
tion also, by which they are to be dilated ; for this is generally
far  less  perfect and regular in the first instance, than when the
same  office has been frequently performed, of which examples
might be brought under many circumstances. But though there
be a somewhat greater chance of women wanting assistance with
first labours than in subsequent ones, there may be no specific
cause of difficulty, and they generally require only more time
to be  given for their completion.  We are to  remember, that
with a first child it would not be proper to denominate  a labour
difficult, till it had continued twenty-four hours, if the presenta-
tion were natural, and no other adverse circumstances should
occur.

                     2. Advanced in age.
  If a woman be far advanced in age at the time of having her
first child,  the difficulty attending her labour may be expected
to be  somewhat greater.  At a certain time of life, every woman
arrives  at maturity,  or that period when she may be considered
as having acquired  the  greatest degree  of perfection of which
her frame is capable: when  the  inconveniences of youth are
passed, and those of age are not arrived.   This state of perfec-
tion, the time of which  will vary in different  constitutions and
climates, and which may be  determined as best fitted for the
act of parturition, may include several years.  But if a woman
should  first be with child before or after this time of perfection,
she will be liable to some difficulties; as in the one case she would
be scarcely able  to bear without injury the changes she must
undergo ; and in the other,  the firmness  which all the  parts
have acquired, might lessen their  disposition or capability  of
dilating. Greater force will therefore be necessary, or the same
degree of force must be continued for a longer time in the latter
case ; in other words, she must have a sharper,  or a longer la-
bour.  In this country, there has seldom been  any reason to sus-
 pect women to  be pregnant, before they were able to bring
 forth children without any or much  inconvenience on that ac-
 count.   For the prevention of such difficulties  as may attend
 the first act  of parturition in those  who are advanced  in age,
 we have been advised to order frequent  and small bleedings to-
 ward  the conclusion of pregnancy ; that the patient  should
 take some emollient laxative  medicine, and sit over the steam
 of warm water every night at bed time, and afterwards anoint
 the external parts with some unctuous application.   Perhaps 
334          INTRODUCTION TO MIDWIFERY.
there is not authority for saying,  that no advantage can be de-
rived from the use of these or such like means ;  but certainly
the impression made upon the mind of the patient by the novel-
ty and peculiarity of the method,  will, in patients of a timid dis-
position, raise such apprehensions of danger and difficulty, as
will overbalance the good which can possibly be derived  from
them.  It is, therefore, better to omit the ese of any such means
on this account; at least, not to recommend them in  a formal
way,  for the specific purpose of procuring an easy birth, more
especially as it does not constantly happen, that the difficulty of
labour is in proportion to the age  of  the patient  when  she has
her first child ;  this being in many cases  as easy at forty years
of age or  upwards, as if she were only twenty-five.   In the
worst labours arising from this cause, there is no peculiarity in
the difficulties, but merely a general increase of those which are
produced by the rigidity of  the parts,  and therefore a longer
time only is commonly required for their  completion.

           3.  Too early rupture of the Membranes.
  The premature rupture of the membranes, whether natural or
artificial, has been often mentioned as  the cause  of much mis-
chief, and of many tedious or difficult labours.   If it be allowed,
that the membranes containing  the waters were intended to be
the medium by which the  os uteri,  and other tender parts, ought
to be dilated, some inconvenience must arise when  these are bro-
ken and the waters discharged, the  head of the  child being  sub-
stituted for them;  and this, being a firmer  and less accommoda-
ting body, cannot for a long time be admitted within the circle of
the os uteri, which will of necesssity be dilated more untowardly
and more painfully.  It should also be  observed, that in this state
of the soft  parts,  the lives  of  children are sometimes brought
into danger,  merely from the violent  or  long continued com-
pression which the head  undergoes.
  After the rupture of the membranes,  many hours, or  several
days, sometimes pass before the accession of labour, and the dif-
ficulties arising from this cause, even in first labours, will  then be
very much  lessened or prevented   if the patient have generally
lain in a recumbent position, and we have deferred,  as far as was
in our power, the coming on of the action of the uterus, till the
most perfect disposition  to dilate was previously assumed by the
parts.  More pain may  be endured, and a longer time will cer-
tainly be required for completing labours attended  with this cir-
cumstance only, principally those  with  first  children;  but they
may in general be more  properly called  lingering or  tedious,
than really  difficult, and they very  seldom  require the interposi-
tion of art.
  The membranes generally lie in close contact with each other, 
ON DIFFICULT LABOURS.
335
but in some cases there is a quantity of water* collected between
them ;  and, though in the former case they break simultaneously,
so that there is, on that account, no impediment to the complete
discharge of all the water of the ovum, I have seen  a few cases
in which one membrane breaking,  the labour has not ensued for
several  days or  weeks; and the  second membrane containing
the proper water of the ovum, has broken in  the ordinary course
of the  labour, without any additional derangement, provided we
did not interfere, nor conclude  that the second membrane ought
to be broken, because the first had  given way.

              4. Oblique Position of the Os Uteri.
  The natural position of the os uteri at the commencement of
labour, and that in  which it is most conveniently distended,  is
at or near the centre of the superior  aperture  of the cavity of
the pelvis ; for when thus placed, the effect of the action of the
uterus  is most favourably produced.  But the os uteri is  seldom
found exactly  in this situation, being, in  some cases, projected on
either side, and in others so far backwards,  that it cannot even
be felt  for many hours after the labour has begun. This oblique
position of the os uteri, to  what direction  soever it may tend,
has been considered not only as a frequent, but as the  most ge-
neral  cause of difficult labours; and  this doctrine,  which was
first promulgated by Deventer, was, at  one  period of time,
taught and received in all the schools of midwifery in Europe.
In  every inquiry after knowledge, in almost any science,  opi-
nions may be advanced, which sometimes lead to further improve-
ment ;  but when experience  with  caution has  proved, opinions
should end; for  if so much regard  be paid to opinions, as hastily
to found any certain practice upon them, and they should prove
erroneous, they become the source of much  mischief; the prac-
tice remaining, when the doctrine  on which  it was founded may
have been disproved, become obsolete  or forgotten.  The  pre-
sent case is a striking example of the truth of this observation ;
for when it was presumed, that every difficult labour was occa-
sioned  by the oblique position  of the os uteri, it was immedi-
ately supposed  necessary to remedy the inconvenience  thence
arising  by manual assistance,  and to drag the  os uteri  from its
oblique, to a central position during the time of every pain, which
must have been greatly prejudicial. The opinion of the oblique
position of the os uteri  being the chief cause of difficult labours
was soon fully proved to be erroneous, yet the practice remained.
Though it were  oblique, such position is not  to  be considered  as
a general cause  of the  difficulty,  but as an accompaniment  of
* [Frequently called the false waters.  F.] 
336
INTRODUCTION TO MIDWIFERY.
some other primary cause.   Thus, when the pelvis is distorted,
the os uteri is constantly found in an  oblique situation, yet the
difficulty of the labonr, as well as the obliquity, is occasioned by
the distortion.
   It must however be allowed,  that some labours are procrasti-
nated by the mere oblique position  of  the os uteri, and that it is
often combined  with other causes of difficult  labours, though,
singly, it may not be of sufficient  importance to  be the cause of
truly difficult ones.  But when it does  retard a labour, or ac-
company a difficult one, it does not  require any manual assist-
ance, or that  we should retract it to  a  central  position with  re-
spect to the cavity of the pelvis; both the  thing itself, and the dif-
ficulty thence arising will be obviated, without detriment or much
trouble, if the patient be confined  to a  proper  position.  If,  for
example, the os  uteri be projected to the left side,  she ought to
rest as much as possible on the same side, and  so of the  right :*
if it be projected backward, which I  think is always  the case
when we cannot reach the os  uteri  in the beginning or early part
of a labour, she ought to lie upon her back.  By this method the
fundus of the uterus, constantly leaning or inclining to the side
of the obliquity,  will gradually,  but effectually  project  the  os
uteri more and more toward a central position.
 • Cases have been recorded, in which  it  was  said, that the os
uteri was perfectly closed, and in which it  has not only been pro-
posed with  a pair of scissars, to make an artificial opening instead
of the closed natural one, but the operation has actually been per-
formed, the labour,  it is said, being  thereby accelerated, and the
patient recovering without inconvenience.   I do not know that I
should be justified in saying,  that such necessity has  never oc-
curred, because  it has not occurred  in my  practice; but 1 am
persuaded, that there has been an  error in this account, and that
what has been, in some cases, called a  perfect closure of the os
uteri, has not been such, though the opening may have been very
small, but that the practitioner has, at perhaps an advanced pe-
  * [This situation of the os uteri is not so very rare an occurrence,
especially in  women with wide pelves.  There may  be a lateral
obliquity of the uterus, however,  and the os uteri may be situated
in the  hollow of either ileum without being within reach.   This
happened in  an  instance of protracted labour of late  occurrence.
After the labour had continued some  time, attempts were made to
ascertain the state of the os uteri: by the ordinary mode of exami-
nation it  could not be reached ; at length, by introducing the hand
into the vagina, the mouth of the uterus was found in the  hollow of
the  left ileum : the  membranes were ruptured and the child turned
and delivered by the feet.  F.l 
ON DIFFICULT LABOURS.
337
riod  of the labour, been unable to discover it by  reason of  its
obliquity:  and with regard to any operation  by  which the os
uteri is to  be artificially opened,  to  common apprehension that
cannot be void of danger.

             5.  Extreme Rigidity of the Os Uteri.

   Difficult, as well as tedious and  very painful  labours, are fre-
quently occasioned by the unusually rigid  state of the os uteri.
The manner of, and the time  required for its dilatation, will de-
pend upon two circumstances : first, the degree  of  disposition to
dilate, which  it may  have previously acquired; and  secondly,
the degree or force of the action  exerted by  the  uterus.  The
former of  these is, in  general, far less perfect, or  more slowly
produced With first than with subsequent children, as well as in
premature labours, even presuming it to be in its most  natural
state; but when the os uteri assumes from any cause a still greater
indisposition to dilate, of course the  labour will be both more
difficult and  tedious.   In a first labour it not unfrequently hap-
pens,  that the os  uteri may not be dilated  in less than twenty-
four or even forty  hours, when the rest of  the  labour may  be
completed  in four, or  perhaps a  shorter time, yet the very same
person may have  the whole process with her next child comple-
ted within six hours, or even a shorter time.
   We have before taken  notice of the advantages arising from
the changes in the state of the soft parts  being perfected, before
the accession of labour.  But  when these are as favourable as can
be wished, by the very action of the uterus  pressing its contents
upon the os uteri, or by the reaction of the  part, and much more
frequently by attempts to dilate it artificially,  this part may be-
come  inflamed, and indisposed to dilate according to the degree
of inflammation.   The inflamed  state of the part is often indica-
ted by its heat and dryness ;  but whenever  it is extremely rigid,
and there  has been a  long continued  action of the uterus,  with
Kttle or no advantage,  the  impediment to the progress of the la-
bour being clearly occasioned by the resistance made by the os
uteri, 1 believe it is always right to consider that part as inflamed,
provided there be apparently  sufficient pains.  If this be allowed,
instead of  attempting to dilate it  artificially, it is the proper ob-
ject of art, to recover in the first place the natural disposition  to
dilate, and then the pains of labour will be  equal to the purpose,.
With this view it will be necessary  to take away some blood, to
give cooling medicines and drinks, to direct emollient clysters to
be frequently injected, and, instead of using any means with the
intention of increasing the force of the pains, to confine the pa-
tient to a recumbent posture ; to gain, if it  were in our power, a
suspension of the labour, till the inffammatory disposition be  re-
                              43 
338
INTRODUCTION TO MIDWIFERY.
moved, when the dilatation will proceed more speedily, less pain-
fully, and without danger of affecting the constitution.
   When a labour comes on prematurely, or before the parts have
acquired their dilatable  state, as it may be called, the position of
the os uteri will at that time be very different.   In some cases it
begins to dilate when it is high up in  the pelvis ; but in others,
especially when  the  pelvis is,  in comparison with the child, very
large, the os uteri may be protruded very low down before there
is any degree of dilatation, though it is spread so thin over the
head of the child,  or the membranes, as to give the feel of the
membranes alone.    If, under these circumstances,  the external
parts should be  much relaxed, and the pains at the same time
strong,  it is possible for the  head  of the child to be expelled,
though enveloped in the os uteri, and much mischief may be there-
by occasioned.*   For the prevention of this accident, or any ten-
dency to it,  when there is reason to dread it, the patient ought to
be confined to a horizontal position, and the practitioner to re-
strain the advancement of the head ; or if the case should actu-
ally have happened before he was called, he must use all the jneans
he safely can, to extricate the  head,-and to support or replace the
os uteri.  When the pelvis is large, and the head of the child, be-
ing moved from  its resting place upon the pubis, drops by its own
weight into the lower part of the cavity of the pelvis, bearing the
os uteri before it, the accident often becomes a cause of a proci-
dentia or prolapsus of the uterus,  which cannot, as far as I know,
be always prevented, and which  is a grievous  misfortune to all,
especially to those who are obliged to work for their livelihood.
   All that art dictates to be done at the time of labour, is to ren-
der this as slow and gradual as possible, and after delivery to con-
fine the patient longer to her bed or to a horizontal position, using
at the same time such applications  as may strengthen the tone of
the parts, without interrupting the customary discharges.

       6. Uncommon Rigidity of the external Parts.
   The state of the external as well as of the internal parts is very
different in different women, both  in the beginning and in the pro-
gress of labours.  Even in first labours they readily yield in some
women,  so as  to allow the head of the child to pass through them
with great facility and safety, but in others they are extremely rigid
and unyielding, and withstand the action  of  the uterus, though
strong,  for a very long time ;   and then do not dilate without great
danger  of laceration.  A more difficult dilatation is always to be
expected in first labours than in others, and more care is required
to prevent a laceration.  In the original structure or formation of
* Os uteri aliquando prolabitur.—Tfavscft, Obs. Anatom. XXV. 
ON DIFFICULT  LABOURS.              339
these parts there is  also a considerable difference,  as well as in
their state or disposition, which requires  some attention in every
labour.  There ought to be, and usually is, a correspondence be-
tween the  state of the parts and the power of the pains; but in
some cas°s the external parts  are rigid when the pains are feeble,
whilst hi others, when the parts are indisposed to dilate, the pains
are exceedingly strong, pushing, with unabating force, the head
of the child, so that the parts  must either dilate  or be lacerated.
Of many of these circumstances we have already spoken.
   In first labours, the external parts may require  one or several
hours continuance of the pains, before they are sufficiently dilated
to allow (he head of the child  to pass through  them without
danger of  laceration ; but the difficulty  thence  arising does not
seem to require,  or to be relieved by our interposition, farther
than to prevent injury as far as that is  in our power, from too
speedy an exclusion of the  head of the child, in the manner
before advised.  The merit of our conduct under these circum-
staces will  be  chiefly negative; for if we cannot give to the
parts their disposition to dilate, and ought not to dilate them ar-
tificially, there only remains for us to wait the due time in order
to avoid mischief; art being more frequently exercised on such
occasions in remedying the  evils, which the  mistaken exercise
of the  art has before produced, than in  rectifying those which
are necessary or unavoidable.   It is also to be  observed, when
the head of the  child passes through the  inferior  aperture of
the pelvis  with difficulty, though the external parts are pressed
upon with considerable  force, that the impediment to the deli-
, very does not  always arise  from the resistance made by these,
but properly  speaking from the elongation or bending of the
spinous processes of the ischia,  and the labour should then be
referred to the next order.*

                         section VI.
 On  the third order ; or, Labours  rendered Difficult by dispro-
   portion  between the dimensions of the cavity of the Pelvis and
   the Head of the Child.

             1.  Original Smallness of  the Pelvis.
   The cavity of the pelvis  in women generally bears a certain
proportion to  the  common size of the  heads of  children; yet
  * [It would be superfluous to say any thing in recommendation
of bloodletting, in the various  species of rigidities noticed by our
author.   The practice is now generally  pursued by American phy-
sicians, with a result amply justifying its still more extensive adop-
tion.  F.J 
340         INTRODUCTION TO MIDWIFERY.
as they both  admit of considerable  variation, independent pi
distortion or disease, it is possible, that a woman with a pelvif
rather under  the common dimensions may have  conceived a
child far beyond the usual size ; and when this is the case, there
must of course be an increased difficulty at  the time of parturi-
tion.   When,  therefore, the smallness of the cavity of the pel-
vis, and the largeness  of the head of the child are mentioned,
they are  to be considered as relative, and not as positive terms;
because the pelvis of some individual woman may  be so large,
as to suffer  the  largest head of a child, of  which we have any
example,  to pass easily through it; and the smallest head may
be esteemed large,  if compared with a yet smaller pelvis.
  Though a labour may from either of these causes, separate or
combined,  be  rendered more tedious and painful than usual,  as
in consequence of the action of the uterus,  the head of a child
rather larger than ordinary will be  compressed into a much less
compass, and  moulded to the  dimensions as well as the form of
the cavity of the pelvis, there is not usually occasion for the assist-
ance of art,  if the labour be in other  respects natural.   But we
are to wait patiently for those  changes, which in due time may
be reasonably  expected,  and scarcely  ever fail  to take place;
obviating also  any occasional impediments which may arise.

                2.  Distortion of  the Pelvis.
  On the causes, kinds, and degrees of distortion of the pelvis,
we have already spoken very fully. (See chap 1. sect 10.)  The
effects produced, or the obstructions caused by this distortion, at
the time of parturition,  will somewhat depend upon  the  part dis-
torted, or upon the kind of distortion, but chiefly on the degree
of change made in, or reduction of, the dimensions of the cavity,
by which the natural relation between it and the size of the head
of the child is perverted or destroyed.  Distortion of the pelvis
at the superior aperture creates an obstruction to the passage of
the head  of the child, which will be overcome with more difficulty
by the powers  of the constitution,  and which  will  be  more incon-
veniently managed by art, than an equal degree of obstruction in
the lower part  of the pelvis.  The greatness  of the difficulty will
nevertheless chiefly depend upon the degree;  and in the various
degrees which  are found to occur, every person must see an evi-
dent cause for  all  the kinds of difficulty which he may meet with
in practice.  A small degree of distortion, like an originally small
pelvis, may occasion a  difficult labour of that kind  which may
not be an object proper for  the exercise  of his art,  as it will at
length be completed by the long continued action of the uterus ;
first moulding  and reducing the form and size of the head till it is
adapted to that of the pelvis, and  then forcing it through the di-
minished cavity.   Or, the degree of distortion may be such, that 
ON DIFFICULT LABOURS.
341
notwithstanding all the moulding and reduction of the head, which
can be accomplished by time  and the efforts of the  constitution,
there does not exist sufficient room for the passage of the  head
through the pelvis; but it may nevertheless be at length brought
into such a situation, as to afford us the hope of safely delivering
the patient by the use either of the forceps or vectis, and  of pre-
serving the life of the child.   Or, the distortion may be so consi-
derable,  that it is impossible  for the  head of the child to be ex-
pelled without lessening it, and the child,  if living, must be sacri-
ficed to the safety of the parent.   Or, lastly, the distortion may
be actually so great, that if the head of the child could be lessen-
ed, there would not be a possibility of extracting it, and we  must
either submit to lose the lives  both of the parent and child, or at-
tempt to save that of the latter, by the cesarean section, or by some
other operation, fruitless, yet almost equally hazardous,  such as
the division of the symphysis of  the ossa  pubis.
   In many  of those cases in  which there is a very great  degree
of distortion of the pelvis, the impossibility of the head of the
child passing through it is  self-evident, and  readily discovered on
the first examination per vaginam.   But in less degrees of distor-
tion, no judgment can be  formed a priori whether  the  head can
pass or not: and  we then ought to  defer any determination  upon
the necessity or propriety of giving assistance, as well as the kind
of assistance to be given, till  we  are  convinced  by consequences,
that the difficulty  cannot be overcome by the powers of the con-
stitution ; and the conviction is  in many  cases not satisfactory,
till the efforts of  the  patient are discontinued,  or cease entirely.
Degrees  of difficulty  to our apprehension insurmountable are
often overcome by the  mere  force  of the pains, and  so long as
these continue vigorous, we are not to despair of a happy event;
but encouraged by experience,  and supported and justified  by
moral as well as  scientific principles, we  must rely upon  the ad-
vantages which time and proper conduct may afford.
   The far greater part of those labours,  which  are rendered dif-
ficult by the distortion  of the pelvis, only require  a longer time
for their  completion.   Some, however,  must demand the assist-
ance of art; and when this  is the case,  the kind of assistance
must vary according  to  circumstances; but these  will be  more
particularly stated, when we  come to speak of the various opera-
tions in the practice of midwifery.

 3.  Head of the  Child uncommonly large; or too much ossified.
   No arguments  are  required to prove, that a small body wif'
pass through a small  space  with more facility than one that is
large; the size of the  body being supposed to  bear any  reason-
able comparison  to the dimensions of the  space.   Of course,  it
may be presumed, that the larger the head of the child is at the 
342
INTRODUCTION
TO MIDWIFERY.
time of  birth,  with  the greater  difficulty it will be  expelled.
Should the pelvis not be distorted, but  of a  common  size, we
may always expect that the woman will  be ultimately delivered
by her natural pains, if there be no other cause of difficulty than
the largeness of the head, though a longer time  may be required
for the completion of the labour.
  But it  is not merely from the size of the  head  of the child, that
a labour  may be rendered more tedious, more painful, or even
truly difficult.   The usual connexion of the bones of which the
head is constructed, is such as to allow of considerable diminution
and change of form in its passage through the pelvis.   The ex-
treme degree of diminution  and  change,  which it is  generally
capable of undergoing,  is perhaps impossible to be determined;
but it does not seem unreasonable to conjecture,  that it may be
reduced one third below its original  size, without  the destruction
or even  injury of the child from the compassion, the alteration
being so  gradually made.  The advantages gained by this com-
pression  of the head  in all cases of difficulty,  occasioned  by the
natural smallness of the pelvis, or in less degrees  of distortion, are
often greater than could have been hoped for, on almost any cal-
culation,  as was before observed.  .But  as there is great differ-
ence in the degree of ossification in  the heads  of different chil-
dren at the time  of birth, those  heads, which  are  most perfectly
ossified,  must  of course be capable of undergoing  the  least
change;  and  the degree  of change which they  can  undergo,
must be produced with the greatest difficulty, and purchased at
the expense of more severe or longer continued pains.  On this
account a large head, with a very imperfect ossification, is often
found to  pass through a pelvis, which might be  considered as re-
latively small, with  more ease than a smaller  head in which the
ossification was  more complete; and yet  the cause of the delay
may not  be discovered before the birth of the  child.  In cases of
difficult labour, proceeding from these and similar causes, it not
being in  our choice to select the circumstances, all that  we can
do is, to  manage such as occur in the most  prudent manner ; and
we have commonly to wait only for  those effects to be  produced,
which may be esteemed as consequences of the efforts of the con-
stitution  fairly exerted;  and never to despair so  long as these
efforts are properly continued.

          4.  Head of the Child enlarged by Disease.
   Two diseases have been  mentioned  by writers as  the cause
of this enlargement, tumours growing on the  heads of children,
and the hydrocephalus ;  but either of these very  rarely occurs.
With respect to the first, it has been said,  that when the tumour,
of whatever kind it may be, is of such a size as  to be an abso-
lute impediment to the birth of the child, it should and may be 
ON DIFFICULT LABOURS.
313
opened or extirpated, and that the operation is not only per-
fectly  consistent with the safety of the mother, but frequently
with that of the child also.  Of the existence of these tumours
the instances recorded do not  leave a doubt ;* or of the-possi-
bility, when they are  large, of their obstructing the delivery of
the patient; but of their extirpation  with safety  to the child
I should very much doubt, though no human being can circum-
scribe  possibility.  Yet  as it is the duty,  and must ever be the
solicitous wish of every practitioner, to preserve a life, when it
is in his power, he may  be induced to try the extent of his art,
when there is  little  hope of success.  From long continued
compression, the integuments of the head of the child may be-
come so  much tumefied, and  altered from their  natural form
and state,  as sometimes  to give the feel of a distinct  and ad-
ventitious  tumour; and yet simply considered,  such are so far
from requiring any surgical assistance, that it would be absurd
and flagitious to intermeddle with them.   Yet when there real-
ly are any unnatural tumours or excrescences, the point of prac-
tice would depend upon the degree of impediment to the pas-
sage of the head, which might  be thereby occasioned ; or upon
the nature  of the  tumour, whether it could be extirpated, or
only admitted of an opening to be made into it for the purpose
of lessening its bulk ;  or if neither of  these could be done with
propriety, by acting as if no such tumour existed, on  the ge-
neral principles by which we are to be guided in difficult la-
bours.
  With regard to the  hydrocephalus, which, if  of a  certain
size, would certainly  be a great obstacle to the delivery, this
is not readily to be distinguished in  the early  part of a labour,
because the membranes of the ovum, in some cases, resemble
by their thickness the integuments of  the head in  others.  But
if we were assured, that a hydrocephalus did exist, there would
not always be occasion for us to act, as  it is far more  eligible
even then to wait so long, as to give time for the expulsion  of
the head of the child by the natural efforts, if they be  equal  to
that effect.   Should the head be so much enlarged by the quan-
tity of  fluid contained in it, that it cannot pass through the pel-
vis, even in this case the integuments will generally burst by the
force of the pains.  But when the fact is ascertained, and the
labour is  rendered extremely tedious and lingering from this
cause,  or  if any suspicious symptoms should arise,  it would
not be  justifiable to allow the patient to undergo such long con-
tinued  pains, as when  we have any hope of saving the life of
  * Partus difficilis a tumoribus, e capitibus foetmim dependentibus.
—Ruysch. Obs. Anatom. LU. 
SH
INTRODUCTION TO MIDWIFERY.
the child, or of producing a child with a reasonable chance of
living.  The delay recommended is not intended, therefore, to
go farther than the prevention of mistakes.  But when we have
determined  upon the necessity or  propriety of delivering the
patient, all that generally is necessary to be done, is merely to
perforate the integuments of the  head, immediately after which
the water flowing away, the head is speedily expelled, and the
birth soon and easily completed.  In the extraction of the child
by the feet, there is not much more difficulty on this account, the
force with which we have the power of extracting, being so
great, as to burst the integuments, as I have several times ex-
perienced ; or any other necessary assistance may be easily
afforded.

              5. Face inclined toward the  Pubes.
  On a former occasion we have mentioned, that there are fou*
varieties in the position of the  head of the child at the time of
birth.  The first, when the vertex or hind  head is turned or in-
clined toward the pubes : the second, when the face is  turned
toward the pubes : the third, when  the head presents with one
or both arms : the fourth,  when  the face  presents.   The first
of these may be considered  as the  standard position, because
it is not only the most  common, but the  most easy also ;  the
head of the child being so constructed as to admit, in this posi-
tion, of the greatest and most ready compression and adaptation
to the pelvis, and of course the easiest passage through it.  Yet
the other positions are not to be considered as constituting la-
bours of any other class, but as varieties of the natural position:
though they must of necessity occasion  considerable delay in
all labours in  which  they happen ;  either because a portion of
that space, which would be wholly devoted to  the head of the
child, is occupied by some other part unfavourably; or because
the bones of the cranium, in such  positions, more slowly and
imperfectly conform  to the size or shape of the pelvis ;  or be-
cause unfavourable changes of position may be equal to increase
of size.   When the face of the child is inclined toward the
pubes, the peculiarity of the position is not usually  discovered
in the early part of the labour, or even when  the first stage is
completed, the practitioner being generally satisfied with  know-
ing, that it is a presentation of the head.  But when there is any
unusual delay, perhaps  without any very obvious cause, it  then
becomes a duty to investigate and  explore the cause, and it is not
a very unfrequent thing to find the face turned toward the  pubes.
This position is most  readily known by our being able to feel the
greater fontanel in a common examination,  though it is also pro-
ved by other  circumstances  relating  to the features of the face,
or various parts of the head, which may be readily discriminated,, 
ON DIFFICULT LABOURS.
346
When this is found to be the position, it does not follow that any
artificial assistance  ought to  be given,  but knowing that these
cases are not in general dangerous, we are to wait a longer time
for the effect of the  natural  pains;  experience having proved,
that the head in this position may be, and almost universally is,
ultimately expelled without the assistance of art.    Yet in some
of these presentations, that of the face towards the pubes in par-
ticular, it is said, that by pressure with the fingers the  face may
be gradually inclined to the sacrum, and the head reduced without
much difficulty to the first, or that which was stated as the most
eligible position.*  But when this change cannot  be effected, or
not without violence,  and the pains cease ; or when  we are fully
convinced that they are unequal to the exigencies of the case, such
assistance must be given, as the situation  of the parent may re-
quire and allow.
   With this  position of the head,  besides the greater length of
time which may be required for moulding and expelling it, there
will also be a greater distention of the external parts, because the
hindhead cannot properly be cleared of the perinaeum before the
chin has descended as low as the  inferior edge of the symphysis
of the ossa pubis ;  by which an inconvenience is produced equal
to what  an increased depth of the cavity  of the pelvis,  or a defi-
ciency in the arch of the pubes, would occasion.  There are  also
some peculiarities in the operation when we deliver  with the for-
ceps or vectis; but of these we shall speak, when we come to the
directions for the use of those instruments.

                  6.  Presentation of the Face.
   The presentation of the face is  discovered by the general  ine-
qualities of the presenting part,  or by the distinction of the par-
ticular parts, as the eyes, the nose, mouth, or chin, which is usu-
ally, if not always inclined toward the pubes.   In this presenta-
tion the child will generally be expelled by the natural efforts, but
a much greater length of time will be required for the completion
of the labour, especially with first children, for the reasons men-
tioned under the last clause,  which are in this perhaps increased.
But the child may be, and generally is, born without any injury,
though the face will sometimes be swelled in an astonishing man-
ner, and the  external parts of the mother being infinitely more
distended than in a natural position, greater care is  necessary to
prevent their laceration.
   If, after a long continuance of the labour, we should be convin-
ced that extraordinary assistance is required, then the same ob-
  * See Transactions, Medical and  Chirurgical,  Vol. ii. in which
there is a paper on this subject by Dr. J. dark.
                               44 
m
INTRODUCTION TO MIDWIFERY.
servation  may be made with regard to the use of the forceps or
vectis as in the preceding  article ;  but of the peculiar conduct,
which it may be necessary to pursue, we shall speak hereafter.

          7.  Head presenting with  one or both Arms.
  Though the head should present with one or both arms, expe-
rience hath fully proved, that a woman may be delivered by  the
natural  efforts with safety to herself, and without prejudice to her
child, if the pelvis be well formed.   But as a part of the cavity,
which should be appropriated  to the head, will be filled by the
additional bulk of the arms, there will be  an  evil similar to what
would be produced by a small, or by a somewhat distorted pel-
vis.  Should  the pelvis be in the first instance barely of sufficient
dimensions to allow the head of the child to pass through it, then
the additional bulk of the  arms must render the passage  of the
head impossible; or the labour may be  so much retarded, as to
make it  what is properly called difficult.
  In the beginning, or in the course of a  labour of this kind, the
practitioner will often be able to return and to detain the present-
ing arm or arms beyond the head  without any detriment;  at all
events, he must make and repeat the attempt,  and be very careful
not to solicit  the descent of the arm before the  head, lest he should
change  the whole situation  of the child,  and convert  that  which
would have been only a variety of a natural, into a preternatural
labour.
  In some cases we are enabled to feel the head, a  foot, and an
arm at the same time, and it will then be expedient to grasp and
bring down the foot, and to deliver in that manner.   But it be-
hoveth us  to  distinguish very cautiously between a  hand and a
foot, because  the mistake would lead us to the  necessity of turning
the child,  an  operation which would otherwise not have been  re-
quired.
  In presentations of the head, together with one or both arms,
unless there should be any  particular  reason  for wishing to turn
the child,  the propriety of which must rest upon the judgment of
the practitioner; or unless  we have the power of returning the
arm, we are to be prepared to wait with patience for the expulsion
of the child thus placed, by the natural efforts.  When we are
convinced by their failure or cessation, that these are not equal to
the effect,  such assistance is to be given as the nature of the case
may require ; and whatever the instruments are, which it may be
necessary  to  use, their action must be nearly  the same as if the
arms had  not been in the pelvis.
  Whether these cases are completed by the natu ral efforts, or by the
assistance of instruments, the arms of the child will be very much
tumefied or bruised, and  the child is for a certain time as unable
to use them, as if they were paralytic. But by the help of fomen- 
ON DIFFICULT LABOURS.              347
tations and poultices, if  needful,  and by moderate motion and
gentle friction, their natural appearance and use are recovered in
the course of a few days; at least I have not  seen an instance of
any permanent mischief from this cause.
   When the extremities present at the time of birth,  there is
often a doubt whether the child  be living or not, unless it can
be perceived to move.   Now the fact may  be ascertained by
the consequences of any violence, as no part of a dead child
can either tumefy farther than by compression,  or  change its
colour, however compressed  it maybe, only  showing one effect
of violence, that of solution of continuity.
  From long and  severe compression at the time of birth, the
head of the child becomes  wonderfully elongated, or slewed and
awry after birth, and  so remains  many years, or  even during
life; particularly observable  in the face, the features of which
are thrown out of their proper line, as appears  evidently  in the
position of the eyes of many  people.

                        SECTION VII.
On the Fourth  Order, or Labours rendered difficult  by  the Dis-
                    eases of the soft Parts.
                   1. Suppression of Urine.
  The  various  affections of the urinary bladder during preg-
nancy  have been already  mentioned.   On  the commencement
of  labour,  it was  said, that an  involuntary  discharge of the
urine might be occasioned,  but in  its  progress, there  is more
commonly a frequent inclination with a difficulty in voiding it,
and sometimes there is a total suppression.  The inconveniences
thence arising will be according to the quantity  of urine retained,
and to the length of time that the bladder may continue distended.
The first may hinder the proper action of the uterus, and be an
impediment to the passage of the  head of the  child, by occasion-
ing a less space for it to pass  through, projecting it also out of its
proper direction.  By the latter the bladder  itself may be inju-
red, in consequence of the continued pressure  which some part
of it may  undergo from  the repeated actions  of the uterus, cau-
sing inflammation terminating in  partial gangrene; and in some
cases in which relief was not given, the bladder  has  even been
ruptured,  the patient being thereby speedily destroyed.*
   In the  beginning and course of labours,  especially of those
which  are  expected to be tedious or difficult,  great attention is
therefore to be paid to the state of the  bladder; the patient is to
  * See Chapman, page 143. ; see also  Medical  Observations and
Inquiries, vol. iv. 
348          INTRODUCTION TO MIDWIFERY.
be frequently admonished  to  void the urine,  and in  all cases of
doubt  we are not to confide  in any  representation  made to us,
but to  be satisfied only with seeing the  quantity of urine which
has been discharged ; error being often committed by confound-
ing the water of the ovum with the urine.  By the application of
the hand to the abdomen  of the patient,  it is generally an easy
matter to distinguish between the tumour of  the uterus  and the
flattened but circumscribed  tumour of  the  bladder, which lies
below  and before that formed by the uterus.  The patient her-
self is  sometimes capable also of distinguishing that  pain which
is the consequence of the  action  of the uterus, from that which  is
occasioned by the pressure upon the distended bladder.
   To  remove that  obsnele to the passage of the child,  which
may be produced by the distention of the bladder,  and to pre-
vent any  injury to  the bladder itself, it  is necessary to  draw off
the urine with the catheter, whenever it is retained beyond a cer-
tain time or degree.   In slighter cases  the common catheter will
answer the purpose; but when the  head has been long wedged
in the  pelvis, there is not sufficient  room for that to pass, even
though the head be elevated  or pressed toward the hollow of the
sacrum.  But in such cases the flattened catheter, contrived by
my very  worthy and ingenious  friend Dr.  Christopher  Kelly,
will often pass  with ease and  convenience; though  the  elastic
catheter, and that kind which is made of a  soft and pliable me-
tal, is  often to be preferred even to  this.   But whatever catheter
it may be found  expedient to use, or however necessary it may
be to draw off the urine,  we are to  take  great care  not to intro-
duce the instrument with violence,  or  precipitation, because we
 may do as much  positive mischief with the instrument, as  we aim
 or wish to prevent.  In some cases, from want perhaps of timely
 care, though we are assured  there is a great  quantity of urine in
 the bladder, the head of the child is so immoveably locked in the
 pelvis, that we cannot possibhvintroduce any  catheter,  and are
 therefore obliged to submit""to"The inconveniences which may fol-
 low the distention of the bladder.   But if care were  taken in the
 beginning of labour, this does not often happen ;  nor is it always
 attended with the evils  we might dread, the head of the child
 being at length pressed so low  as  to allow  the urine to escape,
 though very slowly.  Yet in all cases, in which there has been in
 the course of the labour a suppression of urine, or any doubt of
 its having been voided, it will be prudent and necessary to intro-
 duce  the cattieter before or soon after the expulsion  of the pla-
 centa, that we may prevent the mischief which might be expected
  to follow such great distention  of the bladder, if this were to re-
  main may hours after delivery. 
ON  DIFFICULT LABOURS.
349
                  6. Stone in the Bladder.
  If a woman should  have a stone in the bladder, this would be
no cause to prevent her being with child, or proceeding through
her pregnancy without molestation.  Nor,  if it were of a small
size, would it be any impediment to her delivery; though if it
were large, the head of the  child could  not pass through the pel-
vis, or not without much trouble and probable mischief.   Of this
cast I have never met with an instance in practice, and may there-
fore be allowed to consider it as very rare, though there does not
appear to be any reason  for judging it impossible.   I have re-
flected upon the case, and upon  the conduct which it might be
necessary  to pursue, if it had occurred  to me;  and though it be-
hoves me to speak with reserve, and to be satisfied if little confi-
dence be placed  in what 1 advance, it  is better on the whole to
give my opinion,  than to leave the matter without considering,
or making mention of it.
   In the beginning of labour,  supposing there is a stone of a
large size in the  bladder, one of these consequences must  follow :
the bead of the child must advance before the stone, or the stone
must  be  protruded before the head of  the child.   If  the former
should be the case, we might presume that the labour would pro-
ceed in a natura] way, as if the  stone did not exist; there would,
at least, be no demand for the assistance of art, and no justifiable
reason for exercising it.   But if the stone should be protruded
before the head  of the child,  our conduct must be regulated by
the c rcumstances.  It seems  reasonable,  that we should  first
attempt to raise  the head in such a manner,  and to such a degree,
as  to allow us  to return the stone beyond  the head.  Or if this
should  be found impracticable, either because the head  of the
child was too far advanced,  or  firmly locked in the pelvis,  we
must then weigh the evils to be apprehended, from the compres-
sion of the soft  parts, that is of  the anterior part of the vagina,
and the posterior part of the bladder,  between the head of the
child, and the stone in the bladder; besides the distraction of the
parts which must be necessarily occasioned.  Whatever conduct
we might pursue may be attended with some evils,  but as it is
only in our power to choose the least of these, it seems  better,
even in the time of labour, to suffer the evils which might follow
the performance of the operation for extracting the stone, than to
suffer those which may be occasioned  by the compression and
probable  laceration of the parts.  With regard to the common
operation, there is both less difficulty and danger in it to women
than to men, though these will  in some  measure depend upon the
size of the stone and other circumstances.  In  some cases, inde-
pendent of pregnancy also, in  which the stone is contained in a
distinct cell of the bladder, and conld not therefore be grasped or 
350
INTRODUCTION TO MIDWIFERY.
extracted by the forceps when introduced, it has been proposed to
make an incision through the anterior part of the vagina, directly
upon the stone.  This operation, which  may  in some cases be
eligible, has been performed twice, by two surgeons of great abi-
lity and eminence in the country, and, as I was informed, without
occasioning the effect to be apprehended ;  that of leaving a fistu-
lous opening, by which the urine would have been involuntarily
discharged for the remainder of the parent's life.

               3. Excrescences of the Os  Uteri.
  Excrescences of the os uteri are usually combined with some
degree of scirrhous disposition of that part.  It was before ob-
served, that these excrescences do not prevent conception, or
disturb pregnancy, at least in the early period ;  but according
to their size and situation,  they must necessarily be obstacles
at the time of labour.   The following case,  which was curious
in the circumstances  attending,  as  well  as the nature of the
complaint, 1  may be permitted to transcribe, as  it was an ex-
ample of an excrescence of the largest size I have ever seen.
  In June, 1770, I  was desired  to see a  patient in the  eighth
month of her pregnancy, who in the preceding night had a pro-
fuse hemorrhage.   Her countenance showed the effects  of the
great loss of blood she had sustained ; and from the representa-
tion of the case given  me by the gentleman who was first called
in,  I concluded that the placenta was or had been fixed  over
the os uteri.  On examination, I felt a very large fleshy tumour
at the extremity of the vagina, representing and nearly equal-
ling in  size the placenta, which 1 judged it to  be.  Had this
been the case, there could not be a doubt of the propriety and
necessity of delivering the patient  speedily; and with  that in-
tention  I passed  my  finger round the tumour, to discover the
state of the os uteri.  But this I could not find, and on a  more
accurate examination,  I was convinced that this tumour was an
excrescence growing  from the os uteri, with a very extended
and broad  basis.  1 then concluded that the  patient was not
with child,  notwithstanding the distention of  the  abdomen, but
that she laboured under  some disease  which resembled  preg-
nancy, and that the  hemorrhage was the consequence of the dis-
ease.  A motion which was very evidently perceived when I ap-
plied my hand to the abdomen, did not prevail with me to  alter
this opinion.
  It was of all  others a case in which a consultation was desira-
ble, both to decide upon the disease,  and the measures which it
might be necessary to pursue; and several gentlemen of eminence
were called in.  That she was actually pregnant, was afterwards
proved to the satisfaction of every one; and it was then conclu-
ded, that such means should be used  as might prevent or lessen 
ON  DIFFICULT LABOURS.
351
 the hemorrhage, and that we should wait and see what efforts
 mig-ht be naturally made for accomplishing the delivery.
    No very urgent symptom occurred till the latter end of Julyr,
 when the hemorrhage returned in a very alarming way, and it was
 thought necessary that the patient should be delivered.  There
 was not a possibility of extirpating  the tumour,  and yet it was
 of such a size,  as to prevent the  child from being born in any
 other way than by lessening the head.   This was performed; but
 after may fruitless  attempts to extract the child,  the patient was
 so exhausted, that it became necessary to  leave her to her repose,
 and very soon after our leaving her, she expired.
   We were permitted to examine the body.  There was no ap-
 pearance of disease  in any of the abdominal viscera, or on the
 external surface of the uterus, which was of its regular form; and
 when a large  oval piece was taken,  out of the anterior part, the
 child, which had ho marks of putrefaction, was found in a natural
 position.   An incision was made on each side of the cervex  to
 the vagina, and then a large  cauliflower excrescence was found
 growing to the whole anterior part of the  os uteri.  The placenta
 adhered with its whole surface; so that the blood which she had
 lost must have been wholly discharged from the  tumour.  This
 uterus, containing the child, is now in the  museum of the late Dr.
 Hunter, who saw the patient before her death, and afterwards ex-
 amined the body.
   The propriety or advantage of a practice, by which the life  of
 neither the parent nor child was preserved, ought to be considered;
 but such cases occur so rarely, that there is always room  for ani-
 madversion, when they are concluded.   Yet the general princi-
 ple of its being  ever our duty to preserve both their lives, if pos-
 sible ; or to preserve that of the  parent; or, if she  cannot be
 preserved, then to save the child, if it be in our power, would
 have been a guide to better practice on this occasion, than that
 which was followed.
   Excrescences of a similar kind, of a smaller size, though con-
 siderable, are not very unfrequently met with in practice; and as
 even these  are usually accompanied  with some degree of scirr-
 hous  disposition of the os uteri,  more time is  required for the
 completion of the labour.  It is to be remarked, that in cases of
 this kind, there is often a long continuance of the pains without
 any sensible effect; but all at once,  the rigid os uteri yields and
 dilates speedily and unexpectedly, or perhaps, in some instances,
 is  lacerated.   In some cases also,  the  excrescences are of so ten-
der a structure, that they are crushed by the passage of the head
over them, and entirely destroyed.  During labours of this kind,
 and after delivery also, the great object is to  guard against all
 causes of inflammation, at first perhaps local, but afterwards ex-
 tending to other parts, connected or  readily consenting with the 
352         INTRODUCTION TO MIDWIFERY.
uterus, and more immediately necessary for the functions of life;
but I have not known any case of this kind to prove immediately
fatal, except that above described.

                4. Cicatrices of the Vagina.
  From diseases of the soft parts, especially those arising from
violence sustained in former hard  labours, and from other causes,
the vagina may have become ulcerated; and when care was
not taken to prevent the surfaces from abiding in contact with
each other, the opposite sides might adhere in jifferent degrees,
according to the depth and extent of the  ulceration. When the
ulceration is slight, and the inflammation is not so great as  to
bring the tumefied parts into contact,  after a certain time they
heal; but circular  cicatrices  being  formed in the vagina, the
diameter of the passage is lessened, and the part is left with a
disinclination to yield on any future occasion.   In some cases a
superficial slough has been thrown off from  the whole internal
surface of the vagina, and cicatrices of an  irregular kirjtd were
formed from the os uteri to the external orifice.  In otl>er cases
there has been a cicatrice only  at one part, and if this should
happen near the external orifice, the contraction has been such
as to mimic an unruptured hymen.
  Amidst a great number and variety of cases  of cicatrices  in
the vagina, I have not met with one example in which they were
able to withstand the pressure of the head of the child,  if the
pains were of the customary strength.  The labours have in-
deed been considerably prolonged,  but they have  terminated
favourably.  But when the difficulty arising from this cause has
been combined with other causes, it must of course have  added
to the trouble, which the patient would otherwise have under-
gone.   Or, if the  pains should cease before the labour is com-
pleted, then such assistance must  be given as the case may  re-
quire ; being  on our  guard that we do not offer assistance be-
fore there are proofs of the necessity, and are assured that the
difficulty cannot be overcome by the natural efforts.
   I was informed by the late Dr. Hunter of the case of a patient,
who was under his care, in whom, after her delivery, which was
not attended with any circumstances of  peculiar difficulty, the
whole internal surface of the vagina, and all the external parts,
entirely sloughed away.

                  5. Adhesion of the Vagina.
   Adhesions of the vagina are occasioned by an  increased degree
 of the same causes as those  which occasion cicatrices.   There
 may be an adhesion from disease in women who were never preg-
 nant, or it may be the conseque ice of a slough  thrown off after a
 former labour with or without the use of instruments.  Cases of 
ON DIFFICULT LABOURS.             353
 adhesions of this kind are commonly mentioned as of very easy
 management, nothing more being required, it is said, than to se-
 parate the united surfaces  with a knife, and to prevent their re-
 union by the introduction  of a  tent or canula  for this purpose.
 It is true,  when an adhesion  has taken place  near the external
 orifice, that  it may in general be  managed successfully and with-
 out difficulty ; but when there has  been a deep slough, and the
 parts adhere high up in the vagina, perhaps through its whole
 extent, it is  clear from the structure and  connexion that there is
 need of the greatest circumspection, lest on the  one hand we per-
 forate the bladder, or,  on  the other,  the  rectum,  all these parts
 being drawn close together; an accident 1 have  seen  happen
 under the hands of a very  dexterous  and  able surgeon; and it
 seemed unavoidable.
   In some cases, then, it appears,  that the adhesion  is of  such a
 kind, as not  to admit or justify any attempt to  separate the parts
 with a knife; but even in  these, by suffering the menstruous dis-
 charge to be collected, after a certain  time, the part, where an
 incision or puncture with a trocar may be safely made, will some-
 times be pointed out, and this being  gradually dilated,  a cure
 may be effected.
   It is possible  for an  adhesion  to take place after  a woman is
 become pregnant,  and of this I have  been informed of one in-
 stance.  Of course, when labour comes  on, the contents of the
 gravid uterus would be  impelled  against  the adhering parts,
 which would either be separated, or it would resist the exclusion
 of the child.   In the  former case,  nothing wouJH  be required to
 be done by art; but  in the latter, it would be necessary to divide
 the united parts by an incision  made with  great care, and only
 to a certain degree, leaving the full separation to be made by the
 membranes containing the waters, or  by the head of the child,
 which will then  effectually answer the purpose,  and probably in a
 better way than by any more extended operation.

                   6. Steatomatose Tumours.
   Of this cause of difficult labours I have never met with an in-
 stance in my own practice; but  the following case was commu-
 nicated to me by a gentleman, whose authority and accuracy are
 unexceptionable.
   A lady, after the birth  of her eighth child,  fell into a state of
 bad health,  with many painful and troublesome symptoms,  but
 no marked disease.  These were by some physicians considered
 as nervous, by others as scorbutic, and by others  as rheumatic,
 or of a gouty nature.  Various medicines  were given, and  dif-
ferent means tried for her relief, but without  any good effect.  At
 the expiration of two  years she became  again pregnant.  All her
 former labours  had been very easy and  natural;  but when Dr.
                              45 
354
INTRODUCTION TO MIDWIFERY.
Hunter was called at the commencement of this, he found an ob-
struction at the superior aperture of the pelvis, which he believed
could only be occasioned by the projection of the lowest of the
lumbar vertebrae, or the upper part of the sacrum.   It was then
supposed, that she had the osteo-sarcosis, of which her complaints
had been the symptoms.  It was impossible for her to be deli-
vered in any other way than by lessening the head of the child.
She died on the fourth day after her delivery.   Leave was given
to open the body, and when the pelvis was examined, the tumour
which was imagined to be a projection of the bones, was found to
be an excrescence of a firm,  fatty substance, springing  from one
side of the upper part of the  sacrum, and passing across so as to
fill up a great part of the superior aperture of the pelvis.
   It is probable that the preceding complaints of this lady were
occasioned by the pressure of this tumour upon the uterus ;  and
had the real state of the case been known before the time  of labour,
or even during her labour, it does not appear to have been proper,
or within the  bounds of art,  to have attempted or to have afford-
ed her any other  assistance; but had it been known that the tu-
mour existed, before the accession of labour,  it might have been
judged equally justifiable and expedient to have brought on pre-
mature labour, as in cases of actual distortion of the bones of the
pelvis.*
  * [Tumours within the pelvis, obstructing delivery, or rendering
it impossible, have recently been noticed by several  writers.   The
most able and satisfactory account we have, is that by Dr. Merriraan,
in the Transactions of the Medical and Ohirurgical Society of Lon-
don, Vol. X.  From Dr. Merriman's enumeration of cases of this
nature, it appears, that in eighteen instances of tumours in the  pel-
vis, (comprehending thirty-eight lives,) of the women, six recovered
perfectly, three imperfectly, and  nine  died.  Of (he children, two
were born alive, one was born alive but incapable of living ;  fifteen
were  dead,  and two were  uncertain, of which probably one was
alive and the other not. So that the lives actually preserved amount-
ed to  twelve, and of those not preserved, to twenty six.
  In August, 1820, I was called in consultation with my friend, Dr.
Dyckman, to visit a patient, aged twenty-eight years, who w to re-
presented to have been in labour  nearly thirty hours.  On exami-
nation we found a tumour almost of the size of a child's head, tense,
and  somewhat elastic,  situated about an  inch  and a  half high,
between the vagina and the sacrum,  but rather inclined to the right
side of the pelvis.   Not being able to determine  its  nature, and
finding that it so  intrenched upon the  capacity  of the  pelvis,  that
the mother could not be successfully delivered, after several inef-
fectual efforts to displace it, by making pressure on it, and thus en-
large  the aperture of the pelvis,  an anodyne was  administered to 
ON DIFFICULT LABOURS.
355
                7. Enlargement of the Ovaria.
   Diseases of the ovaria, both of the schirrous or dropsical kind,
especially the latter, are known to be  very frequent.   Either of
these must generally prevent conception; but as one of the ovaria
may be very much  diseased,  when the other  is in  a perfectly
healthy state, instances  sometimes occur  of  women  becoming
pregnant under such circumstances, and then the enlarged or dis-
eased ovarium  may produce  inconveniences during pregnancy,
or become an obstacle to the progress of labour.
   With the history of two cases of this kind I was many years
ago favoured by Dr. John  Ford, a gentleman of great skill and
experience.   In the former he was surprised to find a  large and
firm tumour  lying between the rectum and vagina, filling  up all
the concavity of the sacrum, and a considerable share of the cavi-
ty of the pelvis.  Being convinced of the impossibility of the child
passing by this tumour, which did  not  yield or diminish by the
force of the pains, it  was determined, in consultation, that the
patient ought to be delivered by lessening the head of the child.
The operation was performed  with great care, but the  patient
died at the end of three weeks. When the body was opened, the
tumour  was found to have been an encysted  dropsy of the  ovari-
um, in which there was a considerable quantity of hair.
   In the latter case, which in all its circumstances resembled the
former,  instead of lessening the head of the child, a trocar was
passed through the posterior part of the vagina, directly into the
tumour.   A large quantity of water was immediately discharged,
the tumour subsided, and a living  child was born without  any
further assistance.   This patient recovered from her lying-in, but
quiet the irritations of the patient, and to suspend the labour pains.
In the mean while it was agreed upon to see her within a few hours.
An operation  was now  declared to be her only chance of relief.
The tumour could be  easily felt compressing the rectum, and
greatly  lessening the direct diameter of the pelvis.   The tumour
was punctured, but no discharge  followed : the  tumour was then
broken down and mostly removed.  The head of the  child could
now be readily felt, the  os uteri was fully dilated ; the  membranes
had  been ruptured and the waters discharged.   The head of the
child, however, made but a slight descent, and the natural efforts of
the mother proving of no advantage, on account of her great weak-
ness, the child was delivered by the crotchet, as no other means
could be devised.  The remains of the tumour were discharged by
suppuration, and the woman recovered after sixteen weeks confine-
ment.
   She has since proved pregnant.  She had been the mother of two
living children, previously to her unfortunate  illness.  F.] 
356          INTRODUCTION TO MIDWIFERY.
sometime after becoming hectic, she died at the end of about six
months, though  from the symptoms it did not appear  that the
fever was occasioned either by the disease or the operation. This
patient was not examined after her death.
   If the dropsical ovarium,  even should  it be of a considerable
size, lie in the cavity of the abdomen,  the inconvenience it occa-
sions is merely from  its bulk, and the  consequent distention, or
its turning the uterus to one  side during pregnancy;  and none*
that I recollect, of importance at the time of labour;  but of this
I have seen several instances which have generally left some doubt
of the existence of pregnancy   So that having related these two
cases, J have said all I have to advance on the subject, except that
I have met with more than one instance of a circumscribed tumour
on one side of the pelvis, which  I at first suspected to be a diseas-
ed ovarium.   But as these tumours have always given way to die
pressure of the head of the child, the passage of which they have
only retarded for a short time, I have concluded they were formed
either by some soft fatty substance collected there, or were cysts,
formed  from  the cellular membrane containing lymph casually
effused.  But on taking an examination after delivery, the tumours
were found to  have again acquired their primitive form and size,
and to have resumed their former situation.  One of these tumours,
which grew on the anterior part of the vagina to a considerable
size, was opened previous to the excision of the sac, and was found
to contain a quantity  of common gelatinous  fluid, but this pa-
tient was not pregnant.

                  8.  Rupture of the Uterus.
  The human  uterus is  found to retain its original thickness dur-
ing the time of pregnancy,  notwithstanding its distention ; or as
some have thought,  to become  somewhat thicker than it was in
the unimpregnated state.  This thickness, immediately produced
by the enlargement of all the constituent parts of the uterus, we
have therefore reason to think,  is consequent  to some principle
acquired coeval with  conception.  But if the whole,  or any part
of the uterus, should  be deprived of this principle, or affected
with any disease destructive of the operation  of that principle,
then the whole uterus,  or the part so affected, would be mechani-
cally distended, and become thinner in proportion to its disten-
tion; and at the time of labour, when the action exerted becom-
ing greater than the unthickened part was able to bear, the uterus
would be, almost  of course,  ruptured.   Or if the uterus, which
had  acquired its proper thickness, became affected with inflam-
mation or any other.disease, weakening its power, and speedy in
its progress,  the texture of some part so affected might be des-
troyed, and die uterus ruptured by its own  action in the time of
labour.   Or, independently of  disease, the uterus may be worn 
ON DIFFICULT LABOURS.
337
through  mechanically, in long and severe labours, by Pressure
and attrition between the head of the  child and the project ng
bones in a distorted pelvis, especially if they be drawn into points
or a sharp edge.   Or, it has been  supposed,  a  rupture may be
occasioned by a  violent and spasmodic action of the whole or
some part of  the uterus, independent of  disease or of any me-
chanical cause.  Or the uterus  may be ruptured by violent ac-
cidents happening to the mother in  the advanced state of preg-
nancy.  If the uterus be strongly contracted, it may be ruptured
also by attempts to  pass the hand for the  purpose of turning a
child; but in This last case  a  rupture  could only happen  when
the force with which the hand  was introduced was combined with
the proper action of the uterus; for the strongest person has not
the power to  force his hand through a healthy and unactmg ute-
rus.  The part of the uterus which generally gives way, whether
posterior, which is most common, or anterior, or lateral, is usu-
ally near the  union of the cervix with the vagina, in which such,
 a change is made at the time of labour, when the os uteri is com-
 pletely dilated, that the distinction between them is lost  the va-
 gina and uterus forming together one  cavity, though of unequal
 dimensions.   Perhaps  something of a similar  kind happens to
 dancers, who when they make extremely  violent exertions, are
 apt to have the lendo achillis broken.
   Some of the causes of the rupture of the uterus are unavoida-
 ble for it is not within the sphere  of  human abilities to give to
 some  part the principle by which it has the disposition or power
 to perform any function ; allowing that art may sometimes excite
 the power to action, if the principle be dormant,  or repress it
 when too vehement.  Nor is  it often possible to discover or pre-
 vent the degree of  pressure  or attrition, which some particular
 part may undergo  in a  difficult labour,  before the effect is pro-
 duced   But the two other causes, that which is  preceded by
 inflammation, or that which may be occasioned by attempts to
 turn  the child, may be corrected or avoided, by abstaining from
  the use of all such  means  as are likely to act as causes or promo-
  ters of inflammation, and by proper treatment when it does exist;
  or from making such  attempts as may be thought necessary for
  the purpose of turning a child, while the action of the uterus is
  very powerful; and it may also  be proper to caution the patient
  against making at that time  any violent, voluntary  exertions.
    The rupture  of the  uterus is accompanied with  a  sense of
  something giving  way internally,  always perceptible by the pa-
  tient, and sometimes audible by  the  attendants, with sudden ex-
  cruciating pain in some part of the abdomen, a receding of the
  part of the  child  which  presented,  with an instant vomiting of
  the contents of the stomach, or of a brown fluid,  and an abate-
   ment  or a total cessation of the pain, together with some degree 
358          INTRODUCTION TO MIDWIFERY.
 of hemorrhage from the vagina; as the placenta has uniformly
 been found to have been partly or wholly separated in every case
 which has  come within my knowledge.  After these symptoms,
 by the application of the hand to the abdomen, the  limbs of the
 child are so easily distinguished through the integuments, as to
 leave no room to doubt of the accident;  and if  the head of the
 child were  not  locked  in the  pelvis, it immediately recedes or
 even goes out of the reach of  a  common examination, however
 low it might have descended.  The death of the patient usually
 follows soon, though not immediately, after the accident; but I
 have seen  one  case,  in  which there was reason to believe,  that
 the woman walked a considerable distance, and lived  several days
 after the uterus was ruptured, before her labour could be properly
 said to commence.
   In general there is reason to think, that the children have died
 immediately, or soon after  this accident,  and there  is certainly
 little chance of any person surviving a  rupture of the uterus.   It
 therefore might  be doubted, whether it would be more eligible to
 suffer the patient to die  without giving  her further trouble;  or
 whether it were our duty, hopeless as  the case must  be,  and
 really is, to pass the hand into the  uterus,  to turn and deliver
 the child by the feet; or with  the forceps, or  vectis, or in any
 way the case would allow.  What  might be  the sentiments  of
 former practitioners,1 is not  to us very material; for  beside some
 others of which  I have been informed, or which are recorded, a
 case occurred to my very worthy, able, and experienced friend,
 the late Dr. Andrew Douglas,  in which,  though the uterus was
 ruptured, he turned the child,  the patient recovered, and after-
 wards had children, at the birth of one of which I was present.
 If no other case had been recorded, this would be  of sufficient
 authority, to render it  in future the  duty  of every practitioner,
to attempt without delay to deliver the patient, and  bad as her
 chance  certainly would be, to  be  strenuous in using all the
 means which art dictates, to extricate her, if possible, from  her
 imminent danger, and to preserve the child.   But for more par-
ticular information on this subject, I must refer the reader to an
essay on the rupture of the uterus by Dr. Douglas, and to seve-
ral periodical papers  of that time, in which  similar cases are re-
lated ; but from the statement of some of these, one cannot help
 doubting whether the uterus was actually ruptured.
   I was called  to a case of a very extraordinary  kind, in which
 that part where the vagina and uterus are united was ruptured;
 the child remaining in the cavity of the uterus,  the os uteri being
 little  dilated.  Here  my advice was, not  to  attempt to deliver,
 because so much force would  be required  for dilating, that  it
was feared the uterus would be completely torn from  the vagina,
 before the hand  could be passed  into the uterus, at  least before 
                  ON DIFFICULT  LABOUR^             359

the child could be extracted, and then the case would have been
more horrible.
   I have known two cases in which it appeared that the uterus
was ruptured by the very effort which expelled the child.  If the
placenta be afterwards retained, and  it should be thought neces-
sary  to extract it, on  passing the hand  for  that purpose, this
would be  more likely,  without  the  greatest circumspection,  to
pass  through the ruptured part  into the cavity of the abdomen,
than  into the  uterus,  the  os  uteri being more contracted.   It
might then be possible to mistake some of the  viscera for the de-
tached placenta.  This  mistake was actually made, with very
aggravated circumstances, in a late unfortunate case;  and the
immediate  loss of the patient's life,  and  irreparable destruction
of the attendant's  character, were  the  natural and  unavoidable
consequences.*
  *  [It is probable that rupture of the uterus  is rarely occasioned
by any peculiar disease of the organ itself, as in the recorded cases
no previous  symptoms appear during  pregnancy from which we
might apprehend the liability to such accident:  it generally happens
most unexpectedly.  A case of rupture of the uterus in the sixth
month  of pregnancy,  is given  in the London  Medical Repository,
vol. 7 ;  and Professor  James has published in  the New-York Me-
dical Repository, an interesting case of a woman to whom this mis-
fortune  occurred,  when there was the immediate  prospect of a
happy delivery : she had been the mother of several children.   In
a case which took  place in this city several years ago, at the exami-
nation of which I was present, the accoucheur, a  man of much ex-
perience, declared the patient to  be doing well, half an hour be-
fore  the fatal event.
  Although the prognosis is sufficiently discouraging, we  are  not to
despair,  in  every instance, of the  ultimate safety of the patient.
This opinion is supported by undoubted evidence.
  Upon the whole, we may safely conclude (to use the language of
Dr. James) " although a rupture of the uterus is not necessarily and
inevitably fatal, though generally so,  it is the most correct practice,
where we  are  convinced that it has taken place, to proceed imme-
diately either  to the extraction of the child by the forceps, where
the head is within their proper grasp, and nothing forbids  ; or to in-
troduce the hand, turn the child, and deliver by the feet."  If some
time shall have elapsed after the rupture has occurred, the state of
the womb may require the operation of gastrotomy.
  In a volume of Practical Observations on Midwifery, by Dr. Rams-
botham,  just published, I  find recorded a case of rupture of the
uterus, about the fourth month of pregnancy.   Upon  inspection, the
uterus was  found to be ruptured  on its left side, and the ovum had
escaped  in its membranes entire  into  the  cavity  of the abdomen.
Dr. R. has  also given  a case in which death was occasioned by a 
360           INTRODUCTION TO MIDWIFERY.


                        SECTION VIII.
  These causes of difficult  labours I  have enumerated in this
order,  with the hope of pointing  out  a more  useful  method  of
arranging  the knowledge we possess, of increasing our know-
ledge,  and of removing some part of that obscurity, in which the
practice  of midwifery has been involved,  and by which its fur-
ther improvement hath  been hindered.   Two things appear  in
the general result; first, that the evils attending parturition are
more frequently adventitious, than unavoidable or of necessity;
and secondly, that the native powers  of the  constitution,  when
not interrupted, are not only  superior to the common obstruc-
tions of the process, but in general, to the various  kinds and de-
grees of deviation from  the natural course of  labours.  Yet with
every prudential regard to our own conduct, and the most judi-
cious regulation of that of our patients, we shall in practice cer-
tainly  meet with cases  in which, either from the debility of those
powers which commonly exist,  and which are generally exerted ;
or, from the greatness or stubbornness  of some  obstructing
cause; or, from some cause actually  produced by the lab  -ar it-
self, we shall be compelled  by necessity to give artificial  assist-
ance, or the mother, or  child, or both, will be lost.
  Before we  proceed to the  consideration of  the various means,
which  have been contrived for the relief of women in cases of dif-
ficult parturition, it may be again observed, that the causes of diffi-
culty are generally combined ;  and as there are very few instances
of a disease according to the simple definition of it in nosologi-
cal writers, so there  are few examples of difficult labours pro-
duced  or attended by one single cause.  Together with  the drib-
bling of the waters, there will often be a retraction of the head of
the child from the shortness of the funis ; and  with great rigidity
of the  parts, or a small pelvis, there may be a weak action of the
uterus ; and so on to an almost endless variety.   One cause will
however predominate, and of course must be the principal object
of our attention.  But when by time, or  skill, this cause  is re-
moved, we must apply  ourselves  to the removal of that which is
important in the next  degree; and sometimes  the same means
rupture of the peritoneal coat of the  uterus.  The rent extended
several inches in length on its  back surface, reaching nearly to the
insertion of the left broad ligament, in  which the fleshy structure of
the uterus did not  seem to be  implicated.  See  also  Dr.  Coffin's
cases in the New-Fngland Journal, vol. 3. and Dr. M. Anthony's, in
the Eclectic Repertory, vol. 4.   In this last, a schirrous condition of
a portion of the uterus was perceived.   F.] 
ON DIFFICULT LABOURS.            361
 may be properly used  for the removal of difficulties procee ling
 from several different causes.
   But beside the causes already mentioned, there is one much
 more frequent  than  the rest, which is, the derangement of the
 order of the labour by an officious interposition, or by improper
 management.  Upon this subject it would  be  unpardonable to
 make an assertion, which is not supported by experience; but I
 am now fully convinced, that the far greater number of really
 difficult  labours  to which I have been  called,  (and  I must not
 conceal the truth on  this occasion,  many  of those which have
 been originally under my own care,) were not of that denomina-
 tion from unavoidable necessity, but were rendered such by im-
 proper management, in the commencement or course of the la-
 bour.  Nor does the disturbance of the order of a labour depend
 upon the practitioner alone ;  for the intractability of the patient
 herself,* or of her friends and attendants, which, though it  may
 be founded in affection  and compassion to her sufferings,  may
 also arise from many other motives, is too frequently productive
 of the same effect.
  In the management of difficult labours there is required much
 previous knowledge and present  judgment on the part of the
 practitioner, to distinguish in cases of great difficulty, which of
 them may demand the assistance of art, and when this ought to
 be employed; and which may be resigned to the efforts of  na-
 ture ; and  no situation  can be imagined, that requires greater
 address to procure the confidence  and co-operation of all  the
 parties concerned; or more firmness in the pursuit of the nega-
 tive conduct, which it is often absolutely necessary, yet extremely
 difficult to follow. Whatever may be the resolution of particu-
 lar  women,  and whatever may be  the general estimation of na-
 tural labours, every  woman is impressed with the  opinion, and
 the  opinion  is often well founded, that in difficult ones, her life is
 to be preserved by the skill and judgment of the  practitioner,
 under whose care she is placed.  If, therefore, her confidence be
 secured, the delay to give assistance will be construed into a
 proof that none is required, and of freedom  from danger.
  The distress and pain, which  women often endure while they
 are struggling through a difficult labour, are beyond all descrip-
tion,  and seem to be more than human nature would be able to
bear under any other circumstances.   The great principle of all
their patience and resolution is perhaps that deep  rooted affec-
  * De la  part de la mere c'est quelquefois sa mauvaise humeur,
son impatience, son  indocilite-,  la violence et  I'irregularite des
mouvements.
  Puv, la Pratique des Accouchements.—Livre II. Chap. 1.
                            46 
362          INTRODUCTION TO MIDWIFERY.
tion of the parent to the offspring, implanted in the female mind.
Bat the principle of self-preservation, though varying in its ope-
ration, will recur, and demand its share of regard.   In long con-
tinued labours it is therefore proper, by frequent allusions to the
child, to encourage and  strengthen the former  principle, for its
power is lessened or overcome by the weight of their present dis-
tress ; their love for their child is then conquered ; and the pros-
pect of distant pleasure is not able to stand in competition  with
the evils of the present moment.   With the firmest determination
to do what is right, they willingly persuade themselves,  that the
child is dead; that the object,  for which they should persevere,
no longer exists;  and the practitioner, in  opposition to his own
feeling, and against the solicitations of those who confide  in him,
is often the only advocate for t,he child.   But his decision to act,
in cases in which  the life of a child is concerned,  must stand upon
a better principle than conformity to the  inclinations of others;
for though he might avoid present censure, or even gain present
credit by giving artificial assistance unnecessarily, when the case
comes to be reviewed,  and  it  always is reviewed, the blame of
acting precipitately, in cases which do not terminate fortunately,
will be cast upon  him, and  the satisfaction of others will be esta-
blished by  the discovery of some cause of blame in his conduct.
In the exercise of the most hazardous part of a profession, per-
haps  in general more subject to  censure than  any other, it  be-
hooves us to be particularly circumspect:  and though events  are
often beyond the  power of human  control,  we may always act
with  intelligence,  with prudence, and firmness; and no man's
character can long be supported, if he  be not governed by the
determination to do what is right, to the  best of his own judg-
ment and power, under every  circumstance.
   The events of  difficult labours, either with respect to the mo-
ther or child, very  much depend  upon the prudence and fore-
sight with  which women may be conducted  through them;  but
however averse the practitioner may be  from  the use  of such
means as may prove hazardous to or even destructive of the child,
cases must occur, in which the assistance of art will be absolutely
needful, and the use of instruments justified.   A time does  cer-
tainly come, when, if they be not delivered by art, in case of the
inability of the powers of the constitution to effect the  purpose,
women would either immediately or consequently inevitably pe-
rish.  As correct  a judgment  must therefore be exercised, and
equal care taken,  that he does not delay that assistance which
may be necessary, so long that it cannot answer the end for which
it was given ;  or while he is endeavouring to preserve the life of
the child, he may lose that of the mother also, which is undoubt-
edly of much  more value. 
ON DIFFICULT LABOURS.
363
  The intention in the use of instruments may be of three kinds:
First, to preserve the life both of the parent and child; secondly,
to preserve the life of the parent; and thirdly, to preserve the life
of the child.   The instruments  which have been contrived to an-
swer the first intention, are, the fillet, the forceps, and the vectis.
Of each of these, together with all the collateral circumstances
which demand our regard, we  shall speak in their turn, and then
proceed to the consideration of other parts of our subject. 
34
INTRODUCTION TO  MIDWIFERY.
                     CHAPTER XI.

                         SECTION I.

            ON THE FILLET, FORCEPS, AND VECTIS.

   When men, first collected into societies, had  provided  for
their subsistence, they would endeavour to amend their state,
by removing such  evils and inconveniences as were most ur-
gent, either from their importance or frequency.  Next to those
arts  by which  the means of support were acquired, that of me-
dicine would be of principal consideration,  as  from the nature
of their employments, hunting, fishing, pastoral, or agricultural,
men must  have been liable to diseases and to injuries,  which
by accident or trial they would learn some method of relieving;
and  he that should by more accurate observation,  or by age,
have gained the greatest collection of knowledge, or the most
dexterous method of applying it to useful purposes, would be-
come a physician.   But the origin  and progress of that  branch
 )f medicine, of which we are treating, would be somewhat dif-
ferent.  When the customs  and manners of life were simple,
and  not much disposed to produce  diseases, difficulty or danger
in the parturition of women would seldom occur; and, notwith-
standing the distress with which  they might sometimes be ac-
companied, the general termination of labours would be easy
and safe. In the very few cases which might require  more than
ordinary  assistance,  there were none  to afford it; and those
women, who could not bring forth their children by their own
efforts, were suffered to die  without any  attempts being made
to relieve them, according to the relations  which are given of
the people of some countries, even at this day.
  As mankind advanced in civilization, the evils attending par-
turition would  probably increase, though ignorance and inabili-
ty to give  relief might long continue.  But the supplications
for assistance, and the affections of men, would not permit them
to remain unconcerned or  inactive spectators  of the misery of
those to whom  they were  indebted for the  chief  part of their
happiness.   They gave such aid as their information or ingenui-
ty enabled them to devise, and this, in the first instance, consist-
ed of ceremonies, or of particular  precatory exclamations,* of
  * It is extremely curious to see the many ancient puerperal cus-
toms preserved by Ovid, in several parts of the Metamorphoses :
        --------Nee habent sua verba dolores ;
      Nee Lucina potest parientis voce vocari. 
ON  DIFFICULT LABOURS.
365
amulets, or of medicines, to which some mysterious properties
are attributed,  as the skins and some  other parts of serpents,
the eagle stone, the blood stone, the stony substance found in
the head of a shark, with many others of the like kind ; and such
things would, by their influence  on  the imagination, mightily
succour the minds of women,  strongly impressed with a sense of
their utility, in a state  of actual danger, overwhelmed at the
same time with extreme  pain and apprehension.  In times more
enlightened,  for every kind of distress religion offered its con-
solations, by soothing the mind, by teaching mankind, when op-
pressed with  difficulties, to use their own endeavours, by incul-
cating the necessity of submitting to evils which could not be
prevented or avoided, and by encouraging with the hope of
happy events.  After the discovery of the mechanic arts,  these
were applied to the exigencies of every occasion;  and  when
the sufferings of women in child-birth could no longer be endur-
ed, attempts  were made to relieve them by extracting, without
regard to its safety, the head of a child which could not be ex-
pelled by the efforts of the mother;  and for this purpose the
first kind of forceps with teeth on the concave  surface was in-
vented and used.  The same motives of compassion or affection,
which led to  the wish of relieving women, would readily ex-
tend to children ; and, to combine the interests of both, fillets,
and the forceps  now in  common use, were contrived. When
the head of a child was  found to be too large, to pass through
a very small  or distorted  pelvis with the help of such contri-
vances, there was no relief to be obtained except the head of
the child was lessened,  and for this purpose, perforators and
hooks or crotchets of various  kinds were invented.  The intre-
pidity of some man seeing no other way of giving relief, or the
desperate resolution of some woman frantic with her sufferings,
might lead to  a more summary way of obtaining it ;* and, with
a determination to free  herself from the cause of her misery,
or to put an end to her  existence, a child might have been ex-
      Constitit ad ramos mitis Lucini dolentes ;
      Admovitque manus ;  et verba puerpera dixit,
      Reddit onus ;  vagitque puer, quem mollibus herbis
      Naiadis impositum, lachrymis unxire parentis.
                                Metamorphos. Lib. x. Fab. x.
  * See London Medical Journal, Vol. VI. and VII. in which there
is a curious history of a Negro woman, who, in the agony of her la-
bour, performed this operation upon herself; given by Sir E. Home.
I was informed by  Dr. J. Hunter, that the same woman, for she re-
covered, was obliged to be watched  in her  subsequent labours,  to
prevent her from again performing the same operation. 
366          INTRODUCTION TO MIDWIFERY.

tracted through a wound made into the part which contained it,
and the manner of performing the Cesarean operation would be
shown.
  In some times and countries, in which the forceps and other
instruments of that kind were  not  known, or their  use not fully
understood, and afterward, in some cases not thought suitable for
their use, it became a custom in many difficult labours, by what-
ever cause produced, to return the presenting head, to pass the
hand into the uterus, to turn  and  deliver the child by the  feet.
But this operation of turning could only be performed under very
limited circumstances;  for if the head of the child were very low
in the pelvis, or the uterus strongly contracted round its body, it
could not be turned ; or not without defeating the very purpose
for which the operation was performed,  producing at the same
time great danger to the parent.   This practice was in general
very  unfortunate in  the event, as  1 have been assured by some
who have used it; yet cases may occur, in which, by turning the
child, the chance of saving its  life is greater  than can  be gained
by the use of any instrument, of which the following is an exam-
ple.
   Many years ago, I attended a patient in two labours, in  both
of which there was a necessity of delivering with instruments, on
account of the smallness and distortion of the pelvis, and neither
of the  children could be preserved.   In her next pregnancy I
made a proposal to bring on premature labour, to which she and
her friends would not consent, and I was dismissed from  my at-
tendance.  In the course of twelve or fourteen years she had five
more children, not one of which was born living.  In the forty-
sixth year of her age she proved with child, and again applied to
me.   When her labour came on,  the  first stage was suffered to
proceed without interruption, but when  the membranes broke, I
without delay  passed my hand into the uterus, and easily brought
down the feet  and body of the child; but the head being stopped
by the narrowness of the  superior aperture of  the pelvis, I was
obliged to exert, and to continue much  force before it could be
extracted.  The child  was born with very little  or no appearance
of life; but by the strenuous  use of the common  means recom-
mended for this  purpose  it was recovered.  On the left parietal
bone there was a depression  of considerable extent,  and to my
 apprehension  of  full one inch in depth,  occasioned  by the pro-
jection of the  sacrum ; but the depressed part gradually rose,  in
 the course of  a few months  the bone regained its natural form,
 and the child  was for several years in good health, with its facul-
 ties perfect.   The  woman recovered without any untoward cir-
 cumstance.
   But the success of such attempts to preserve  the life of a  child
 is very precarious;  and the operation of turning a child, under 
ON DIFFICULT LABOURS.              367
the circumstances before stated, is rather to be considered among
those things,  of which an experienced man may sometimes avail
himself in critical situations, than as submitting to the ordinary
rules of practice.

                         SECTION II.

                         On  Fillets.
   The  fillet  used in the  practice of midwifery is a single band,
intended to be fixed upon or beyond the head of a child detained
in its passage through the pelvis, for the purpose of extracting
the head.
   It has been supposed,  that fillets were used  in  the practice of
midwifery as early as the time of Hippocrates ; but whenever
they were invented,  they have  since undergone a variety of
changes, by which it  was intended to gain some advantage, or to
avoid  some  inconvenience.   Fillets have been  constructed of
silk, cotton, linen, or leather  of divers kinds, strengthened, or
rendered  more commodious  for application,  by  the addition of
cane, whalebone, wire, or very thin and  narrow  plates of  iron,
variously braided  and  worked together according  to the opi-
nion or judgment of the  contriver.
   The manner of applying the fillet was, by conducting  it with
the finger, or an instrument contrived for the purpose, to some
fixed point, as the chin, or round  the circumference of the  head
of a child, as high up in the pelvis as  could  be  reached ;  then,
after twisting the two ends together to acquire a firm hold,  we
were taught to extract, in a proper direction,  with all the force
the fillet enabled  us to use, or  the necessity of the case might re-
quire.
   The  peculiar advantages expected  to  be derived from fillets
were these :  They were  supposed to be applicable with great fa-
cility in every direction of the head, or when tin* was too high to
allow of the  use of any other  instrument  recommended with  the
same intention ; to supply us  with  sufficient power to extract the
head when detained an unreasonable time, by any cause, to the
hazard  of the mother or child; and  to do  less injury to either,
on  account  of the  softness  and  pliability of the  materials of
which they were  composed.
   But experience has fully proved,  that a  fillet of any kind could
not in many cases be either safely or effectually  applied  without
much difficulty and trouble; that when applied it was very  apt
to slip;  that when  it remained fixed, it was often inadequate to
the purpose of extracting the  head ; that it created new difficul-
ties, or added to  those which before existed, by changing the di-
rection of the head disadvantageously; and that the injury done
to the mother or child was not  in proportion  to the hardness of 
368          INTRODUCTION TO MIDWIFERY.
the materials of which instruments were constructed, but accord-
ing to the force or violence with which they were used.
  For these, and  perhaps  various other reasons, fillets of every
kind gradually declined in estimation, and they are now wholly
neglected.  They may be considered among  the first attempts
of art to give relief,  which have  been superseded by  other con-
trivances, equally safe and more efficacious.

                       SECTION III.

                      On the Forceps.
  The forceps used in the practice of midwifery  is an  instrument
composed of two equal parts, each  part consisting of a curvec!
blade and a straight handle, so formed that, when applied sepa-
rately upon the head of a child obstructed in its  passage through
the pelvis, they may be connected or locked together, and used
as two alternate or conjoined levers, for the purpose  of extracting
it.
  Forceps have been occasionally made of wood or silver, but
those now generally used  are formed of iron properly tempered,
with wooden handles, and when  used,  are covered with smooth
and thin  leather, which,  without any  significant increase of
bulk, renders the:r introduction  more easy, and takes off, both
in appearance  and reality,  the asperity of the instrument.  Each
blade must be  introduced separately, but in such directions,  that
when introduced they may be connected as  antagonists to each
other; and there have been different contrivances or locks at the
part where  the handles and blades unite, to keep them fixed to-
gether.
  It would be difficult to determine the time when forceps were
first used, but we have very early accounts of two kinds, with
one of which  it was  intended to extract the child, without re-
gard to the  injury which it might sustain, and with the other to
extract it without hurt and preserve its life.  The first was arm-
ed  with teeth  or sharp protuberances, on the internal surface,
which grasped the head ;  but those of the second  kind had no
protuberances, and when used, were clothed with linen or some
soft material  to  prevent their  doing any injury to  the child.
The first are  never  used at the present time, and would have
been forgotten, except for the patterns which  are  preserved in
the collections of those who teach the art.  Of the  latter kind
there is  an  endless variety, but  every  variety regards  one or
other of these conditions; their length, their strength, or their
different degrees or kinds of curvature.
   From the length  of the forceps formerly made, we may con-
clude, that it was usual, at least sometimes the practice, to ap.
ply them before, or as soon as the head of the child had entered 
ON DIFFICULT LABOURS.             369
 the superior aperture of the  pelvis ; and  from their strength,
 that it was thought necessary  to  provide for  the exertion  of
 great force.   The common  curvature was varied according to
 the opinion entertained of the  form and dimensions of the head
 of a child at the time of birth, but the  lateral  curvature was
 given for the accommodation of the  instrument to the form of
 the pelvis, or for lessening the  pressure upon, and of course the
 danger of lacerating the external parts, while the child was ex-
 tracting.  As  the forceps, though  well applied, sometimes slip-
 ped from the head when brought  into action, a groove, with a
 slight eminence on each side, was  proposed to  be made on that
 part of the internal surface which embraced the head,  to  pre-
 vent that accident, and to allow of a change in  the manner of
 acting, by admitting of some degree of rotation.
  Forceps have also been contrived in such a manner, that one
 blade received the other, and these were called male and female.
 They have also been made with hinges or joints between the han-
 dle and the blade of each, answering no other purpose than that
 of concealing  them, that there  might be an opportunity of per-
 forming the operation with them in a clandestine manner.  But
 as the reasons for using the  forceps will justify the operation to
 the most severe examiner; and as these may be explained without
 adding to the terror or distress either of the patient or her friends,
 there never can be occasion for concealment, which, in these ca-
 ses, ought to raise a suspicion of the judgment or integrity of those
 who  should attempt to practise it.  There  is, in  truth, at the pre-
 sent time, more frequently  a necessity for resisting the solicita-
 tions both of patients and friends, urging us to the use of instru-
 ments, than of  persuading  them to comply with our  proposals
 when we really think them needful.
  Beside the  different kinds of forceps  which consist of two
 blades, others have been contrived  with three, which, when sepa-
 rately applied, were received and screwed into a hollow handle, or
 fixed by some other contrivance. By those who supposed labours
 to be chiefly obstructed or rendered difficult by the inflection of
 the os coccygis,  a third blade was  added for the  purpose of rais-
 ing the head of the child over that part.  But those who supposed
 difficulties to be occasioned by the sacrum  jetting, and of course
 projecting the head of the child over  the symphysis of the ossa
 pubis, added  a third blade, for  the purpose of bringing back the
 head thus projected into a right line with the cavity of the pelvis,
 before  any attempt was made  to  extract  it with the  other two
 blades.   Whatever credit may be due to the authors of these con-
 trivances for their ingenuity, the third blade has certainly been
added  on erroneous principles; and forceps thus constructed
 would not only  be embarrassing in practice, but in every case,
                            47 
370          INTRODUCTION TO MIDWIFERY.
as far as can be judged, useless, or extremely injurious.   (See
Chapman.)
   It is  remarkable that  forceps  were made  of an unnecessary
length, when we were forbidden to apply them before the head of
a child had descended very  low into the pelvis; and they  were
made very strong,  when it was well understood,  that the force
which they enabled us  to use, was far greater than could be ex-
erted with propriety or safety to the mother.  They were, how-
ever, by degrees made shorter and less cumbersome, and about
the  year 1748, Dr. William Smellie, who was eminent in prac-
tice, and as a teacher of midwifery in London, after many trials,
altered them, and brought  into general  usage a kind of forceps
more convenient than any before contrived.   These before they
are curved do not measure more than twelve inches from the end
of the handle to the extremity of the blade; and  when properly
curved, little more than eleven inches, of which the handle mea-
sures near five inches.  The widest part of the blade measures
about one inch and five eighths,  and this gradually declines to-
ward the handle, preserving at the same time the flatness of the
blade till it meets the handle.  Being simple in their construction,
applicable without  difficulty, and equal to the management of
every case in which the forceps ought to be used, 1 have, with
very little alteration, adapted the following rules  to them.   But
if forceps of any other  kind should be preferred, though the prin-
ciples will hold good, the rules must be varied, according to their
size and form, at the discretion of the person who may perform
the  operation.   1 might also observe, though Dr. Smellie redu-
ced  the common size of the forceps for general use, he afterwards
retained some partiality for the long forceps,  as Dr. Mackenzie
his assistant informed me.*

                         section iv.
                    [General Observations.
   It has been long established  as a general rule in this country,
that the use of instruments of any kind ought not to be allowed
in the practice of  midwifery from any motives  of eligibility.!
Whoever will give  himself time to consider the possible mistakes
and want of skill in younger practitioners, which I fear many of
  * [Haighton's forceps is  the best and most  popular form of this
instrument now in use in this country.  F.]
  t Non nisi summa necessitate illud exigente atque turn demum
educendis ex utero infantibus admovenda esse ferramenta, quum nihil
omnino spei reliquum est  fore ut solarum manum subsidio extra-
here ipsos liceat.—Heister.  Capt. Liij. ix.  and many other wri-
ters. 
ON DIFFICULT LABOURS.
371
us may recollect, the instances of presumption in  those who by
experience have acquired dexterity, and the accidents, which,
under certain circumstances, seem scarcely  to be avoided,  will
be strongly impressed with a sense of the propriety  of this rule,
as well as from the general reason of the thing.   But when, from
any cause,  the parent  becomes unequal to the expulsion of the
child, the assistance of art, by  whatever means it can be afford-
ed, is justifiable  by  necessity; because without such assistance
the parent would die  undelivered, and  with her life, that of the
child  would also be inevitably lost.  Yet it behooveth every per-
son, who may use instruments in the practice of midwifery, to be
well convinced of this necessity before  they are used, and to be
extremely careful in their use;  that he may not create new evils,
or  aggravate those which might be existing.  But though it be
our duty to avoid if possible the use even of those instruments,
which are intended to be employed  without injury either to the
mother or child, it would, on the other hand, be absurd to defer
their use till the child was dead,  and the mother  reduced to a
state,  not of apprehended, but of real danger; or, which is worse,
that if she  should survive, her  life would be  rendered miserable
from  the  consequences of mischief done before the instruments
were used.  But if we  compare the  general  good done with in-
struments,  however cautiously  used, with the evils arising from
their unnecessary and improper use,  we might doubt whether it
would not have  been happy for the world, if no instrument of
any kind had ever been contrived for,  or recommended in,  the
practice of midwifery.
  When it is proposed  to deliver women with  the forceps,  the
intention is, to supply,  by their means, the total  want, or defi-
ciency, of the  natural  pains of labour; in  other words, to ex-
tract the head of a child, which  cannot be  expelled by  the ef-
forts of the mother.   But so long as these efforts  continue with
any degree of vigour, there is always reason to hope,  that they
will ultimately accomplish the effect  of expelling the child with-
out any artificial assistance,  in  which case the use  of the forceps
is not required.  We are moreover to recollect, that in labours
of long continuance there will often be an abatement, or even a
temporary cessation of the pains, for many hours, without any
apparent  reason  or alarming symptoms; but that cessation of
the pains, which is  the  consequence  of  long continued,  fruitless
action, and of great debility,  is to be considered as the only jus-
tification of the use of the forceps.
  Before the completion of the first stage of a labour,  that is,
before the os uteri is perfectly dilated, and the membranes broken,
the use of  the forceps cannot properly  come under contempla-
tion.   Because the difficulties  before  occurring  may depend
upon  causes, which  do not  require  their use; or, if  required, 
372           INTRODUCTION TO MIDWIFERY.

they could not be applied with safety or propriety before those
changes were made.
   There  is  infinitely greater  difficulty  in deciding upon the
proper case and time when the forceps ought to be applied, than
in applying or using them ; but it is universally agreed,  that the
lower the head of the child has descended into the pelvis, the
easier  will  their application  be, and the  operation with them
more certain and successful.   With a view to this observation, a
practical  rule has been formed, that the head of  a child shall
have rested for six  hours, as  low as the perinaeum, that is, in a
situation which would allow of their application, before the for-
ceps are applied, though the pains should have  altogether ceased
during that time*  This, with other rules,  was intended to pre-
vent the rash or unnecessary use of the  forceps, and  certainly
time, in these and many other cases, is a very  good corrector of
practice.   It  is scarcely possible  to say too much against  a
hasty  recourse to  the  forceps, even in cases which may ulti-
mately  be  relieved by  using them; and neither  this,  nor any
other instrument, is used in the practice of midwifery, one twen-
tieth part so frequently as they were fifty years ago.
   The forceps ought to be applied over the ears of the child, be-
cause when thus placed,  there is the least  likelihood of doing in-
jury to  the child, or of their slipping, and they enable  us to act
with the greatest advantage and safety to the mother.   It must
therefore  be improper to attempt to  apply them  before an ear
can be  felt, either because the head is too  high to allow us to
reach that part, or  because it is so  closely locked  in the pelvis,
that there is not sufficient  room to  pass the finger for that pur-
pose between  the head of the child and the sides of the pelvis.  If
an ear of the child  can be felt,  the case  is always manageable
with the forceps, should their use  be required.  But when the
question, whether they ought  to be  applied, comes under consi-
deration,  the ears are not turned to the sides of the pelvis, but
that ear which is to guide us  will be found toward the pubes, or
in a diagonal direction, with regard to the pelvis.   However, we
are always to remember, that  the forceps are not to be applied
because we have the power of  applying them, but because the ne-
cessity of the case  is such as to  require their use.  Yet cases
sometimes occur in practice,  in which we  may despair of the
ability of the  mother to  expel the child; and  which, though not
  *  [I am aware how earnestly this rule is  inculcated,  yet must
confess I cannot see the propriety of its universal application, inde-
pendent of convulsions or hemorrhage.   In some instances, we are
justified in waiting longer than six hours;  and in others it would be
criminal to delay so long.  F.] 
ON DIFFICULT LABOURS.
373
exactly such as have been stated as perfectly suitable for the use
of the forceps, become suitable, merely by waiting a certain num-
ber of hours, and a repetition of the slight efforts of the parent;
In that desponding state, with which every tedious and truly dif-
ficult labour is accompanied, I have  also found the patient very
much comforted and  encouraged, by having  some distant time
held up to her when  she should be assisted, if the labour were
not before concluded: as this gives her new resolution, by offer-
ing to her imagination a certain period to her suffering.
  Every change in the position of the head,  and every  altera-
tion in the construction of the forceps from those already  stated,
will require  some difference  in the  manner  of applying  and
using them.   But  the preference, which ought in reason to be
given, of one kind of forceps to another, is merely because one
instrument may be more handy  and convenient than another, for
an intelligent and skilful man would be able  to apply and use
those of any form or  size, in such a  manner that they should ef-
fectually answer his  purpose;  as an expert surgeon would be
able to amputate a limb with a  knife of any kind.  No consider-
ation or advantage to be gained by instruments of any particular
structure  ought to lessen our  attention  and care when we use
them ; as the success of every operation must necessarily  depend
not upon the excellence of the instrument, but upon  the justness
of the idea entertained of the case in  the mind of the  person who
may perform it,  and the dexterity or skill with which the instru-
ment may be guided by his hands.
   When we have determined on using the forceps according to
the preceding observations,  corrected by our  own judgment;
and when we have represented our opinion,  and candidly ex-
plained the reasons for it to  the friends of the patient, as is cus-
tomary in all other operations, we must prepare for this in the
following manner : The patient is to be placed upon her left side,
across, and very near the edge of the bed  on which she is laid,
with her knees  drawn  up to the abdomen, and a pillow placed
between them, that we may be  able  to reach the patient  with all
convenience, and possess the free and uninterrupted use of our
own hands.  The instruments,  being warmed in water, and
smeared with some unctuous application, are to be so placed,
 that they can be readily taken hold of by ourselves, or handed to
us by an assistant.
                          SECTION V.
                On the  application of the Forceps.
    The first part of the operation  consists in passing the fore-
 finger of  the right hand between the ossa pubis and the head of
 the child to the ear.   Then taking  the part of the forceps to be
 first introduced, by the handle, in the left hand, the point of the 
374          INTRODUCTION TO MIDWIFERY.
blade is to be slowly conducted between the head  of the child
and the finger, till the instrument touches the ear.
  There can be no  difficulty or hazard in  carrying the instru-
ment  thus  far, because  it will be guided, and in some measure
shielded, by the finger.  But  the farther  introduction must  be
made with a very slow semirotatory motion,  keeping the point of
the blade, as it is advanced, not rigidly, yet closely to the head
of the child, by raising the handle toward the pubes.  In  this
manner the blade must be carried gently along the head, till the
lock reaches the external parts, near the anterior angle of the pu-
dendum.
  The point of the blade, while introducing, sometimes hitches
upon  the ear of the child, and then it requires a little elevation,
which is given by depressing the handle.  But when it has pas-
sed the ear, and is beyond the guidance  of the finger,  should
there be any material check to the introduction either of this or
the other blade, it should be withdrawn a little, to give us an op-
portunity of discovering the cause  of  the  obstacle, which we
must never strive to overcome  with  violence, though  we must
proceed with firmness.   When the first blade is properly intro-
duced, it must be held steadily in its  place, by pressing the han-
dle toward the pubes, and it will  be  a guide in the introduction
and application of the second blade.
  Let the second blade be introduced in this manner.   Keep the
blade first  introduced in its place, with  the two small fingers of
the left hand, and carry the fore-finger of the same hand between
the perinaeum  and head of the child,  as  high as  you can reach.
Then take the second blade of  the forceps by the handle in the
right hand, and, conveying the point between the finger placed
within the perinaeum, and the head of the child, conduct the in-
strument, with the precautions before  mentioned, so far, that the
lock shall touch the anterior part of the  perinaeum, or even press
it a little backwards, or be insinuated within it.  In order to fix
the two blades thus introduced, that which was placed toward the
pubes must be slowly withdrawn, and carried so far  backwards,
that it can be  locked with the second blade  retained wholly, or
nearly, in its first position : and care must be taken, that nothing
be entangled in the lock, by passing the finger round it.  When
the forceps are locked, it will be found convenient to tie the  han-
dles together with sufficient firmness to prevent them from sliding
or changing their position, when they are not held in the hand,
but not in such a manner as to increase the compression upon the
head of the child.
  Should the  blades of the  forceps be introduced so as not to be
opposite to each other, they could not be locked ; or if when ap-
plied the  handles should come  close together,  or  be at a great
distance from each other, they would probably slip, or there would 
ON DIFFICULT LABOURS.
375
be a failure of some kind  in  the  operation, as the bulk of the
head would not be included, or they would be fixed on soire im-
proper part of the head ; though allowance is to be made for the
difference of size in the heads of children.   But if a case be pro-
per for the forceps, if they be well applied, and we were to act
slowly with them, there would not  be much risk of failure or dis-
appointment.
   The difficulty of applying the forceps is most frequently occa-
sioned by attempting to apply them too soon; or by passing them
in a wrong direction; or by entangling the soft parts of the mo-
ther between  the instrument and the head of the child, against all
which accidents we are to be on our guard.

                         SECTION  VI.

          On the action with the forceps when applied.
   It was before observed, that the forceps, when applied, and fix-
ed upon the head of a child, might be considered as a compound
instrument, which allowed of a separate action with either of the
parts of which it was  composed;  or of a conjunct action, as if
the two parts formed one instrument.   The separate  action with
either part will be on the principle of the lever; but that with both
the blades will be simple traction.   Yet in practice we shall find
very few  cases,  in which it will not be necessary to exercise or
to combine both these kinds of action, in a greater or  less de-
gree.
   As it is the intention, when the forceps are used, to supply with
them the total want or insufficiency of the natural pains of labour,
the whole power or force, which the instrument enables us to  use,
ought not to  be exerted in the first instance, but such a degree as
any individual case may require; which can only be  known  by
first trying a moderate degree of force, increasitg  it slowly  and
deliberately,  according to  the exigence of each case.  Because
the impediment may not be  great, and the point of obstruction
may exist only at one part; and these being surmounted by one,
or a few  gentle  actions with the instrument, there would be no
cause for  acting any more.  In some cases also, though the pains
had entirely  ceased, they will return with force sufficient to expel
the child, from the irritation made by the  mere application of the
instrument.   But when the forceps have been applied, they should
not be removed  before the head is expelled, though their assist-
ance be not required, lest the pains should  cease, and we should
be under  the necessity of applying them again.
   The  effects of the forceps,  or the  consequences which result
from their action, are these: compression of the head,  descent of
the head, inclination of the face to the hollow of the sacrum,  ex-
traction of the head.   As the descent of the head precedes  the 
376          INTRODUCTION TO MIDWIFERY.
inclination of the face to the hollow of the sacrum, it would be
improper to attempt to change the position of the head before it
has descended,  which was formerly the practice, and it is after-
wards unnecessary.  Because if the  action  with  the forceps be
slow, and according to the direction of the handles, the position
of the head becomes altered in proportion to its descent, without
any aim on the part of the operator, and without his guidance.
  When the  forceps are  first locked,  they are placed  far back-
wards, with the lock close to, or just within the internal  surface
of the perinaeum; and they can have no support backwards, ex-
cept the very little which is afforded  by the soft parts.  The first
action with them  should therefore be made by bringing the han-
dles, grasped firmly in one or both hands, to prevent the instru-
ment from playing upon  the head of  the  child, slowly  toward
the pubes,  till they come to a full rest.  Having waited a short
interval with them in this situation, the handles must be  carried
back in the same slow but steady manner to the perinaeum, ex-
erting, as they are carried in the  different  directions,  a  certain
degree of extracting  force; and after waiting another interval,
they are again  to be raised toward  the pubes, according to the
situation of the handles.   Throughout the operation, especially
the first part, the action of that blade  of the forceps, originally
applied toward the pubes, must be stronger and more extensive
than the action with the other blade; this having no fulcrum to
support it, and chiefly answering the purpose of regulating the
action with the other blade.  If there were  any labour pains
when the operation was  begun, or should they come  on in the
course of it, the forceps  should only  be acted with, during the
continuance of the pains; the intention being not only  to supply
the want or insufficiency  of the pains, but to assist them,  and
imitate also by the action with the forceps the manner in which
they return.
   By a few repetitions of this alternate action  and rest, before
described, we shall soon be sensible of the  descent of the head;
and it will be proper to examine very frequently, to know the pro-
gress made, that we may not use more force than needful, or go
on with more haste than may be expedient or safe.   In every case,
even those which allow of the easiest management, we ought to
proceed slowly and circumspectly,  not forgetting that a small
degree of  force,  continued  for a long time,  will in general be
equivalent to a greater force hastily exerted, and with infinitely
less detriment either to the mother or child.  But after some time,
should we not  perceive the head to advance, the force hitherto
used must not only be continued, but gradually increased, till it
is sufficient to overcome the obstacles  to the delivery of the pa-
tient.
   It was before observed, as the head of the child descended, 
ON DIFFICULT  LABOURS.              377
 that the face would be accordingly turned toward the hollow of
 the sacrum, without any am or assistance on our part. Of course,
 the position of the handles of the forceps, and the direction in which
 we ought to act with them, should alter; for they becoming first
 more diagonal or oblique, with respect  to the pelvis, and then
 more and more lateral, every change in their position will require
 a differently directed action, because the handles should ever re-
 main, and be acted with, as antagonists to each other.   In pro-
 portion also to the  descent of the head, the handles of the forceps
 should  approach nearer to the  pubes;  so that though in the be-
 ginning of the operation we acted in the direction of the cavity
 of  the pelvis, toward the conclusion we should act in that of the
 vagina,  to prevent  a laceration of the parts.  When we feel that
 we  have the command of the  head by  its being cleared of any
 obstruction in the pelvis, and the external parts begin to be much
 distended, we ought to act yet more slowly, especially in the case
 of a first child, or there would be the greatest danger of a lacera-
 tion of the soft parts: and this can only be prevented by acting
 most deliberately,  and in the direction of the vagina; by giving
 the parts time  to distend; by  duly  supporting  the perinaeum,
 which is  the part  chiefly in danger, with the palm  of  the hand
 firmly applied; by soothing and moderating the hurry and ef-
 forts of the patient; and, in some cases, by absolutely  resisting
 for  a certain tirne the passage of the head through  the external
 parts, as in a natural labour.  When the head of the child is born,
 the  forceps are to be removed,  the  delivery being completed as
 far  as their assistance was required, and the remaining circum-
 stances  are to be managed as if the labour had been natural.
  On the whole, it appears, that necessity alone, and not  any
 sense of eligibility  or expediency, will justify the use of the for-
 ceps ; that when  such necessity exists, their use is not only justi-
 fiable, but may be highly advantageous, by improving our chance
 of preserving the life of the child ; that with care  they may be
 safely applied; that slowness and steadiness  in our  action with
them will effectually secure both the parent and child against un-
 toward accidents; but that no skill or knowledge can prevent dis-
 appointment or mischief,  if they be  prematurely or  improperly
 applied, or if the operation with them be performed  with hurry
 or violence.  It is  not possible to fix any limits  to the time that
 may be  required for  the operation  with the forceps; but I have
 frequently known more than an hour pass from the time  of fixing
 the instrument, before I could with suL:ty extract the head of  the
 child through the external parts.
                         SECTION VII.
 On the application of the Forceps under various circumstances.
  We have already considered the manner of applying and using
                              48 
378
INTRODUCTION TO MIDWIFERY.
the forceps, when the head of the child presented in the most na
tural way, that is, with the face inclining toward the sacrum.  But
they may be equally necessary in other positions of the head, that
especially which is in the next place most frequent, when the face
is  inclined toward  the pubes.   This position is discoverable by
the readiness with  which  we can feel  the  greater fontanel  in a
common examination, by  the direction of the ear, and often by
feeling distinctly the features of the face tending toward the sym-
physis.
   It was before observed, that this position of the head only con-
stituted  a variety of natural labours,  as far as position was con-
cerned in the definition.  We  are not, therefore, to be guided in
our opinion of the propriety of using the forceps by any position
of the head of the child, but, whatever the position  may be, by the
necessity of any case, proved by the probable or  absolute inabi-
lity of the mother to expel the child.   Should such necessity ex-
ist with this, or any other position of the head, the forceps are to
be applied, in the manner  before described,  over the ears of the
child.   But when they are applied  we must  act  with them with
the greatest caution;  for, having a different and less perfect hold
of the head, they are more apt to slip, and, acting with less  ad-
vantage, the operation, in  this position of the head, must be more
precarious.  But if we succeed, when the head thus situate is
brought so low  as  to distend the  external parts, there will  of
course be greater danger  of laceration, if we be ever so much
upon our guard; because, in extracting the head, the chin of the
child, unless the head be unusually small, or admit of a change of
positibn, should be cleared of the ossa pubis, before the hind head
is  suffered to slide over the perinaeum, which  will  very much in-
crease the distention,  and produce the same  effect as if the arch
of the ossa pubis was too small to receive the head of the child.
   The same observations  are also generally true  when the face
of the child presents; or when, together with the  head, there are
one or both arms.    For though in such cases  there might be a
necessity for, and a propriety  in, using the forceps, the  operation
with them would be  neither so certain nor so easy as in the position
of the head first stated.
   In labours attended with convulsions, or dangerous hemorrhage,
or when from any other urgent cause it may be necessary to
hasten the delivery of the patient, to free her from immediate
danger, should the forceps be used, the  general rules will be
sufficient to guide us, varying and  suiting our conduct to the
exigence of any particular case.
   Lastly,  when there are signs of imminent danger, however
averse we may be  from the use of instruments,  we may be in-
duced to try the forceps, though a case might not be altogether
such as may be esteemed most eligible for  their application ; 
ON DIFFICULT LABOURS.
379
merely  to  take  an indifferent  chance of saving the life of a
child, which must otherwise be  inevitably lost.  In such cases,
we must advert to the general principle, and make our attempts
in a manner consistent with the  safety of the parent; and, from
motives of prudence, prepare the friends for that  disappoint-
ment which it may not be in our power to prevent.

                       SECTION VIII.
                      On  the  Vectis.
   The vectis  used in the practice of midwifery, is an instrument
consisting of one blade, slightly curved,  and a handle; some-
what  larger,  but similar in form  to  one of the blades of the
forceps.
   The true origin of this instrument,  or time when it was first
discovered, is not known; but before any accounts of the vec-
tis were published,  some difficult  cases were  recorded,  (See
Chapman,) in which women had been  delivered  with one blade
of the forceps, which might then be well considered as a vectis,
though not called by that name.  But when only one blade of
the forceps had  been used, the operation  was  mentioned as
something extraordinary, to  show perhaps the judgment, skill,
or good  fortune  of the person  who performed  it, and not as
leading to the use of a particular instrument,  or to a rule of
practice.  It is probable, that the instrument used by the Cham-
berlens, in the last century, was the vectis ; but this is conjec-
ture, for,  after much inquiry, though scarcely credible, no per-
son has yet been able to discover, that any of them left either
a  pattern  or description of the instrument which they used.*
In the second volume of Heister's Surgery, there  is a delineation
of a true vectis,  recommended  to him in very strong terms by
Palfyn,  a  surgeon  of eminence  at  Ghent; but neither this  in-
strument nor its  description engaged  much attention, nor was
the vectis generally  known in  this country,  before  the year
1750.   For though it has been  used before that time by Rhon-
huysen, a surgeon at Amsterdam, after whose name it has been
since generally called, it was reserved by him with great secre-
cy, to his  own  credit and advantage; and,  after his death, it
became the  property of his only daughter, from whom it was
purchased by de Bruyn, an eminent surgeon of the same place.
It appears that  de Bruyn  concealed the secret with as much
  * [The original obstetrical instruments of the Chamberlens have
lately  been discovered, and are now deposited in the cabinet of the
Medico-Chirurgical Society of London.   Mr. Cansardine has amply
described them in the ninth volume of the Medico-Chirurgical Trans-
actions.   F.] 
380          INTRODUCTION TO MIDWIFERY.
 caution  as  Rhonhuysen ; or that he  instructed students in the
 use of the vectis at a considerable price,  and with an obliga-
 tion not to divulge to others what he taught them ;  which must
 have  raised great suspicion of imposture on his part, and of cre-
 dulity in those whom he taught.   The  names  of other gentle-
 men who changed or improved the instrument soon became
 known;  and annexed to a paper written on this subject by the
 celebrated  professor Camper, in the  fifteenth volume of  the
 Memoirs of the Royal Academy of Surgery,  is a  plate repre-
 senting the  vectis used by Rhonhuysen,  Boom, and  Titsing.
   The advantages arising from the use of the vectis in the hands
 of de Bruyn, ostentatiously urged, appearing  to be very great,
 Vischer  and Vander Pol, two  ph}'sicians at  Amsterdam, from
 motives of pure benevoleuce, purchased the secret from de Bruyn,
 in the year  1753, and immediately published a description of the
instrument,  with directions for using  it; but none of the papers
 printed on this subject in the  Dutch language have, as far as 1
 know, ever been translated into our  own.  While the vectis re-
 mained a secret, the reports of the benefits obtained by it were
probably much exaggerated, especially those of de Bruyn, though
Van Swieten says  he was an honest man; but, when it was di-
vulged,  and the positive  and  comparative  merits of the vectis
strictly examined, it retained its credit and estimation, in the opi-
nion of many competent judges, in different parts of Europe.
   When  the vectis was very much  used,  and highly esteemed, at
Amsterdam, as an invaluable improvement in the practice of mid-
wifery, the  forceps was the favourite  instrument in this  country,
especially as lastly altered by Smellie, who was then the princi-
pal teacher of the art in London.   But the chief practice in this
city was  successively in  the hands of Drs.  Bamber, Griffith,*
Middleton, Nesbit, and Cole,  some,  if not all of whom, except
Dr. Bamber, whose forceps I have seen, preferred the vectis to the
forceps.   To these gentlemen  succeeded Dr.  John  Wathen, a
man of great ingenuity, and  most pleasing manners,  who altered
the form  and reduced the size of the vectis,  and frequently used
it with a  dexterity that has astonished  me.  In the  year 1757,
that most excellent charity for delivering poor women at their
own habitations was  established ,  and Dr.  John Ford was  the
first physician appointed to conduct it. On every occasion which
required instruments of this kind, Dr.  Ford used the  vectis ;  and
  * Mr. Maiden, of Putney, very obligingly  showed me a letter  of
Dr. Griffith's, containing directions for the application and use of the
vectis,  but  in those there was nothing particularly excellent.   Dr.
Sims has also a letter on the same  subject, written to his father by
Dr, Griffith,                                                J 
ON DIFFICULT LABOURS.
381
his coadjutors and successors, Drs.  Cooper, Cogan, Douglas,
Sims, Dennison, Squire, and Croft, withmany others, have follow-
ed his example. From the deserved reputation of these gentlemen,
who  have  at all times expressed their approbation of the vectis
in preference to the  forceps,  many have been induced to try it,
and the general opinion of its utility  has increased.   At the pre-
sent time, all who are engaged in the practice of midwifery would
consider themselves as deficient, if they were not acquainted with
the structure and manner of using the vectis; some who former-
ly preferred  and  used the forceps have relinquished the use of
this  instrument for the vectis;  and others  who,  from education
or habit, continue to use the forceps,  are  very willing to allow
the equal, if not superior utility and convenience of the vectis.

                         SECTION IX.
                On the different kind of Vectes.
   The first vectis of which we had any knowledge in this coun-
try was similar to that of Palfyn, before mentioned.   The instru-
  *■'            * •   -% T •  1     __ _1  "\ T___>JAU T)n.l  tiTUinh  limn rv\n/lo
pears to be some difference in the form, length,  manner, and de-
gree of curvature of the vectes used by de Bruyn, Boom, and
Titsing.   But if the powers of the instrument were preserved,
and the'general  principle of using it followed, it is probable that
all those who preferred the vectis thought themselves at liberty
to alter its form, or to vary its dimensions, making the instrument,
by such alterations, suitable to their own ideas of the properties
required.                         ...           ,   j    •.  ,
  When the vectis was first known in this country, that described
by Heister was preferred to those recommended by the  surgeons
at Amsterdam.  The vectis used by Dr. Cole was like one blade
of the forceps somewhat lengthened and enlarged.   That of Dr.
Griffith was of the same  kind, with a hinge between the handle
and blade; and  that of Dr. Wathen was not unlike Palfyn's, but
with  a flat  handle, and  a  hook at the extremity of the handle,
which prevented its slipping through the hand, and might be oc-
casionally used  as a crotchet.   Many other changes have  been
made in the construction of the  instrument, but the  vectis now
generally used is of the following dimensions:
   The whole length of the instrument, before it  is curved,  is
twelve inches and a half.
   The length of the blade, before it is curved, is  seven inches
and  a half.                              .....      j
   The length of the  blade,  when  curved, is six inches and a
half. 
382          INTRODUCTION TO  MIDWIFERY.
  The widest part of the blade is one inch and three quarters.
  The weight of the vectis is six ounces and a half.
  The handle is fixed in wood.
  From this  description, any person acquainted with the forceps
could find no difficult}' in forming a just idea of the vectis, or an
artist in making it.   It appears also that a single blade of the for-
ceps might, in many cases, be used not inconveniently, instead of
any other vectis, and would generally answer the purpose with-
out the trouble of introducing the second blade, as I have often
experienced before I  was acquainted  with the vectis.
  With respect to the part of the blade of the vectis which ought
to be curved, and  the  degree of curvature,  there  has been some
difference of opinion ; but this must relate to the ease of introdu-
cing, or the advantage of acting.  With a small degree  of curva-
ture, diffused  through the blade, the instrument may be most ea-
sily introduced, and it is  most suitable to the form of the head ;
nor can the degree of curvature required,  on any principle, be
very great.   But if, together with the  power of the lever, we
aim at acquiring much extracting force, the  curvature should be
somewhat increased toward  the  extremity; because the  two
centres on which the force used would rest,  would be at those
parts of the head on  which the instrument might  bear, and the
part on which it would rest,  whether the sides  of the  pelvis or
the hand of the operator.
  For rendering the introduction of the instrument more easy,
and for preventing all the inconveniences which might arise from
the difference of curvature,  Dr. Aitkin of Edinburgh, contrived a
vectis, which  he  has fancifully called the living  lever.  When
this is at rest  it is quite straight; but while it is introducing, by
turning a screw in the handle, the blade is jointed in such a man-
ner as to bend gradually forward as the instrument is advanced,
so that the extremity of the  blade is  always kept close to the
head of the child, of whatever dimensions that may be.  There
is much ingenuity  in the contrivance;  but  of the effect in prac-
tice 1 cannot  speak, having never tried  this  instrument,  not wish-
ing for one more perfect than the simple one  in ordinary use.  But
a gentleman  informed me, that in a trial  he made, the  chain on
which the mechanism chiefly depends, broke,  and  he was obliged
to finish the operation with a common vectis; so that in all pro-
bability the common vectes are actually preferable to any of the
complex kinds.
  To lessen the pressure made by the instrument, when in action,
upon the parts of the mother, on which it might bear, some  per-
son contrived two holes on a part of the blade, not far from the
handle, through which a strong ribband or tape was to be passed,
which being  afterwards tied  and pulled firmly, when the instru-
ment was acted  with,  was supposed to confine it firmly to the 
ON DIFFICULT LABOURS.              383
head of the child, and prevent or lessen the pressure which might
otherwise be made upon the parts of the mother.  But it appears
that the same end may be answered better by an intelligent and
dexterous management of the instrument  with the hand, than by
this contrivance.

                         SECTION X.

        On the comparison of the Vectis with the Forceps.
  The general principle of practice, that the use of no instrument
is to be allowed, except in cases of absolute necessity, ought not
to be infringed, because  we entertain a high opinion of any in-
strument, or because we may have acquired dexterity in using it;
for such reasons would be indefensible, and any conduct founded
upon them  would  often be  highly  culpable.   This principle,
founded on  common  sense  as well as medical  knowledge, and
confirmed  by daily experience, must be held inviolable.   The
real value of any instrument will be  shown by its efficacy to an-
swer the purpose for which it may be used, and by the safety and
convenience with which it can be managed, when its use becomes
absolutely necessary.
   There has been much  verbal dispute among those who vindi-
cated the superiority of the vectis to the  forceps, and those who
maintained the long established credit of the forceps against the
encroachments of the  vectis:  but  the  comparison between the
two instruments  has never been brought fairly  to  an  issue;
which might have been done by a discussion of the two  following
questions.
   Is it possible to deliver a woman safely with the forceps, in any
case not manageable with the vectis  ?
   Is it possible to deliver a woman safely with the vectis,  in any
case not manageable with the forceps ?
   We may take it for granted, and I believe it is true, that in far
the greater number of cases  which  occur in practice, either of
these instruments may be used indiscriminately,  with equal safety,
advantage, and ease, allowing for the dexterity which may have
been acquired by the habit of using  either instrument.  It is but
lately that those who prefer  the forceps  have asserted,  that they
could deliver a woman in any case of difficulty not manageable
with the vectis;  but as far as my experience enables me tojudge,
such a claim in favour of the forceps cannot be  supported.  The
debate on this point of the question seems to  have  turned for-
merly, not upon the superior efficacy, but upon the greater safety
and facility with  which the forceps might be used ; and upon the
abuse,  rather than the  proper use  of the vectis.  I  have not
heard of any well authenticated instance, in which  after being
foiled with the vectis, and  without  a  change of circumstances, 
384           INTRODUCTION TO  MIDWtFERY.
any operator,  who had acquired a commonly dexterous use of
this instrument, was able to succeed with the forceps ;  though it
is worthy of notice, that some who are accustomed  to the use of
the forceps only, think themselves at  liberty  to depreciate  the
vectis, and others who  do not use them, speak of the forceps  in
terms of unjustifiable contempt.
  It  might be  questioned, if we were to admit the objections made
by the approvers of each instrument, to their full extent, whether
they do not ultimately lead  to the abandonment of both ; and it is
certain, that the greatest improvement in the practice of mid-
wifery at the present time  is to be attributed to an established
aversion from  the use of instruments of any kind, whenever they
can possibly be -avoided.
  With respect to the second question, we will take the facts, and
relinquish the  arguments, used by  those who have  preferred the
vectis to the forceps ; which I allow sometimes  to have been ex-
travagant, as is not unusual with those who are the introducers of
novelties to public notice, till experience has corrected partialities.
If any confidence may be  placed  in medical reports, it appears
that  many cases have occurred, in which, after the introduction of
the first blade  of the forceps, it has been very difficult, or scarcely
possible, without the hazard of mischief, to introduce the second
blade,  and  the operation  has  been  performed with  the single
blade, used as a vectis.  Of this  I  have  known and  been  in-
formed  of  several  instances.   It  appears also, that before the
head of the child has been  so low  down as was  stated  to be eli-
gible for using the forceps, that the vectis has sometimes been rea-
dily  applied, and effectually used, with safety both  to the mother
and  child, when the necessity of some particular case immediately
required the operation.  When the head  of a  child has not only
been high up, but locked also  in  the pelvis, when  there was not
space sufficient to admit the two blades,  or more force  perhaps
was  required than the  forceps  in that situation enabled us to exert,
and  we should otherwise have been compelled to lessen the head,
it has been feasible to  apply  the vectis, and the patient has been
safely delivered, with a probable chance of preserving the life of
the child ; but of this  I have not myself known any instance.  It
is also to be observed  whenever more than common force is ex-
erted with the forceps,  that it appears to be obtained by using the
two blades as  distinct vectes.  Moreover,  in all the  deviations
from that position of the head, which is most natural, as when it
is turned with the face toward  the pubes, or when the face pre-
sents, in which it is allowed that the forceps cannot be used with
the utmost advantage or certainty, in all  such cases, 1 know the
vectis  may be applied and used both with  safety  and efficacy.
From this statement it may be  presumed, that  the vectis, pru-
dently used, is, in every case, an equally  safe and  efficacious in- 
ON DIFFICULT LABOURS.
385
 strument with the forceps, and one better adapted in many cases
 which occur in practice.  It is with this persuasion,  that several
 teachers in the art of midwifery in London, at the present time,
 never use the forceps, or speak of them in their lectures; while
 others, to whose judgment  I  owe much respect, continue to use
 the forceps, and  think  1 have advanced more than  experience
 will justify in favour of the vectis.  But these different opinions
 regarding the preference due  to the forceps and vectis prove to
 my mind, that in the generality of cases, either instrument may,
 in expert hands, be used with equal safety and advantage, as was
 before  mentioned.   I may also be permitted farther to observe,
 that I know several gentlemen of eminence, in the early part of
 their  lives, accustomed to use  the forceps, who discovering by
 accident or  trial, that they were able  to  afford every assistance
 with  a single blade, have  abandoned the forceps,  afterwards
 never using more than a single blade, or the vectis; but 1 never
 knew an example of any person, who,  having  been accustomed to
 the vectis, relinquished its use and resorted to  the forceps.  The
 reader will observe, that in giving my opinion on these instru-
 ments, I do  not speak of their abuse,  but of  their use on really
 necessary occasions;  and may be assured that I generally con-
 sider  disputes about  the  preference of instruments,  among the
 frivolous and  most  unworthy occupations of  men of under-
 standing.*
                         SECTION XI.
              On the manner of using the Vectis.
  Bv the first accounts  it appears, that the vectis was  recom-
 mended, not only in such cases as were thought fit  and suitable
 for the forceps, but to supersede the necessity of ever lessening
 the head of the child;  it was, in short, asserted, that no other
 assistance could, in any case, be required, beyond that which
 we were enabled to give with the vectis.  But if those accounts
 were  allowed to be true, they would prove the  miserable state
 of the principles and practice of midwifery at the  time, and in
the country in which they were written, in much stronger terms
 than they would describe the excellence of the instrument;  or
that such degrees of obstruction  did not there exist, as are not
 unfrequently met with in this country.
  *  [I cannot  yield the superiority  claimed by Dr.  Denman, for
the vectis over the forceps, but have only room here  to refer the
reader to the triumphant arguments of Dr. Osborn in favour of the
latter.   See his Essays on the Practice of Midwifery in Natural and
Difficult Labours.   London, 8vo. 1792.   F.j
                             49 
386
INTRODUCTION TO  MIDWIFERY.
   The  general  condition and circumstances of labours before
stated, as requiring the  use of the forceps, will hold good, and
with equal propriety, when the vectis is intended to be used ; and
the rules already given for the forceps will shorten what we have
occasion to say  respecting the manner of using the vectis.  For
though this instrument might be applied when the  head of the
child was high in the pelvis, or sometimes even when it was firm-
ly locked in the pelvis, in cases of great emergency, success in the
management of such cases depending upon much previous know-
ledge and experience  with the instrument, I dare  not attempt to
form a precise rule for the extent of our  conduct with the vectis }
that is, how high we may venture  to introduce it,  or with what
degree of force we may use it.  But when, without regard  to the
facility  with which the vectis may be introduced, or any other
consideration except the necessity of the  case,  under the circum-
stances before stated, we have determined upon using this instru-
ment, the patient being placed in the same situation, and  every
thing prepared as when the forceps are to be used, the operation
is to be performed in the  following  manner:
  Pass two fingers, or the forefinger of the right hand, to the ear
of the child, nearest to the pubes, and introducing the vectis be-
tween the fingers and the head of the child, conduct it slowly for-
ward till the point of the vectis reaches the ear, wherever that may
be.  Then  advancing the instrument as  if  it were a blade of the
forceps, carry it  on till,  according  to your judgment, the extre-
mity of the blade may reach as far, or a very little beyond,  the
chin of the child, when the line of the head, on which the instru-
ment rests,  will be in  a straight  direction from  the  vertex, over
the ear, to the  chin of the child;  and this is the most favourable
position in  which it can be placed.  Then grasping the handle
of the instrument firmly in the right hand, wait for the accession
of a pain, during the  continuance  of which, raise the handle of
the instrument gently  but firmly toward  the pubes, at the same
time exerting a small degree of extracting force.  When the pain
ceases, let the instrument rest;  and when it returns, repeat the
same kind of action;  and every  time of acting, endeavour to les-
sen  the pressure on the soft  parts of the  mother, with the two
fingers, or the inferior side of the palm of the left hand, placed in
such a manner as to form, in  some sort,  a cushion on which the
instrument may play, or be supported; or perhaps a pad of folded
linen cloth  may be advantageously applied between the instru-
ment and the part of the pelvis on  which it would press.  By  a
repetition of this action during the continuance of the pains, the
head of the child will  soon be perceived  to descend, and the face
to turn gradually toward the  hollow of the sacrum.  But should
the very moderate force we have recommended be found insuffi-
cient to bring down the head of the child,  it must be gradually 
ON DIFFICULT LABOURS.
783
and cautiously increased, till it is sufficient to answer the purpose:
and this may  be done consistently with the safety  both of the
mother and child.  When the vertex begins to fill and protrude
the external parts, it is probable there may be no farther occasion
to act with the instrument; or,  if farther action be  required, it
must be extremely gentle, taking all possible care, by turning the
handle toward the ischia or side of the pelvis, by supporting  the
perinaeum, and by slow proceeding, to guard against a laceration
of the parts, as was before advised in the use of the forceps.
   During the operation, the vectis being  confined  to that part of
the head where it  was originally placed, must,  as the head  de-
scends, necessarily change its relative situation to the mother, and
be gradually turned  from the  pubes to the  side of the pelvis,  as
was remarked of the handles of the forceps.
   It is also to be observed, though from the name of the vectis,
it might be supposed  we had the power of acting  with it as a
lever only,  that it will be found to possess a  considerable degree
of extracting  force, even when the  curvature is but small; and
that we are able, at the time of using it, if necessary, to direct
with convenience, and in various ways, the head of the child  as
it descends.                          ^*
   In using the vectis, some have recommended the application of
it  toward  the  hollow of the sacrum, and spoken of  the advanta-
ges of this mode of application.  But I have persuaded myself,
that the opinion which could lead  to this practice was erroneous,
that the instrument would then be  worked with less efficacy, and
there would be a greater hazard of doing mischief to the mother
and child.
   It may lastly be observed, that some gentlemen are said to have,
by frequent practice, acquired  such wonderful  dexterity in  the
use of the vectis, as to finish the operation  of extracting the head
of  a child with one single action  of the instrument.   But being
ever afraid of sacrificing safety to dexterity, 1 only  pretend to
describe a method of using this  and all other instruments secure-
ly and efficaciously ; and must  therefore be  excused from com-
menting farther on all that has been unadvisedly objected against,
or advanced for, the use of the vectis, under  various circumstan-
ces.*
  * See a full and accurate history of the Vectis, in Observations on
Human and Comparative Parturition, by R. Bland, M. D. A. S. S. 
388         INTRODUCTION  TO MIDWIFERY.
                      CHAPTER XII.

                         SECTION I.

           ON LESSENING THE HEAD OF THE CHILD.

  Having finished  all the observations we  had to make on the
use of those instruments which have been contrived to answer the
first intention in practice, that of  preserving the lives of both the
mother and child, we come to  consider an operation  yet more
important, though the  necessity of performing it occurs far less
frequently.  In this operation, being convinced that, under cer-
tain circumstances,  it  is impossible  that both their lives should
be preserved,  we feel ourselves justified in acting as if the child
were already dead,  as  the only measure by  which the life  of the
mother can be preserved.
  The operation has  ever  been  esteemed of the utmost conse-
quence with regard  to its principle and practice.  The right or
equity of taking away  one life for the preservation of another be-
ing doubted,  the question was  referred to  divines,  as the most
competent judges of the case; and by them it was decided to be
unlawful to take away one life, on any account, for the preserva-
tion of another.*  The reference of the question may perhaps be
considered as an instance of humanity and  benevolence,  and in
some  measure, as a  proof that this operation had been performed
too frequently ; and the decision seemed actually to forbid it alto-
gether.   But,  as far as the general determination could be sup-
posed to relate to this operation,  there appears to have been fal-
lacy in the statement  of the question, and sophistry in  the reply.
For by the first it was presumed that the child was always living
when this fatal operation was to be performed, though that could
not universally, nor indeed, very frequently, have been the case ;
and by the latter it was allowed, that the authority of the decision
did not apply,  or might  be suspended,  if  there were reason to
believe that the child  was already dead.   It  was  probably  for
these causes that all the symptoms of a dead child, certain and
equivocal, were collected and distinguished by authors with such
great assiduity and  circumspection, because they were the  autho-
rities for, and the justifications of, a practice, which without them
would have been very  reprehensible,  if not punishable.
  * Peu, in his Pratique des  Accouchements,  has preserved the
forms of the statements and decisions upon this subject by the Doc-
tors of the Sorbonne.
  Non enim licet unum interficere alterius vita? gratia.
                                         Rodericus e Castra. 
ON  DIFFICULT LABOURS.
389
  In cases of dangerous parturition, the prerogative of deciding
upon the life or death of the mother or child, was supposed by
some to be inherent in the husband, to whose powers of judg-
ing, or of feeling, appeals were to be  made.  This erroneous
opinion,  though I have formerly heard it mentioned in practice,
being also contrary to the rights and interests of society, never
could have satisfied  the mind, or justified  the conduct of any
person who should have submitted to  be governed by it.   Nor
do these cases admit of such election ;  for if the  husband had
preferred the child, his wish of preserving it at the expense of
the life of the mother, could seldom have been gratified ; he at
least could be no  competent judge of the necessity of the case,
and certainly could claim no peculiar dominion over the  life of
either of them.  Were the mother, under any circumstance, to
perish, the death  of the child, unless under  some  very rare in-
cident, would be an inevitable consequence.   But I cannot per-
suade myself, nor can  I think it reasonable or just, that the head
of a child should ever be lessened on the testimony and judg-
ment of  any single person, however  well  he may be informed
and experienced, if a consultation can be obtained.
  True religion, and the common sense of mankind, appear to
have nothing contradictory.  The doctrine  they  teach, of its
being our duty to do all the good in our power, and to avoid all
the mischief we can, is applicable to  the exigencies of every
state, and we may be easily  reconciled to it  on the present oc-
casion.   In some cases of difficult parturition, it is not possible
that the lives both of the mother and child should be preserved.
Of the life or death and safety or danger of the mother, we can,
under all circumstances, be assured ;  but of the life or death of
the child there is often reason to doubt, when we are called upon
to decide and to act.  The destruction of the mother, or which
has by many been considered as synonymous, the cesarean ope-
ration, would not, in  the generality of cases which may  bring
the operation of which we are  speaking under contemplation,
contribute to the preservation of the child, that being already
dead ; but the treatment of the child as if it were actually dead,
with as much certainty of  success as  is found in  other  opera-
tions, secures the life of the parent.  It then becomes our duty,
and is agreeable to our reason, to pursue that conduct, which
will give us the most probable chance of doing good ; that is. of
saving one life, when two lives cannot probably or possibly be
saved.
  1 forbear  to inquire into the comparative value of the lives
of an adult and a child unborn, because that does not seem to
me to be the present question, nor that any advantage can be
obtained by  the  depreciation of the  life of either ; and the 
390
INTRODUCTION TO MIDWIFERY.
subject has been in that view  well considered.*  Nor does  it
seem necessary to  our purpose  to  discuss another  question,
which has been lately agitated, whether a child unborn has  any
feeling, because the fact of their  having feeling, of some kind,
or in some degree, may be clearly proved by any one who will
observe the effect of irritating the soles of the feet of a living
child when these present, or the palm of the hand when that
presents, the  body and head being yet retained  in the uterus.
But  there is an argument  to be  drawn from the circumstances
which sometimes occur in cases of laborious parturition, which
applies with  greater force toward justifying this operation, in
preference to any other which might prove more hazardous to
the mother, than any abstract reasoning.  In all difficult labours,
properly so called, especially such as are  occasioned by great
disproportion between the head of the child and a small or dis-
torted pelvis, one of the first effects of long-continued and strong
pains, is the death of the  child, generally, long before there are
any tokens of the mother being in immediate danger.  The head
of a dead child collapsing and admitting of pressure into a form
more suitable to the dimensions of the pelvis, than a living one,
will  frequently be expelled through a space  too  small to allow
that  of a living child of the  same size to pass.  But after this
change which follows the death of the child, should  the head
remain too large  to pass  through the pelvis, putrefacfion ad-
vancing,  the  integuments of the head begin to decay, and  the
bones to  loosen from each other. By the continuance of the
action of the uterus upon the child, the integuments of the head
at length burst, and the bones being  separated, the brain of the
child may be evacuated through the  opening thus naturally pro-
duced.  The bulk of the head thus  lessened, may be excluded
by the force of the pains, and th<• body, impaired  by an equal
degree of putrefaction, may readily follow, and the labour  ter-
minate without the assistance of art.  All these changes may be,
and  in several instances to my own knowledge, have been gone
through with perfect safety to the mother, without the interposi-
tion  of art; so that the artificial opening of the head of a child
is, in fact, no more than an imitation in one case of what hap-
pens spontaneously to another; and such imitation may be con-
sidered as the true ground on which the whole practice of surgery
has been  founded.  It may also be observed, that the resources  of
nature, in every thing which relates to parturition,  are infinite,
and  constantly exerted for  the  preservation of both the parent
and child; yet when the two objects are incompatible, the  lite  of
the child  is almost uniformly yielded to that of the parent.
* See Dr. Osborn's Essay on Laborious Parturition. 
ON DIFFICULT LABOURS.
391
   From the number of the signs of a  dead child given by au-
thors,  and by  the context of their  writings, it appears to have
been the practice, whenever the death of a child was  ascertained,
to use the means of extracting it; or to have given medicines to
excite and aid  the constitution for expelling  it, without any rea-
son drawn from the present state of the mother, but to prevent re-
mote and suspected danger.   This practice corresponded with the
theory of  the ancients, that a living child was born by its own ef-
forts, but a dead child, being destitute of all power, must be  ex-
cluded or extracted by art.*  But no fact is more clearly proved
than that  of a  dead child remaining in the uterus inoffensively,
for several weeks before the accession of labour, and being then
expelled in a manner  perfectly natural, though in a quite putrid
state.  No injurious absorption takes place, nor does the uterus
suffer  by being in contact with it.  The certainty of the death
of the child would not, therefore, immediately, indicate the neces-
sity of the operation we are  considering ;f but the reasons for, and
justification of it, must be  deduced from the state of die mother
only ;  and that state must  be such as to prove her absolute inabi-
lity to  expel  the child;  and  the  impossibility of extracting it
safely by  any of those means which have been contrived for the
purpose of delivering  women, giving at the  same time a chance
for preserving the lives of children ; together with the uselessness
and danger of delay.  But as  the signs of  a dead child, if deci-
sive, would, on many occasions, have their influence  on practice,
and might at least induce the most cautious and prudent man to
hasten the time of performing this operation, which  he might
otherwise  defer; and as the knowledge of these signs will lead to
a more full investigation of the subject, it is proper to enumerate
them, and to inquire at the same time how far each of them may-
be allowed to determine the fact which they are  adduced to prove.

                          SECTION II.
               ON THE SIGNS OF A DEAD CHILD.
    1. Recession of the Milk, and flaccidity of the Breasts.X
   Should the child die when  a  woman is far advanced in her
pregnancy, and before the commencement of labour, these signs
  * Ad bonum partum, duorum corporum vigore est opus, et gravida?,
mulieris et  infantis.   Gal. in Aphorism. Hippocrat.
  t Si sub  ipsis partus doloribus ac labonbus  infans  ernoritur, nee
tamen minus decenter, sed naturaliter compositus esse deprehenditur.
non statim, quamdiu scilicet de morte non satis certi sumus, unci vel
alia admovenda sunt instrumenta.   Heister. Chap. CLII1.
  t Qu» corrupturae sunt fcetus, iis mammae extenuantur.—Gal. in
Aphorism.  Hippocrat. 
392          INTRODUCTION TO MIDWIFERY.
are seldom wanting.  But if they were to be offered as proofs of
the death of a child  destroyed  by  the  severity of a labour, it
would have been  needful  to  have  compared  the  state of  the
breasts at  two specific times;  first, on the  accession of labour,
when  the child was living,  and they might be turgid ;  and,  se-
condly, in the advanced state of labour, when the child was dead,
and they might have  become flaccid.   But as it is not customary
to inquire into the  state of the  breasts before some suspicion is
entertained of the death of the child, and as those of no two wo-
men,  under any circumstances, exactly resemble each other; and
as the milk is often secreted irregularly  at  different periods  of
pregnancy, all indications taken from the state  of the breasts,  or
the secretion and quantity of milk,  must be uncertain,  and any
judgment founded upon such indications, extremely liable to error;
granting, however, that in some situations, they do become com-
mon,  or collateral proofs of the question we may wish to deter-
mine, especially in  the latter stages of pregnancy, though not in
the course of a labour.

                 2.  Coldness of the Abdomen.
   When children die toward the conclusion of pregnancy, women
not unfrequently complain  of coldness of the abdomen, and, at
the instant of their  death, there  is usually one  violent shivering.
But when women  in  labour speak of this coldness, there is  not
actually  external coldness,  but  a sense  of it felt by the patient.
A supposition that  a dead child  is colder than a living one, is the
principle which gives  to  this  sign its  chief importance.  But
whether  a child has been dead for a short or a long time, it is  ge-
nerally found to be of the same degree of heat with the uterus in
which it  was contained, and  it  is even hotter  than the uterus
while it is in the act of putrefying.  The principle being  falla-
cious, the inferences must often mislead,  and a child is not unfre-
quently born living, though the mother, before her delivery, com-
plained of this coldness; which  may be produced by some con-
tingent circumstance,  as the great heat of the room when she is
in a profuse perspiration, or the sudden admission of cold air un-
der the bed-clothes in  winter.  Little stress is to be placed  on
this sign alone, but, when accompanied with others, particularly
a considerable diminution of size, it  must increase our suspicions
of the perilous state of the child, if not of its death.

              3.  Mechanical zveight of the Uterus.
   If a woman in labour, or in the latter part of pregnancy, should
feel the uterus fall with.a sense of increased or unresisted weight
 when she turns from  one side to  the other,  or changes her posi-
 tion, it is often surmised that the child is dead; the bulk of the
 child being diminished, and all thatresilition observed to exist in 
ON DIFFICULT LABOURS.
393
every living body being lost.  But this sense or effect may often
be explained in  a more  satisfactory  manner from other causes,
especially when a woman is in labour.  Should, for instance, the
waters of the ovum be suddenly discharged, the uterus will con-
tract till it  comes into contact with the  body  of  the child ; but
the integuments of the abdomen, not contracting with equal ce-
lerity, and  the uterus  wanting that support  which they afforded
when it was fully distended, must of course fall to whichever side
the woman may turn.  Should the waters be discharged slowly,
or should the integuments of the abdomen contract  speedily, or
should  the head of the child drop into the pelvis  immediately
after their discharge, there would not be this sense of unsupported
weight,  whether the child  were living or dead ; because in one
case the uterus would be  held firm  by the  general contraction,
and in the  other, the child would be prevented from that kind of
motion  by its confined position.
  When a child is diseased, or dies in the latter part of pregnancy,
the flaccidity and subsidence of the abdomen are considerable ;
but it is from  a very great degree of these we are led to suspect
either the death or wasting of the child,  some subsidence being
one of the  natural changes which  precede  labours.  From the
appearance of some infants  born  alive, it is often evident,  by
the wrinkled skin, that they are less than they were some weeks
before  their birth, and the manner  in which these changes are
made,  frequently shows, whether they died suddenly, or declined
gradually.

               4. Want of Motion of the Child.

   The kind and degree of motion  which may be caused by the
child varies in different women,  and at different periods of preg-
nancy.   By some  the child is  scarcely ever perceived to move,
and with others it is scarcely ever at rest,  but it is often quiet a
few days before, and in the time of labour.   By  the  motion of
the child its living state is ascertained; but the want of motion
does not prove that it is dead, nor would it,  for this  reason, be
justifiable to perform  any operation, which might be injurious to
it if living.
   Some pregnant women, even among those who have before had
several children, have scarcely ever been able to perceive the mo-
tion of the child through the whole time of pregnancy, and have
even attributed their bigness to disease; then the regular increase
of size  is a good proof of pregnancy, and of the well doing of
the child.   Some have asserted that they have felt the motion of
the child, though the event has  proved  that they were not  preg-
nant.   Others  have  not doubted of the life  of the child, though,
after its birth,  there were certain marks of its having been long
dead.   In  long and very severe labours, natural affection may be
                              50 
394          INTRODUCTION TO MIDWIFERY.
overcome by  present suffering  and distress, and women might
conceal their knowledge of the motion of the child from the hope
of a more speedy delivery, if they concluded, that the judgment
of the  attendant  was guided by this circumstance.  Every al-
lowance must  be made, and every consideration had for human
nature, humbled by infirmities and misery; and under no circum-
stances whatever are kindness,  resolution, and patience, more re-
quired, than in long continued and  painful labours.   The fears
and affection of friends will also warp their judgment; but our
greatest tenderness, and  the propriety of our  conduct, will be
shown,  not by a compliance with requests and  solicitations, but
by following the dictates  of our own reason and judgment; for
we are not to  be governed or alarmed by unfounded apprehen-
sions of danger, but by its actual existence.

           5. Fcetor in the Apartment of the Patient.
   The putrefaction of the child would be an indubitable  mark
of its death, and might create a very offensive smell in the apart-
ment  in w hich the patient was confined;  but every putrid child
does not yield an offensive smell, and such smell  may be occa-
sioned by several other  circumstances.  If a child should die in
the uterus from external injury,  or any internal cause,  and be-
come putrid before the membranes of the ovum were broken, it
would have a peculiarity of smell, but not that foetor which every
animal substance emits, while it is in the act of  putrefying under
the influence of the open  air.   The fcetor to which  we now al-
lude, can only appertain to a  child which was  living in the be-
ginning of labour, and died in the course of it, after the discharge
of the waters ; and in such cases, when putrefaction  does begin,
it is commonly very rapid in its progress.   The  general smell
of putridity in the apartment of a person in labour,  is to be ad-
mitted with very great caution as a sign of a dead child; for if
the room be small,  or crowded with company,  or long kept hot
and uncleanly,  or the common offices of  life are  performed  in
it, as is usually the case among people of the lower class, a simi-
lar effect would be  produced as when the child is dead and be-
come putrid.

         6. Fcetor and ill Appearance of the Discharges.
   The foetor here meant is also supposed to arise from the pu-
trefaction of the child, and the ill appearance to proceed from a
mixture of meconium, sanious,  or  other matter which might be
supposed to flow from a putrefying child, with  the common ute-
rine discharges.  But the appearance of these  discharges natu-
rally varies  in different women, according to their constitution,
 and to the qualities of the waters of the ovum, in the appearance
of which there is a very great difference.  They become altered, 
ON DIFFICULT LABOURS.
395
likewise, by contingent circumstances, as the casual retention of
the discharge, the mixture of a small quantity of blood, or slight
inflammation in the parts,  which in some cases give a strong
scent to  them, hardly  to  be  distinguished from  putrid fcetor.
With every appearance of the uterine discharges,  children have
been born living and  healthy ;  and when they have been long
dead, those have, in many instances, been so little changed, as
not to raise suspicion of any harm  having befallen the child, in
the minds of very experienced men.  The proposal of any ope-
ration which would be injurious to the child, if living, would not,
therefore, be  justifiable, merely on account of the smell or ap-
pearance of the discharges, without other collateral proofs of its
death, or a conviction from other circumstances of the operation
being absolutely necessary.

   7.  Evacuation of the Meconium when the head of the  Child
                          presents.

   Should a child present with the breech or inferior extremities,
the evacuation of the meconium, which is  an absurd name given
to the excrements first  evacuated by the child after  its birth, is
one of the truest proofs of such  presentation.   But when the
head presents, if the labour be very  severe or tedious, the waters
will  be tinged of a greenish  colour, or pure meconium may be
forced away,  and with such appearances,  the child is often sup-
posed  to be dead ; from  a presumption,  that if it were living,
the sphincter of the anus would act with power sufficient to pre-
vent any discharge.  But by experience it  has been fully  and fre-
quently proved, that a child may be born living, though the me-
conium had come away when  the head presents ; its evacuation
proving no more than the weakness  of the child,  or the degree of
compression it has undergone.   The discharge of the meconium
may also depend upon the quantity  contained in the bowels, or
some casual pressure upon the abdomen of the child.  We may,
however,  in general,  conclude,  when the  meconium  does come
away in a natural presentation, that the  state of the child is not
void of danger ; and  for  many years  I never saw a child, pre-
senting with the head, born living, when the meconium had come
away more than seven hours before its birth.  But at length, I met
with a case, in which the meconium was discharged  for more than
thirty hours, at the end of which time, though the woman was
delivered with the forceps, the child  was born healthy and strong;
and  since that time  1 have had many equally convincing proofs,
that  the coming away of  the  meconium is a very doubtful sign
of the death  or dangerous state of  the infant,  whatever  may be
the presentation. 
396
INTRODUCTION TO MIDWIFERY.
8. Edematosc, emphysematose, or other peculiar Feel of the Head
                  or other parts of the Child.
   In many cases in  surgery, information may be  gained,  and
the judgment assisted, by what is called the tactus eruditus, or
that faculty which enables us to perceive and discriminate by the
touch,  with greater accuracy than by any evident or describable
marks.   It has also been said, that we may decide in many doubt-
ful cases, by the feel of  the  head,  whether a child be living or
dead.  But as we know that in  surgery,  the most discerning  and
expert  in this  faculty are  often mistaken,  when they desert com-
mon evidences,  so opinions  formed on  such ground would not
authorize an operation  to which they might be supposed to lead,
in the question on which we are now speaking.  For the integu-
ments of the head  of a child often become edematose to a consi-
derable degree,  from pressure in its passage through the pelvis;
and sometimes emphysematose from a continuance or increase of
the same pressure, when the child may,  in all other respects, be
perfectly well.   If the integuments be squeezed into a smooth,
round  form,  this is said to be unfavourable ; but when they are
corrugated, the tumefaction, though equally great, is thought to
be of less consequence ; the former  being supposed  to prove the
absolute separation of them from the cranium, and the latter,  that
their attachment remains; but this  difference  is in  many cases
accidental.  The original connection of the, bones of the head is
such, as to allow of their being pressed close to, or over each
other, with safety to the child; yet when this has been long dead,
and their natural connexion destroyed,  they may sometimes be
perceived to  be quite loose and distinct.   The loose state  of the
bones of the cranium is  frequently such  as to leave no doubt of
the death of the  child, as well as the abrasion of the cuticle or the
falling off of  the hair;  but proofs of things self-evident are not
wanted in practice, but such as will guide us in doubtful cases.
In very difficult labours, I have more than  once seen a portion
of the integuments of the head of the child burst, and afterwards
slough  away, and the bone laid bare,  without destroying the
child.   Probably  I  may have before observed,  that whenever
children die in the uterus, the greater the degree of putrefaction
in which they are expelled, according to the time during which
they have been dead, the more favourable is the indication to the
mother; showing, I  suppose, that the health and vigour  of her
constitution in general, and of the  uterus in particular, are not
impaired.  But  if a child should remain de*d  in the uterus for
any length of time,  without becoming putrid, this circumstance
might  be considered as a proof that the  powers of action in the
mother were  reduced to  a state of dangerous weakness; as food
remaining unchanged in the stomach would be a proof of the de-
bility of that  part. 
ON DIFFICULT  LABOURS.
397
  Many signs of a dead child have been mentioned by authors,
under the denomination of equivocal, as the extreme languor,  or
livid  paleness of  the  countenance of  the mother, the offensive
smell of her breath, and several  others.  But if it appears that
those signs, which  have been called certain, are in fact doubtful,
it will follow, that very little reliance ought to be placed in those,
which are acknowledged to be equivocal.  If, however, the pro-
priety of performing this operation ought not to be decided even
by the certain knowledge  of the  death of the child,  but by the
circumstances  of the mother absolutely requiring  it for her pre-
servation ; then the consideration  of the life or death of the child
becomes of less importance.   Because if the operation,  when
really necessary for her safety, were not to be performed, the life
of the child would  not be preserved, and that of the parent would
be inevitably lost.
                         SECTION III.
           On the Causes of  the Death of the Child.
   The proportion of children still-born to the  number of births
has  not been accurately determined, nor is it easy to decide the
question; as it may probably vary in  different countries and si-
tuations, and  in different years,  as plainly appears  in different
kinds of fruit.   But it seems to be generally greater than from a
transient  view  woul I  be apprehended,  and perhaps it  is far
greater in human  beings than in  animals, perhaps not less than
one in sixteen, or  between that number and twenty.   The death
of a child in the  uterus may  be  occasioned by various causes,
independent  of the mother, as  by local inflammation or other
disease of some part  of its  own body, essentially necessary to
 life; as in children born blind ; by some original imperfection in
 its structure, which may prevent its acquiring more than a certain
 size, or existing beyond a certain time ; by the smallness or mor-
 bid  state of the placenta, hindering the proper communication
 between the child and the uterus; by  a partial or total separa-
 tion of the placenta, or by the rupture of some  of the large ves-
 sels which run upon its surface; by the vessels of the funis um-
 bilicalis becoming impervious ; by the circulation through them
 being obstructed by the casual  tying of a  knot; by untoward
 pressure of the body of the child upon the  funis, or by this  be-
 coming dropsical  or  otherwise  diseased, and  probably various
 other causes.                    .....        ,.       c
   The child  may  also be destroyed  by affections or diseases of.
 the mother, as by the sudden and violent impression of fear, joy,
 or other tumultuous passion; by the general irregularity of the
 parent's life; by fever;  by improper or unwholesome diet;  by
 any cause capable of depriving the child of  a proper quantity of
 nutriment, or depraving the quality of that with which it may be 
398
INTRODUCTION TO  MIDWIFERY.
supplied ; or by accidents which produce  some positive injury
upon the body of  the child, through the integuments  and parts
with which it is invested and naturally defended.  Some of these
are beyond the power of art to prevent or remedy, though others
might, by proper care and management, be obviated or relieved ;
but at  present we want only to discover those causes of the death
of a child which may occur in the time of labour.
  To the inconveniences  and danger  which  may  arise in the
course  of a labour occasioned by disproportion between the size
of the  head of a child and the dimensions of  the pelvis, we must
submit; as no judgment or  skill can do more than teach us to
wait patiently for the effect  to be derived from the efforts of  the
mother, and the accommodating construction of the head of  the
child.   Though the degree of compression which this may un-
dergo in a very tedious or difficult labour, might be judged  in-
consistent with the safety of children, they will^ often, under such
conditions, be born healthy and vigorous, and the parents recover
more speedily and perfectly, after  such labours,  than  after those
which  were natural and short.   The same  observation will also
hold good of the resistance made by the soft parts to the passage
of the child through  the pelvis, unless their rigidity should pro-
ceed from local inflammation.   But should the natural efforts be
interrupted or subdued by fever, debility, or any other adventitious
cause, or should there be local disease, the state of the patient would
require the assistance of medicine or of art, according to the  cir-
cumstances which might supervene.  Yet, it is in common ob-
servation, that far the greater number  of those labours which
have been considered  as difficult, and which really  were such
toward the conclusion, were not in fact occasioned by the state
of  the patient, but by interposition, and the desire of accelera-
ting labours, which, in their nature, absolutely required  a cer-
tain time for their completion.   This interposition has chiefly
 consisted  of  two points of practice, both extremely  reprehen-
 sible ; the artificial dilatation  of the os uteri, and the  premature
 rupture of the membranes.   By such practice the order of the
 labour becomes disarranged, and there often follow occasions to
 exercise  art, for the relief of those evils which were originally
 caused by the improper use of art, to the  great hazard  of the
 parent or child.  So long,  therefore, as labours proceed natu-
 rally,  that  is, with pains efficient and returning regularly, they
 may-he objects of our observation, reason, and judgment, but
 cannot properly be considered as the objects of art.   Yet when
 the causes of difficulty are proved to be beyond the efforts of
 nature to accomplish, the assistance of  art  becomes justifiable
 because it is necessary, and we may be  reconciled to  the  fate
 of the child, if the life of the mother  cannot possibly be pre-
 served by any means consistent with its safety.  But we are to 
ON DIFFICULT LABOURS.              399
be convinced  of this necessity by  the most substantial proofs,
before we presume to decide upon an action so important both
in a moral and scientific view.

                        SECTION iv.
           On the Instruments used in this Operation.
  The instruments with which this operation was anciently per-
formed, do not appear to have been well  calculated to answer
the intention  of the operator, effectually or safely.  They con-
sisted chiefly of hooks, single or double, blunt or sharp pointed,
differing in form and length,  which were fixed upon any part of
the  head with the view of extracting  it forcibly.  It being some-
times found impracticable to fix  a  hook firmly upon the head,
other instruments were invented  and used to make an opening
into which a hook might be fixed,  but apparently without any
intention of lessening the bulk of the head.   All these instru-
ments it would be useless and tiresome even to enumerate; but
it is remarkable, that Mauriceau,  a man of great experience and
real ability in  his profession,  should  have complained of difficul-
ties in this operation which he could not surmount, from  the want
of better instruments,  and those which he used were certainly
very imperfect.
  Perhaps there is no operation  in  surgery which admits of a
more precise description or distinction, than this of lessening the
head.  It consists of three parts ;  perforating the cranium; eva-
cuating  the brain and cerebellum ;  extracting the head ; and
three instruments have been  commonly used for these purposes.
The first was  the scissars originally used by la Motte, altered and
improved by  Smellie ; the second  was in  the  form of a large
spoon with serrated  edges,  for the purpose  of evacuating the
brain ;  the third was a hook or  crotchet,  straight or curved, to
be  used singly,  or in pairs  like  the forceps, by which the head
was to be extracted.
  Many years ago, Savigny,  the instrument maker, at my reqoest,
prepared two  instruments, which I suppose to be  fully sufficient
for  this  operation, the evacuation  of the brain not requiring a
separate instrument.    The first was a perforator in  the form of
Smellie's scissars, the blade being slightly curved  in the manner
of the scissars used for extirpating  the tonsils, but without any
cutting edge,  which is somewhat dangerous and altogether use-
less ; and strength was added to the instrument by giving greater
thickness to  the  inner part  which  was  before sharpened to an
edge, and is in this blunted.  The second was  a crotchet with a
little degree of curvature, and a hook brought to a flattened point,
about one inch in length,  which is small if compared with  those
before used.  . The  perforator measures  about nine inches in
length, and has  a stop on each blade one inch and a quarter from 
400          INTRODUCTION TO MIDWIFERY.
the point.  The crotchet, which has a wooden handle and a flat
stem, should, when properly curved, be of an equal length with
the perforator.   These instruments, which are now almost in ge-
neral use, are found to be very convenient, and fully adequate to
every purpose  in  the performance of this  operation;  and  as
the intention is well understood, and  the instruments simplifi-
ed, both the difficulty and danger of the  operation are  infinite-
ly lessened.

                         section v.

          On the Manner of Performing the Operation.
   Much consideration is required before we determine to perform
this  operation,  and, according to my judgment, it ought never to
be performed on the opinion of any single person, if that of two
can be procured, both on  account of individual character and
public  satisfaction.   But when we have  once decided upon the
necessity of its being  done, besides great circumspection in the
manner of doing it, there is occasion for  our being resolute and
persevering in our attempts to accomplish it; even when the diffi-
culties to be surmounted appear to be too great for any degree of
skill, or any force we have the power  of using.   One common
error formerly  prevailed  in this and  too many other  surgical
operations, founded on an opinion, that it was needful to perforin
it speedily ; but it is now  proved by experience, and generally
acknowledged, that the more calmly and slowly we proceed, the
less  chance there will be of failing,  or doing mischief.   As the
sole aim of this operation  is to  preserve  the life of the mother,
without regard to the child, whatever  its state might be, it will
be our  duty to be particularly careful to guard  against every
accident which might prove injurious or hazardous to the mother.
But, as by following the distinctions specified  in the last section,
we shall be able to mark and explain all  the circumstances of
the operation as they occur, we will abide  by those distinctions
in describing the manner of performing it.

                          SECTION VI.
                On the Perforation of the Head.
   The ease or  difficulty attending this  and every other part of the
 operation will  depend upon the distance the head may  be from
 us; whether, for instance, it be descended and locked in the pel-
 vis, or be lying at the superior  aperture;  and upon the degree of
 distortion of the pelvis, which may be  only so much as just  to
 prevent the passage of the head,  or so great as  to render even
 the use of the instruments both troublesome and  dangerous.
 Some inconvenience may also be produced by. the os uteri, should
 it not  be completely  dilated; but this  may rather be  esteemed 
ON DIFFICULT LABOURS.
401
 a reason for extraordinary care, and slow proceeding, than as a
 canvs,' of difficulty.
    Without regard to the part of the head which we mean to per-
 forate, but deciding upon that wlrich is most obvious and  easy
 of access, as the most proper, the left hand  flattened is to be in-
 troduced into the vagina, and the  fore-finger of the same hand is
 to be directed  upon that part of the head where we intend to fix
 the point of the instrument.   The  perforator, held in the right
 hand, is  to be  conducted with the convex part toward the  palm
 of the left hand, and with the point  kept close to the  fore finger,
 till  it reaches  the part  where we have  determined to perforate.
 The fore  finger of the  left hand is  then to be passed round the
 point of the instrument,  that we may be assured we have fixed it
 in the right place, and  that  none of the soft parts of the mother
 are in the way of being hurt.   With the instrument held firmly
 in the right hand, we must then press through the integuments of
 the head ; and, the point being fixed upon the bones  of the cra-
 nium, begin to perforate, by turning, with a semirotatory motion,
 the handle of  the instrument.   This motion  of the instrument,
 care being taken to confine  the point to the place where it was
 originally fixed, is to be continued till we judge the  bone  to be
 actually perforated ; and we are to  try occasionally, by advan-
 cing the instrument, whether  the  bone be perforated  or  not.
 When the bone is perforated,  the instrument  being pressed for-
 ward, will penetrate the head, and go on till it reaches the stops
 formed upon the blades.  Then fixing  the  finger and thumb  of
 the right  hand  in the bows of  the handle,  or  pressing the thick
 part of the hand between the stems, or calling for the help of an
 assistant, we should separate the handles of the instrument to
 such a distance as to make a slit or  opening of sufficient length
 in  the cranium ; judging of, and in  some measure guiding, the
 effect produced upon the  blades by the separation of the han-
 dles, and by the  finger of the left hand retained in its primitive
 position.   The handles being  then closed,  the instrument must
 be turned in a  transverse direction, and they are again to be se-
 parated in the  same cautious manner, by which  means a crucial
 opening of a  proper size  will be  made in the cranium.   This
 being completed, the perforator is to be closed, and  withdrawn in
 the same  cautious manner in which it was introduced.
   In this  part  of the operation, the  principal  things  which de-
 mand our attention are, first, that the instrument be carefully in-
 troduced ; secondly, that we be not alarmed at the  discharge
 which follows the perforation of the  integuments of the head, as
 that is to  be expected;  thirdly, that  the point  of the instrument
does not slip while we  are perforating; and  fourthly, that the
crucial  opening iu the cranium be sufficiently large, to allow of
 he exclusion of its contents.
                           51 
402
INTRODUCTION  TO MIDWIFERY.
                        SECTION VII.
         On the Evacuation of the Contents of the Head.
   A very large opening of the cranium has been generally con-
sidered as necessary for the  well-performing of this  operation ;
but this is not absolutely required in any point of view, nor can it
always be made with safety.   It must, however be sufficient for
the purpose of suffering the contents of the head to pass through
it; and for the evacuation of these, it was before mentioned, that
various instruments had been contrived.   But these instruments,
especially the serrated spoon, appear to be both unnecessary and
dangerous; unnecessary,  because the texture of the brain and
cerebellum being broken down, their evacuation will follow  of
course, as the head is  propelled or  extracted; dangerous, be-
cause an  instrument with  many sharp points could not be fre-
quently introduced and  withdrawn, without the hazard of being
hitched on the soft parts of the  mother.  Any smooth instrument
of a proper size and length, such as the handle of a silver spoon,
or a blade of the forceps, will  answer the purpose of breaking
down and evacuating the contents of the head safely  and effec-
tually.  But  the  perforation being completed,  I have generally
introduced the crotchet into  the opening in the cranium; and
turning it round frequently, in various directions, especially near
the basis  of the skull,  have completed this part of the operation
without difficulty.   With  all the care which  can be taken, it is
not always possible to do this on the first attempt; but, if in the
course of the operation it should be found that the head does not
readily collapse, because some  part of its contents had escaped
the action of the instrument,  the same method may at any time
be safely repeated, without delaying the operation.

                        SECTION VIII.
                On the extraction of the Head.
  It was  formerly a rule of  practice, whenever the head of the
child was opened, that the efforts to  extract it  should immediately
commence, and be continued till the purpose was accomplished.
With all  the cautions which have been given for ascertaining the
necessity of the operation before it was performed, it was strongly
inculcated, that we should be on our guard not to defer it till the
strength  of the patient  was  too  much  exhausted; lest by such
delay we should altogether lose the advantage  that would result
from the  natural efforts, which might  otherwise be made for the
exclusion of the lessened head;  and when  the child was extract-
ed, lest the patient should be reduced to a state of the  greatest
danger from mere debility; more especially if there should be a
loss of much  blood, before or after the exclusion of the plaeenta. 
ON DIFFICULT  LABOURS.
403
Our couduct with regard to the extraction of the head, must
then depend upon the state of the patient; whether that state will
permit us to wait for the  advantages to be derived from the pu-
trefaction and compression of the head from the natural pains,
or whether the head should be speedily extracted by art.   If the
os uteri be not completely dilated, when we begin to extract, our
proceedings ought  on that  account to be very gentle.  But if
from the great distortion of the  pelvis  we should have been con-
vinced of the necessity of performing this operation in the begin-
ning, or early part of a labour, the head when  lessened may be
left for many hours to undergo those changes which putrefaction
occasions, to the  diminution  of its bulk by compression, to its
gradual descent into the  pelvis, when  it may be readily extract-
ed, or to the chance of its final  expulsion  without  assistance, as
the reason and nature of the case may  indicate or require. Under
such circumstances, the late Dr. Christopher Kelly* informed me,
and I believe the practice originated  with him, that he had left
the head of a child, after the evacuation of its contents, for more
than twenty-four hours,  without  making  any  artificial attempts
to extract it;  and that the operation was, by this delay, rendered
more safe, and infinitely more easy.   The  late  Dr.  Mackenzie
also informed me, and many other  persons, that  he had in the
latter part of his  life followed this practice with  success.  But the
matter has been  more fully discussed, with great ingenuity, and
as much precision as the question admits, by a  late very sensible
  * The papers of my worthy friend, Dr. Kelly, are in the hands of
my son-in-law,  Mr. Croft, who found among them the following ac-
count of the individual case, probably, of which the doctor had  in-
formed me, which I transcribe in his own precise words.
  *- March 11, 1763.   ----has a pelvis extremely narrow, and, by
the  measure I took,  do firmly believe the distance between the os
pubis  and  projection  of the sacrum is  not more than two inches,
therefore I knew it was in vain to hope to  bring the child alive  by
any means whatever: therefore, for her safety, I opened the head
freely, and emptied the cranium, in about sixteen hours after being
first called to her, and then left it  to settle into the  pelvis twenty-
four hours (as in the case of Mr. Ford's patient) before 1 delivered
her, which  I did with tolerable ease, by  means of the blunt hook
only.   She recovered as well as possible.   This was her first child.
She was so ricketty when a child, as not to be able to walk till nine
years of age, and is now very short.   Her name is-------."
  The  pelvis of this woman came at length into my hands, and  in
6ome  parts of the superior aperture does  not  measure more than
one inch and a quarter, though  on  one side the space is equal  to
two inches.  D. 
404          INTRODUCTION TO MIDWIFERY.
and judicious writer,* who in a case of which  I  was a witness,
left the head of a child more  than  thirty-six hours  after  it had
been  lessened,  and then  extracted it; the woman  recovering
without any untoward symptom.f Of the pelvis of this woman,
who,  I am informed, is  now dead, we were never able to get the
exact dimensions, as she removed from her usual habitation, and
could not  afterwards be traced.
  When the head of the child has  been  lessened, the length of
time during which the patient  may  therefore be trusted in expec-
tation of favourable changes, must be left to the judgment that may-
be formed of every individual  case which may be the immediate
object of  practice.   In some cases,  from the precarious state of
the mother, thtre will exist a necessity of extracting  the head as
speedily as we can with safety; yet the general principle  to be
established is, that the longer we  hive waited  in any case,  the
more easily will the head be afterwards extracted.   But the pa-
tient is to be carefully watched  that we do not wait too long, lest
unfavourable symptoms should come on,  and the end for  which
the operation was performed be ultimately defeated.
  Sooner or later then, according to the state of the mother, it
will be necessary that we should begin to make our efforts to  ex-
tract the head of the child ; and taking care, in  the first place, to
remove cautiously any loosened or  sharp pieces of bone, I have
been accustomed to avoid  using the crotchet, or any kind  of in-
strument, till I have tried what advantage was to be  gained with
my fingers.  With this view, introducing the fore finger of either
hand, armed with my glove, or some such  contrivance, into  the
opening in the  head, and then bending it in the shape of a hook,
I have pulled with all the  force it enabled me to exert, repeating
my attempts at intervals, when the  natural efforts of the mother
returned.
  Should the head of the child be  so high in, or above, the  su-
perior aperture of the pelvis, or this be so much distorted  as  not
to admit of my giving this kind of assistance, or should it be un-
equal to the purpose, I  carefully introduce  the crotchet, guided
by my left hand, into the opening in the head ; and, fixing  the
point of the hook as far from  the edge of the bone as its curva-
ture will allow, I begin to pull moderately by the handle  held in
my right hand, guarding at the same time the hook of the crotchet
with the fingers of the left, lest it should happen to tear away the
bone, or slip.
  * Essay on Laborious Parturition, by Wm. Osborn, M. D.
  t [The delaying all attempts to extract the child till the head has
been opened at least thirty hours, which is inculcated by Dr. Osborn
as a rule of practice, must, at times, expose the mother to great dan-
ger, and does not seem justifiable.   F.] 
ON DIFFICULT LABOURS.
405
  If, on trial, the crotchet be found firmly fixed, but the head be
too much  impacted in the pelvis to  be brought down with  the
force first  used ; that is, supposing the  force required to extract
the head be equal to 10, and the force which can be exerted by
the crotchet not to exceed 5; no other  purpose can  be answered
by striving too earnestly with the force  which cannot be made to
exceed 5, except tearing away the piece of bone  in which  the
crotchet may  be  fixed, which does not facilitate the operation.
We are to be satisfied  with the steady exertion of the force 5,
which, being continued, will at length be found sufficient for  our
purpose,  the resistance gradually diminishing, and the force 5
remaining.  In the repetition of our attempts to extract the head,
which  oiu-t be made at intervals, should the bone  in which the
instrument was fixed, be loosened and come away, wholly, or in
part, the crotchet must be again introduced and fixed in another
place,  and the same method of proceeding followed ; remember-
ing also when we  extract, to pull with  some variation in  the di-
rection, but always in the line of the cavity of the pelvis.   In
almost every case  of difficulty the principal obstacle or cause of
the difficulty is at one particular part of the pelvis, and when the
head has  passed that part there is no farther occasion for using
much force; and we are afterwards to proceed very  circumspect-
ly, that there may be no laceration of, or injury done to the parts
of the  mother, internal  or external.  The principle I wish to  im-
press on the minds of those who may be embarrassed with diffi-
culties  of  this  kind is, that time is equivalent to force, and that
no advantage will be obtained  by pulling away small pieces of
bone, except such as were loose and  likely  in  their passage to
injure  the soft parts of the mother, or  by acting hastily  or vio-
lently.  On the contrary, when the instrument is once firmly fixed
in a part of a bone which affords a good hold, I have been cau-
tious not to tear it away by pulling rashly, considering  that as
something like breaking the instrument  with which I was perform-
ing the operation.   Where  the  resistance  has been very great,
after making my first efforts with all the force  and  skill I could
safely  exert without success, leaving the crotchet fixed, I have de-
sisted for an hour or longer, and then  renewed my attempts.
   In a case of very great difficulty, it  is however, possible, that
all the bones of the cranium might be brought away successive-
ly, and nothing of the head remain but the basis of the scull, with
the integuments.   In such a case it  has happened, quite unex-
pectedly, that I have succeeded in bringing down the remainder
of the head, merely by grasping the  integuments firmly in a
mass, or even'in distinct parts ; and pulling by them in a  proper
direction.   But, if these should be found insufficient, the crotchet
is to be introduced again, and fixed upon the basis of the scull on
any part where we can get a firm hold, and this assuming  a more 
 406         INTRODUCTION TO  MIDWIFERY.   .

 convenient direction, will be more readily brought down.   I have
 not found, in cases of this kind, that I  have acted from a prefe-
 rence for fixing the instrument in  this or that  part, or  in  this or
 that manner; but, giving myself  time to reflect,  the exigence of
 the case has dictated what I ought  to do, so that I am not solicit-
 ous about any  particular method.  Some have thought that it
 was of great importance to fix the  crotchet on  the outside of  the
 head, and others have insisted on the propriety and superior ad-
 vantage of fixing it on the inside;  but I am  persuaded  that such
 things are of little consequence,  and  that in the course of a diffi-
 cult operation, it may  be found necessary and  useful to fix it in
 either way.
   If the disproportion between  the cavity of  the pelvis and the
 head of the  child be very great, we may then allow it to be pos-
 sible, that all the bones of the cranium, together with the basis  of
 the scull, may be brought away, yet the body of the child may
 remain  above the superior aperture of the  pelvis, with  absolute
 inaction of the uterus.  This circumstance may require different
 methods of  treatment.   If the  space between the projecting bones
 of the pelvis would permit the flattened head  to  be passed into
 the uterus, it might be most expedient to turn the  child  and deli-
 ver by the feet, which, thus situate, I  have more than once done.
 But, if the distortion of the pelvis will not allow the hand to pass
 into the uterus, or if there be reason to apprehend  mischief to the
 uterus, from the jagged or loosened pieces of bone, the crotchet
 must be again introduced, and  fixed upon the chest of the child,
 where it may probably meet with some part that will bear a suffi-
 cient degree of force for extracting itv   Should this not be  the
 case, the crotchet must be repeatedly tried, by which the contents
 of the thorax and abdomen may be evacuated, and the general
 bulk  of the child's  body very much lessened.  Then trying  to
 fix the hook of the instrument on some part of the spine,  or bring-
 ing down the  arms, we shall  at length succeed and extract the
 body of the child, whole, or in parts, though we may have been
 frequently baffled.  In an operation difficult as this  now described,
 disagreeable and tedious as it may  appear, and really is, having
 only occasion to attend to the extraction  of the child, in any man-
 ner, without doing mischief to  the mother, the  mind of the ope-
 rator may be at  ease, and he will then avail himself of every ad-
vantage which may offer toward answering his purpose.   On the
whole, I have never known a case attended with so much difficul-
ty, that it could not be surmounted  by steady and slow  proceed-
 ing ; and the operator, after  all his difficulties, if he have  acted
 cautiously, may be repaid by seeing his  patient recover, as well,
 or better, than after the most easy  labour.  But if he has acted
 unguardedly or rashly, he will probably find  some subsequent 
ON DIFFICULT LABOUR3.
407
 mischief that might easily have been avoided, but very difficult or
 impossible to be remedied.

                         SECTION IX.
                 On the subsequent treatment.
   When  a  child has been  extracted in the manner before de-
 scribed, the placenta will commonly be expelled in a natural way;
 but should any difficulty arise, this must be managed according
 to  the rules which will be given in the chapter on Hemorrhages.
   Women, in general, recover well after this operation,  provided
 it was not delayed till some irreparable injury  was already done
 to the parts of the mother, and was  performed with care.  Be-
 side the treatment which may be  proper  for all women in child-
 bed, it will be incumbent upon  us to be  particularly careful in
 these cases that the urine be voided; and if the patient should not
 be  able to do it by her own efforts, that it be drawn off with the
 catheter, very soon after,  if it  were not, or could not be done, be-
 fore her delivery.   The use of the catheter is also to be continu-
 ed twice in the  course of twenty-four hours, till she become able
 to expel the urine; lest there should be inflammation on any part
 of the  bladder or  meatus  urinarius, and a slough be  cast  off,
 which, unless it were merely a small portion of  the meatus might
 be followed by an involuntary discharge of urine ever afterwards;
 which I consider as one of the most deplorable accidents in the
 practice of midwifery.
  While I  am correcting these papers,  a case of this  kind has
 unfortunately occurred,  and  with circumstances that no know-
 ledge or caution could have  foreseen or prevented.  This pa-
 tient, after  a very hard labour with a dead child,  voided her
 urine without trouble of any  kind, for ten days after her delive-
 ry, according to the report  of the patient herself  and her at-
 tendant.  She then complained of some uneasiness after every
 evacuation,  but  no difficulty in  voiding it.   Yet on the four-
 teenth day, a small slough was  thrown off from the bladder.  I
 mention this case, because I have generally suspected the slough-
 ing to be occasioned by the want of due attention to the urine,
 or of a prudent use of the catheter ; and there can  be  no doubt
 but that negligence in these two points has generally  been the
 cause of such accidents.

                        section x.

   On the propriety of bringing on Premature Labour, and the
               advantage to  be derived from it.
  We have before alluded  to this operation as a method of pre-
serving the lives of children, without  adding to  the danger of
women, if in any case the pelvis were so much distorted, or 
408          INTRODUCTION TO  MIDWIFERY.
 so small, as absolutely to prevent the passage of the head of a
 full grown child, and yet not so  far reduced in its dimensions,
 as to prevent the head of a child of an inferior  size from pass-
 ing throngh it.   Melancholy are the reflections when a woman
 has a pelvis so very much distorted (and such women have usu-
 ally a wonderful aptitude to conceive)  that there should be  no
 chance, or very little, of preserving the lives of her children ;
 and yet, in the course of practice, 1 have in many instances been
 called to  the  same  woman, in  five or six successive labours,
 merely to give  a  sanction  to  an operation,  by which  the
 children were to be destroyed.   It is to the credit of  the pro-
 fession, that every method, by which the lives of parents and
 children might be preserved,  has been  devised and tried; and,
 though frequent occasions for using some of these methods can-
 not possibly occur in any one persCn's practice, it is right that
 all should be acquainted with what has been proposed and done
 in every case of  great difficulty, with or without success.
  A great number of instances  have  occurred, of women so
 formed, that it was not possible for them to bring forth a living
 child  at the termination of  nine months, who have in  my own
 practice  been blessed with living children, by the accidental
 coming on of labour when they were only seven months advan-
 ced in their pregnancy, or several weeks before their due time.
 But  the  first account of any artificial method of bringing on
 premature labour was given to me by Dr. C. Kelly.   He in-
 formed me, that about the year 1756, there was a  consultation
 of the most eminent  men at that time in London, to consider
 of the moral rectitude of, and advantages which might be ex-
 pected from, this practice, which met with their general appro-
 bation.  The first case in which it was  deemed necessary and
 proper fell under the care of the late Dr. Macaulay, and it ter-
 minated successfully.   (The patient  was the wife of  a  linen-
 draper in the Strand.)   Dr. Kelly informed me,  that  he him-
 self had practised it, and  among other instances, mentioned
 that he had performed this operation three times upon the same
woman, and twice the children  had been born living.  The
thing  was often the subject  of conversation, and has been pro-
 posed by writers,  but some have  doubted the morality of the
 practice ;  and the circumstances which may render the opera-
 tion needful  and proper, have not been  stated with any degree
 of precision ; but the practice afterwards became almost obso-
 lete or forgotten.
  With regard to  the morality of the  practice, the principle
being commendable, (that of making an attenpt  to preserve the
 life of a child which must otherwise be lost,) and nothing being
 done in the operation which could be injurious or dangerous to
 the mother, but, on the contrary, a probability of lessening both 
ON DIFFICULT LABOURS.
409
her danger and suffering, I apprehend, if there be a reasonable
prospect  of  success, no argument  can be adduced against it,
which will not apply with equal force against every kind of as-
sistance at the time of parturition, against inoculation, or medi-
cine in general, and, in fact, against the interposition of human
reason and faculties in all the affairs of life.  Such an argument
would lead us back to the absurd doctrine of predestination ; if
with justifiable intentions, with the greatest probability of doing
good, and without producing any comparative present  or future
mischief,  we may not use our endeavours to extricate our  fel-
low creatures from evils which threaten them, or under which
they may be  actually oppressed.
  If the morality  be justified, we are next  to consider  the safety
and  utility of the  piactice.
  As to its safety, having reasoned upon the structure  and state
of the parts concerned in the operation, and having carefully at-
tended to  all  the circumstances which have occurred when it  had
been performed in more than twenty cases, in which I have either
performed it, or it has been  done by my advice and persuasion, 1
have  not known one untoward or hazardous accident that could
be imputed to it; and in the greater number  of  these cases the
children have been  born living.  Many instances of this opera-
tion  being performed successfully have, since my first proposal
of it,  about thirty years ago, been  also recorded by others; I
therefore feel authorized to say, as far  as my own reason or ex-
perience, or those of many others, who have favoured me with
the result of their  practice, enable me to judge, that the operation
of bringing on premature labour, in  the cases to which this  dis-
course has any reference, is  perfectly safe to the person on whom
it may be performed.
  But respecting the utility of the operation, the statement  first
made of the intention or purpose with which it ought to be done,
that  is, to try whether the head of a  small child  will not pass
through a pelvis  too much  narrowed in its dimensions to allow
one of a common size to pass, will show, that  the objects of the
operation  are circumscribed  within certain  limits.  Should the
cavity of the  pelvis be of its  natural size, this operation is out of
the question,  and  never can  be required on that account.   If the
cavity of the  pelvis, though reduced in  its dimensions, be such as
to permit  the head of  a  full grown  living child  to be squeezed
through it by the force of strong and long continued pains, this
operation  is not required, and ought  not to be performed, except
in some particular cases in which  it  may be thought eligible.  If
the pelvis  be so far reduced  in its dimensions as not to  allow the
head of a child of such a size as to give hope of its living,  to pass
through it, the operation cannot be attended with success, though
it may free tlie patient from much suffering.  It is in those cases
                              52 
410          INTRODUCTION TO MIDWIFERY.
only in which there is a reduction of the dimensions of the pelvis
to a certain degree, and not beyond that degree,  that this opera-
tion ought to be proposed, or can succeed with complete advan-
tage.
   It would be highly satisfactory, if I  were  able, to state with
precision the exact dimensions of the cavity of the pelvis  of the
person, on whom  it might be needful to perform  this operation,
and on whom it might be performed with success.   But,  as  all
the instruments and methods contrived for measuring the pelvis
in the living woman  too imperfectly answer this  purpose,  to en-
able us by them to form an  unerring guide to practice;  and as
the head of a child before it is born can never be accurately mea-
sured,  of course  the exact relation between  them  must  be un-
known, and the determination must be therefore left to opinion,
and to former proofs: and those who are experienced will not
commit any great mistake in  their conjectures, even if they have
no other  than this  probable evidence,  by which their judgment
may be guided.   Under circumstances and in  situations just pre-
venting the successful use of the vectis or forceps, and just com-
pelling us to the fatal measure of lessening the head of the child,
it may become a duty to propose, on a future occasion, the bring-
ing on premature  labour; at seven months, or any later time, ac-
cording to our sense of the disproportion existing  between  the
head of a child and  the cavity of any particular pelvis.  It can
hardly be doubted, but that the casual events  of practice first in-
spired the notion of this method in the mind of some person, who,
adverting to the fortunate  termination of premature labours co-
ming on spontaneously, or of v„i-y small children, in cases of dis-
tortion of the pelvis, endeavoured to imitate by art what not un-
frequently happens naturally. It is also to be considered, that
in a child  born prematurely, the bulk of the head is not only
much less than at the full time,  but the component parts  of the
head are more loosely  connected, and  far  more pliable,  and of
course its volume is more  readily adapted to the space through
which it is to pass.
   I cannot deny myself the pleasure of relating the following
case, which  occurred very la tely.
   A lady of rank, who had  been married many years, was soon
after her marriage delivered of  a living child, in the beginning
of the eighth month of her pregnancy.  She had afterwards four
children at  the full time, all  of which were,  after very difficult
labours, born dead.   She applied, in her next pregnancy, to Dr.
Savage, whom I met  in consultation.   By  some  accounts she
had received, she was prepared for  this operation,  to which she
submitted with great resolution.   The membranes were accord-
ingly ruptured, and the waters discharged, early in  the eighth
month of her pregnancy.  On the following day  she had a rigor 
ON DIFFICULT LABOURS.
411
succeeded by  heat and other symptoms of fever,  which very
much alarmed us for the event.  On the third day, however, the
pains of labour came on, and she was after a short time delivered,
to the great comfort and satisfaction of herself  and friends, of a
small but perfectly healthy child, which is at this time nearly of
the same rize it would have been, had it been born at the full pe-
riod of i.terogestation, and it has lived to the state of manhood.
In a subsequent pregnancy,  the same  method was pursued, but
whether the child  was of a larger  size than  before, or the pelvis
were become smaller, whether there was any mistake  in the reck-
oning, or whether the child fell into any untoward  position,  I
could not discover, but  it was still-born, though the labour did
not continue longer than six hours.  But  in a third  trial, the
child was born living and healthy, and  she recovered without any
unusual inconvenience or trouble.
   The defects arising from the distortion of the bones of the pel-
vis, have been adverted to, as alone rendering this operation ne-
cessary ; but if the cavity be so far lessened  in its dimensions, as
to hinder the passage of the head of a  child, of its full size, from
any  other cause,  such as  the growth of a tumour like that men-
tioned in section vii. 8. chap* vi. the expediency of bringing on
premature  labour, might be  maintained by equally  sufficient
reasons.
  There is another situation in which I  have proposed, and tried
with  success, the  method  of bringing  on  premature  labour.
Some women, who readily conceive, proceed regularly  in  their
pregnancy till they approach the  full period, when, without any
apparently adequate cause, they have been repeatedly seized with
rigor, and the child has instantly  died, though  it may  not have
been expelled  for some  weeks afterwards.   In  two cases of this
kind I have proposed to brinj* on premature labour, when  I was
certain the child was living,  and have succeeded in  preserving
the children without hazard to the  mothers.   There is always
something of doubt in these  cases, whether the  child might not
have been  preserved without the  operation; but, as such cases
often come under consideration, and as I am disclosing all that
my experience has taught me,  it  seemed necessary   to mention
this circumstance.
  The propriety of this  practice has also been considered,  when
women have, during pregnancy, suffered more than common de-
grees of irritation,  especially when the stomach is in such a state,
that  it cannot bear nourishment of any kind or in any quantity,
and  the patients are thereby  reduced to a state of dangerous
weakness.   Presuming that  these symptoms are purely in con-
sequence of pregnancy, it  may perhaps be justifiable to bring on
premature labour.  Of  the success,  however, of such,  I cannot
speak from my own experience, yet  I can conceive a case of this 
412          INTRODUCTION TO MIDWIFERY.
kind in which  it might be reasonable and  proper, to take this
operation into consideration.
  I may be allowed to  conclude this  subject,  without entering
into a detail of the manner in which premature  labour may be
brought on;  because no person qualified to decide on the pro-
priety of this operation can  be  ignorant of the manner of per-
forming it,  whether  it be  done  with a  quill sharpened at the
point, or  any more formal instrument.   I must,* however, take
notice, that when the membranes  of the ovum are punctured or
ruptured,  some caution is required to avoid injuring the head of
the child,  which may lie close to them; and, after the discharge
of the waters,  it is  necessary to observe, that the time when the
action of  the uterus may come on  will be very  different;  this
happening in some instances in  twelve hours,  and in  others not
under twelve or fifteen days.  During this interval we have only
to wait  patiently for the event, and when  the pains come  on, the
labour,  if natural, is to be suffered to proceed without interrup-
tion ;  or,  if irregular, such  assistance is  to be given, as  the pe-
culiarity of the case may  require.   It is scarcely necessary to
mention, that when we are  considering the propriety of this ope-
ration,  it  ought not to be performed when the patient labours
under any hazardous disease; and that if  complaints  should af-
terwards arise,  our endeavours  must be exerted to remove them
before the accession of labour.    But concluding all  the  obser-
vations  which it seems necessary to make on this  subject,  I must
solemnly deprecate their being  applied to dishonest and  immo-
ral purposes.*
  * [Not the le^st doubt can reasonably exist as to the propriety of
inducing, in certain cases, premature labour, as a means of prevent-
ing the necessity of employing the perforator.  The success of the
practice has been,  in  this country, as well as abroad, confirmed in
many instances ; yet the popular feeling respecting it, will lead the
practitioner, before having recourse to the measure,  to strengthen
his individual opinion,  by that of  some other  experienced accou-
cheur,  where it can conveniently be attained.  Dr. James  has fur-
nished  us with  a valuable paper  on this subject, in the first volume
of the Eclectic  Repertory ; and in a communication published in the
third volume of the Medico-Chirurgical Transactions of London, Dr.
Merriman has laid  down certain rules and cautions in  adopting the
practice that deserve to be extensively known.   I shall here insert
them :
   1st.  As the primary object is to preserve the life of the child, the
operation should never be undertaken till  seven  complete months of
utero-gestation have elapsed ; ;;nd if the pelvis of the mother be not
too much contracted to allow of it, the delay of another fortnight
will give a greater  chance to the child of surviving the birth..  2d.
Thepractice should  never be adopted, till experience has decidedly 
ON DIFFICULT LABOURS.
413
                         SECTION XI.

       Oh the Section of the Symphysis of the Ossa Pubis.
   It was before observed,  that an opinion of the gradual and
spontaneous separation of the symphisis of the ossa pubis, previ-
ously to the commencement of labour, ha*d generally prevailed,
(See chap.  i.  sect. 3.) though  some  had  denied  both the fact
itself, and the advantages that were supposed to accrue from the
separation,  if it were actually made.  With a strong persuasion
or conviction, however, of those advantages at the time of partu-
rition, some rude and evidently dangerous attempts were former-
ly made with very awkward but powerful instruments, to promote
or increase the separation beyond ijs common degree; but the
practice,  probably never  frequent, had,  for very many years,
fallen into total disuse, and was almost forgotten.   Latterly this
idea has been resumed, and among others, Camper, a  celebrated
anatomist and  professor at  Groningen, in order to try the effect
of the separation, and discover its consequences,  had, in living
animals, divided the  symphysis, without much  apparent injury,
either when it was divided, or at any future time.   But in the
proved, that the  mother is  incapable of bearing a full-grown fcetus
alive.  3d.  It is sometimes  necessary to have recourse to the per-
forator in first labours, though there may be no  considerable distor-
tion of the pelvis ;  therefore, the use of this instrument in a former
labour, is not alone to be considered as a justification of the practice.
4th. The operation ought not to be performed when the patient is
labouring under any dangerous disease.  5th.  If, upon examination,
before the operation is performed, it should be discovered that the
presentation is preternatural, it might be advisable to defer it for a
few days, as it is possible that a spontaneous alteration of the child's
position may take place ; particularly if the presentation  be of the
superior  extremities.  6th.  The utmost care should be  taken to
guard against an attack of shivering and fever,  which  seems to be
no unusual  consequence of  this attempt to induce uterine action,
and has often  proved  destructive  to the child, as well as alarming
with regard to  the  mother.    The peculiar  circumstances under
which  the operation is performed,  and the habit of body of the pa-
tient, will determine the accoucheur either to adopt a strictly anti-
phlogistic plan, or  to exhibit opiates or antispasmodics and tonics.
7th. In order to give every  possible chance for  preserving the life
of the child, it will be prudent  to have a  wet nurse in readiness,
that the  child may have a plentiful supply of breast-milk, from the
very hour of its birth.  Lastly, a regard to his own character should
determine the accoucheur,  not  to perform  this operation unless some
other respectable practitioner has seen the patient, and has acknowledged
the operation as advisable.  F.] 
414
INTRODUCTION TO MIDWIFERY.
year 1777, M. Sigault, a surgeon at Paris, first performed this
operation on the human subject, in  the time of labour, the pa-
tient recovering, and the life of the child being preserved ; though
it is not clear from the context, that the  operation was,  in that
case, absolutely necessary.   Some credit might have  been due to
M.  Sigault for the spirit of enterprise which suggested the opera-
tion, and for his  resolution  in  performing it; but the  applause
given to  him by many of the faculty at Paris, (though,  if I mis-
take not, the Royal Academy  refused to give any testimony of
their approbation,) and by the nation at large, was  beyond all
measure extravagant; a medal was struck to perpetuate the fact,
and there could scarcely have been  greater exultation  and  tri-
umph, had he invented a method by which the whole human race
should, in future, have been universally freed from the pains and
dangers of parturition  The influence of vanity was,  at least, as
strongly  marked in these proceedings, as the dictates  of humani-
ty,  and far  more than the  encouragement of science; so that
the  steps taken to aggrandize  the merits of the operation,  then
supported only by a single fact, and the reputation  of the sur-
geon  who performed it, were too hastily and too enthusiastic,
not to raise  a suspicion of error or deceit  in the estimate of the
operation, or in the account given of it.  But the conduct of the
French extended its  influence  on the Continent, where the ope-
ration  has been several times performed with  various  success.
  Immediately after the accounts of the operation were brought
into this country, wishing,  as a matter of duty, to  understand
the  ground of the subject, I had a conference with the late Mr.
John  Hunter, in which  we considered  its  first principle, its
safety; and after the most serious consideration, it was agreed,
that if the utility could be proved, there appeared from the struc-
ture of the parts, or  from the  injury they were likely to sustain
by  the mere  section  of the symphysis, no sufficient  objection
against performing it.  Of its real utility it was however impos-
sible  to decide, before many experiments had been made on the
dead body, to ascertain the degree of enlargement of the capacity
of the pelvis, well formed or distorted, which could be thereby
obtained.  Such  experiments  were soon made, and  their result
published by the late Dr. William Hunter; and these proved on
the whole, that in extreme  or  great  degrees of distortion of the
pelvis, the advantage to be  gained was wholly insufficient to al-
low the head of a child to pass without lessening its bulk ;  and in
small  degrees of distortion, that the operation was unnecessary,
such cases admitting of relief by less desperate methods.   They
proved, moreover, that irreparable injury  would be done by at-
tempts to increase the common advantages gained by the section
of  the symphisis, by straining or tearing  asunder the ligaments
which connect the ossa innominata to the sacrum, and to the soft 
ON DIFFICULT LABOURS.             415
parts contained in the pelvis, particularly to the bladder.  For the
reasons advanced by Dr. Hunter, the operation was never (ex-
cepting in one unhappy case) performed in this country, and so
perfectly were the minds of men satisfied of its impropriety  and
insufficiency, that I do not believe the section  of the symphysis
ever came into contemplation in any  one case of difficult parturi-
tion, with any of the gentlemen who practise midwifery in this ci-
ty.  But as  accounts of the operation were  frequently brought
from the continent, and as active measures were pursued for sup-
porting the celebrity with which it  had  been first brought into
notice, Dr. William Osborn examined all the cases then published,
stated with precision the little advantages gained, the injuries oc-
casioned, and the general result of  the  operation, and proved,
both by facts and arguments,  the cruelty  and futility of it,  in a
very sensible essay, first written professedly on the subject.
   Here the matter might for ever have rested,  but in writing on
the practice  of midwifery, as well as any other art,  it seems ne-
cessary to record not only  what has  been proposed and done
with success, but the trials that have been made of things propo-
sed, though unsuccessful, and on what circumstances  the want of
success depended ;  otherwise there might be  at different times a
repetition of the same trials  and of the same misfortunes.  Per-
fectly convinced though  I am  of the impropriety of  this opera-
tion, and hoping that no attempts will ever  be again  made to
bring it into  practice, it seemed necessary to  give this short ac-
count of it, and I cannot refrain from making the  following ob-
servations.
   It is proved in the first place, that some enlargement of the
capacity of the pelvis is actually obtained by dividing the sym-
physis of the  ossa pubis.
   Secondly,  That the evils, which have followed this operation,
have been very  much occasioned by its being performed unskil-
fully :  or by  injudicious endeavours to increase that enlargement
of the capacity of the pelvis  beyond the degree, which naturally
follows the division of the symphysis.
   Thirdly, That many  women who have undergone this opera-
tion have recovered; though of those who  recovered, many suf-
fered very serious complaints for a long time, or for the remain-
der of their lives.
   Fourthly,  That some children were born living when this ope-
ration was performed.
   We may  therefore presume to say,  that if  a case could be so
precisely marked, that  there should  only be  a deficiency of just
so much space as would be supplied by  the simple division of
the symphysis,  the  operation might in  that particular case be
considered.
   We may  also say, that this operation is not so certainly  fatal 
416          INTRODUCTION TO MIDWIFERY.
to those women  on whom it may be performed, as the Cesarean
operation ; nor so certainly destructive of children as that of les-
sening the head.
   We may then  be allowed to suppose a case, and such a one is
more than possible, for it did  actually  happen, in which a person
of very high rank, the life of whose child might be of the greatest
public importance, could not be delivered, without the destruc-
tion  of the child, or her child be preserved but by  the Cesarean
operation  at the expense or great hazard of her life;  and that she
through human frailty might refuse  to  submit to the Cesarean
operation; yet the great  interests and  policy of the nation might
forbid the destruction  of the  child.   Of course both the mother
and child would  be inevitably lost; and such was really the case.
Should such a case occur, which,  as  I said before, is more than
possible, then the section  of the symphysis of the ossa pubis might
be proposed and performed, as it would in some measure meet
both their interests; being less horrid  to the woman  than the Ce-
sarean operation, and  instead  of adding to the danger, give some
chance of preserving the life of the child.
   But, from the statement of this case, or any thing before ad-
vanced, I hope it will not  be concluded, that 1 mean to insinuate a
wish, or to advance an argument, in favour of this operation, in
the cases for which it was originally proposed, or any other which,
to my apprehension, can be imagined. 
*N DIFFICULT  LABOURS.              417
                     CHAPTER XIII.

                         SECTION I.

                ON THE CESAREAN OPERATION.

  This  operation  is to be  performed  by making an incision,
first through the integuments of the abdomen, and then into the
uterus,  for  the purpose of extracting a child therein contained.
In cases of extra-uterine children, an incision, for the purpose of
extracting a child contained in the cavity of the abdomen, under
various circumstances,  has  been called the Cesarean operation;
but in the importance and consequence of these two operations,
there  is an evident and  very great difference.
  It has been supposed  by some writers, that a name was given
to this operation from a circumstance common to it, and every
other in surgery, in which a knife was used, (a cceso matris utero;)
by others, that it had its name from the extraordinary courage
of the person on whom, or  by whom, it was  performed; but it
was more generally explained by the imagined qualities and rank
of the persons whose lives are said to have been preserved by it.
These, and  their descendants, according  to Pliny, were  called
Caesars, as those born with the feet foremost were called Agrip-
pae ; or when there  were twins, and only  one  was born  living,
Vopisci; and when they were left-handed, Scaevolae.  It seems
not to have  been thought respectful, that men,  who in the course
of their lives proved extraordinary, should  have been presum-
ed even to come  into the world in the  common  way.*  But it
is well known, that the name of Caesar,  though differently spelt,
was not conferred on that great man, or the family who bore it,
from  the manner of his birth, but was  derived from quite ano-
ther source.f  Nor do any of the very  ancient writers in  medi-
cine take notice of this  operation,  and we cannot  suspect they
were so negligent as to  have omitted  the description of it, or so
ignorant as  to be unacquainted with it, when, in all probability,
had it been performed,  they  would  have been the very persons
consulted and employed to perform it.
   Pliny, who lived in the time of Vespasian, is the first author,
  * Auspicatius, enecta parente, gignuntur, sicut Scipio Africanus
prior natus, primusque Cassarum a  caeso matris utero dictus.  Plin.
Histor. Nat. Lib. vii. cap. ix.
  t The mother of Caesar, according to Suetonius, was living at the
time of her son's expedition into Britain, so that she must have sur-
vived the operation many years, had it been performed upon her.
                           * 53 
418
INTRODUCTION TO MIDWIFERY.
as far as I know, who mentions this operation;  but he speaks of
it with reference to those who  lived  before his time, and his ac-
count does not give much satisfaction.  " Rousset, who was  a
strong advocate for the operation, wrote professedly on the sub-
ject in  1581.   Bauhin, in the appendix to Rousset, dated 1588,
gives the  following case: Eliz.  Alespachen had this operation
performed upon her by her husband, who was a gelder of cattle
at Siegenhausen, in Germany, in the beginning of the sixteenth
century.   She had several children born afterwards in the natu-
ral way.
   Pare and Guillemeau wrote against the operation.
   M. Simon wrote two papers on the subject in the first volume
of the memoirs of the Royal Academy.
   Heister and many others  have written  on the  subject; but
Weideman of  Dussendorp, in his Thesis, has given an account
of all the cases of this operation, which have been  recorded be-
fore  his time, and the result of them.  Bat the records of this ope-
ration have been imperfectly preserved even in modern times,
though they are certainly few in number. Yet, from the context
of the cases recorded, it appears that some have been  misrepre-
sented,  and that some are fictitious,  and were alleged to answer
other purposes, as was the supposed one of lady Jane Seymour,
to stamp a  character of greater cruelty, than even he deserved,
on Henry the Eighth;* and that others are related with a change
of circumstances, so as  to appear different, though they were in
fact  the same.  From a detestation of the apparent cruelty of this
operation, from a doubt  of its necessity, or of the advantages
to be derived  from it, from the destructive event which was to
be expected, or from some other cause, it was never performed,
or even  proposed, or hardly spoken  of, in this  country, till
within these  few years.   But at present we have well authen-
ticated accounts of more than ten cases in  which the operation
has been performed, under the direction of, and by, men of un-
exceptionable abilities ; and these may be esteemed sufficient to
enable us to  form a judgment of the  general benefits to be
derived  from the operation,  as well as the manner in which
it ought to be performed, and of its constant or probable con-
sequences.

                         SECTION II.
   By the first writers on this subject, many circumstances are re-
 cited, which were supposed to render this operation necessary,
 some respecting the parent, others the child.  Of the first  kind
  * See Rapin,  Vol. viii. p. 17. and the note annexed to it.  Also
the preface to this Introduction. 
ON DIFFICULT LABOURS.
419
were extreme smallness or distortion of the pelvis; the straight-
ness or closure of the natural passages, from cicatrices, adhesion,
or any other cause; the rigidity of the parts from  old  age, or
their imperfection from youth;  almost every  cause  of a  difficult
labour, when extreme in its degree,  has been  mentioned as a jus-
tifiable reason for proposing or performing this operation. Those
which  respected the child, not only related to its comparative size,
but to  its position also ; and,  on this  occasion, twins, and even
monsters, which  there was no wish  to  preserve, have been men-
tioned.  But, whatever  was the existing cause, it appears that
there must have been a full conviction on the mind of the person
who proposed this  operation, of the impossibility of delivering
the patient by  any other means.  Some  writers have,  indeed,
spoken of this operation, not with a view to its absolute necessity,
but its eligibility, or as deserving preference to other methods  of
delivery which might be practicable.  Such writers have  not met
with general approbation, but their influence  has  been too great;
for, in  several of the histories of the cases recorded, we find some
circumstance which proves that the operation was not necessary,
or that the grounds on which it ought to be performed were not
well understood. The ideal glory of the operation has, perhaps,
had its influence in  France, where it has certainly been often pro-
posed, and sometimes, without  a doubt, performed unnecessarily,
and in some other  parts of the continent, of which the  account
of the following case, given me by  the late Dr. James Ford, is a
proof: While he was attending the hospitals at Paris, a woman
was laid upon the table for the purpose of performing this  ope-
ration, and while the surgeons were preparing for  it, the child
was expelled by the natural pains.  No  other principle but that
of necessity can certainly be admitted  as a justification of this
operation; that is, whenever it is proposed  there shall be  no other
way or method by which the life, either of the mother or  child,
can possibly be preserved; and the impossibility shall  be  con-
firmed, not by the opinion of one, but as many competent judges
as can be procured.   If such satisfaction  could be given, I should
then consider this operation justified by every principle  of reli-
gion, and the laws  of civil society, upon as good and decisive au-
thority as any other  operation which  we  never  hesitate to per-
form ;  because, it submits to the general principle of practice, by
giving us a chance of preserving a life  which must  otherwise be
inevitably lost.
                         SECTION III.
   Three general situations have been stated in which it has been
supposed that the Cesarean operation might be necessary.*
* See Bonet. Sepulch. Anatom. 
420          INTRODUCTION TO MIDWIFERY.
   1. When the parent was dead, and the child living.
   2. When the child was dead, and the parent living.
   3. When both the parent and child were living.
   With respect to the first  situation,  when the parent  is dead,
and the child living, there cannot be any debate; because, with-
out giving pain, or incurring auy one inconvenience, an attempt
is made by this operation to preserve thejlife of a child, which, if
it be not performed, must soon  and inevitably  perish.*
   With respect to the second  situation, as in almost every case
in which  the operation has been performed in this country, the
parent has died, but the lives of many of the children have been
preserved, the operation holds  forth,  as its principal advantage,
which is a very important  one, the hope of preserving the life of
the child; the chance of preserving  the parent being much les-
sened,  at  least not  improved, by an operation so full of danger.
It  will  therefore, I think,  be generally acknowledged,  that the
operation ought not,  or scarcely ever,  to  be performed upon a
living mother, when there is proof, or good reason for believing,
that the child  is dead.
   The third  is the sole statement  attended with any difficulty;
and being the only case which, strictly speaking, comprehends,
in  its true sense, the Cesarean operation, it might lead to a com-
parative estimation between  the life  of  the child and that of the
parent.   But the common sense of mankind being agreed in the
general principles  adopted and pursued throughout this work, of
its ever being our duty, in the first place, to preserve the lives of
both the parent and child; in  the second, to  preserve the life of
the parent; and in the third, that of the child, which have been
on various occasions  inculcated and applied, will point out the
general line of conduct we  ought to follow, according to the exi-
gence of every case which may occur in practice.
   Without regard  to the state  of the child,  this operation has
also been proposed for our consideration under circumstances
which  relate to the mother  alone.
   1. W7hen she was living.
   2. When she was dead.
   Some have been of opinion, that this  operation ought never to
be performed  on the living  subject.   Impressed, perhaps, with the
dread of the operation, they did not distinguish between necessity
and eligibility, and therefore  wished  to  abolish it altogether,
  * [Many cases are mentioned, more particularly by writers on me-
dical jurisprudence, in which,  after the death of the mother, the
child has been extracted alive  by hysterotomy,  and has survived.
Mullerus published a dissertation on tins extraordinary circumstance,
entitled De Partu Hominis post Mortem Matris, in which he gave an
account of several instances of this kind.   F.] 
ON DIFFICULT LABOURS.
421
which would be an unnecessary and improper general rule.  But
if it were to be performed only when the patient was dead, more
particularly if we were to wait for her death, as the only proper
time of performing it, it would generally be fruitless.   For I do
not find any instance of a living  child extracted by this operation
after the death of the mother, unless the child escaped  by  the
same stroke as that  which proved fatal to the mother, of which
the accounts seem to be  almost  fabulous, or merely  accidental.
Yet, as in cases of  women  dying  instantly in convulsions,  he-
morrhages,  rupture of the uterus, or other rapid diseases or acci-
dents, at different periods of pregnancy, or of a labour, it  is pos-
sible for a living child to be extracted after the death of the mo-
ther, by speedily performing this operation ;  and as no harm can
possibly result from the operation, supposing ourselves disappoint-
ed,  no reasonable objections  can be  made to our performing it
under such  circumstances. In some countries, the laws forbid the
interment of any woman who  may have died during pregnancy,
before the child shall have been taken away.  A prohibition to
bury the living with  the dead  is  the spirit of such laws.

                         SECTION IV.
   If it be admitted,  that necessity alone can justify the Cesarean
operation, we are next to inquire into the  causes and proofs of
such necessity.
   Many of the causes which  have been specified by writers as
producing a necessity of performing this operation, are certainly
unequal to so  great an effect.   The size of a child, however large,
unless the pelvis  be  at the same time very much distorted;  nor
any untoward position of the child ; nor twins; nor monsters;
nor the closing or straitness of the soft parts, can ever compel us
to the necessity of performing this operation;  because we know
from reason and experience,  that  difficulties arising from such
causes admit of relief by less desperate and dangerous means. It
may be asserted in general  terms,  that there  is only one  case
which can justify our proposing or performing this operation on
the living subject, and that is, such an extreme degree of distor-
tion of the pelvis as  renders the  extraction of the child, in  its pre-
sent stale,  when  diminished  in  its  bulk,  or even reduced into
pieces,  absolutely impracticable; in other words,  when the situa-
tion is such, that the woman  would in all probability die, if this
operation were not  performed.   But it is also true, if any other
cause could be proved to exist which  produced the same  imprac-
ticability, then the operation would be equally  requisite and jus-
tifiable.  (See the Fourth Order  of Difficult  Labours, Sect, iii.)
   To make a precise statement of that degree of distortion  or con-
sequent diminution of the cavity  of the pelvis, which might re-
quire this operation, is not perhaps  possible in  the  living  sub- 
422
INTRODUCTION  TO MIDWIFERY.
ject.  The natural space of the cavity of a well-formed pelvis,
from the ossa pubis to the sacrum, is about four  inches and a
half, and in  some subjects rather more; and the heads of chil-
dren at the time of birth bear a  general relative proportion to
this space.  But living children  of the full size have  been born
frequently by the natural efforts, when the space was presumed to
be less than four inches ; and if the children were small, when it
did not exceed three inches : and  we may judge  that the head of
a child is capable of  being reduced by compression one third of
its natural bulk, without destruction of its parts, or any perma-
nent injury.   But  should the capacity of  the pelvis be reduced
under three inches, we have no good reason to expect a  living
child, of its full growth, however small, to pass through it, either
naturally, or by  the  assistance of art; though  the head  of one
that is dead,  especially if it be putrefied, or one much below the
common size, may be pressed through a pelvis of about those di-
mensions, even without artificial assistance.  Should the capacity
of a pelvis not exceed, according to our judgment,  two inches
and a half, then the head of a child, unless the contents be eva-
cuated, cannot pass or be extracted through it.  But if the ca-
vity of the pelvis be so far closed, that it should in any part very
little exceed  one  inch,  of which examples have sometimes oc-
curred, we might then presume that the head of a child, though
it were reduced to the least possible size, could not be extracted
through it;  and then the necessity and propriety of performing
the Cesarean operation  would  be allowed, whatever aversion
 we might have to it, especially if we had reason  to think that the
 child was living, or to conclude that it was not dead.
   These general positions every  person engaged in practice will
 bear in his mind, in all cases  of difficulty arising from distortion
 of the pelvis.  But he must also recollect, that the  remaining
 space  of the cavity of the pelvis, in cases of distortion,  will be
 differently estimated  by different persons,  and cannot be  ascer-
 tained with  precision by any one during the life of the patient.
 He will also remember, that the kinds of distortion are as various
 as the  degrees, and that the cavity,  though much diminished in
 one part, may be far less altered in  another; and that even one
 side of the  pelvis may  measure two inches or more, when the
 other is scarcely equal to one; which consideration may make a
 change in our judgment and conduct, of the kind of operation re-
 quired,  widely different,  as  well as in the operation itself.   It
 should also  be remembered, that the size of children  at the time
 of birth, and the firmness of the bones, together with the com-
 pactness of  their union  with  each other, are  very different, and
 might add to, or lessen, the difficulty of a birth, whether  natural
 or artificial.  After a mature consideration of the whole matter, I
 am, however, of opinion, that no rule of sufficient authority to guide 
ON DIFFICULT LABOURS.
423
 us strictly in any particular case, can be formed from such calcula-
 tions only, and that our conduct is not to be governed wholly by
 them; but by the reflections of common sense working in a reason-
 able mind,  stored with the knowledge of such calculations,  and of
 many other collateral circumstances relating to the mother or child,
 which it is impossible  to enumerate or describe, so as to  render
 them applicable to any particular case.   Beside the positive dis-
 tortion of the pelvis,  there  is, in some  crooked people,  such a
 twist or projection of the last lumbar  vertebra over the superior
 aperture, as to increase, or constitute an obstacle to the passage
 of the head, less tractable  and as insurmountable as any degree
 of distortion existing in the bones of the pelvis. Of this, the case
 of the woman on whom the operation was lately  performed at
 Manchester, is an example, and her case seems to have fully jus-
 tified the operation.
   I  cannot, however, relinquish the subject without mentioning
 another statement of this question which has often employed my
 mind, especially when  the subject has  been actually passing be-
 fore me.   Suppose,  for instance, a woman married, who was so
 unfortunately framed, that she could  not possibly bear a living
 child by any method  hitherto known.   The first time of her being
 in labour, no reasonable  person could  hesitate to afford relief at
 the expense of her child; even a second  and third trial might be
justifiable to ascertain the fact of the impossibility.   But it might
 be doubted  in morals, whether children should be begotten under
 such circumstances, or whether, after a  solemn determination that
 she cannot bear a living child, a woman be entitled to have  a
 number of children destroyed for the purpose of saving her life;
 or whether, after  many trials, she ought not to submit to the Ce-
 sarean operation, as  the means of preserving the child at the risk
 of her own life, if she will  submit to have  children under such
 circumstances.  This thing ought to be considered.  Moreover,
 when it has been  ascertained that women could not possibly bear
 living  children naturally, or on any assistance which art can af-
 ford, and  the great end of marriage has been frustrated, some
 have determined on  a voluntary separation from their husbands,
 from a sense of the moral turpitude of  conceiving children with-
 out the chance of bringing  them living into the world.   But the
 law of the land has  afforded  no remedy for the case, though, as
 this fact sometimes  admits of unquestionable proof, it would not
 be difficult to adjust  terms of separation between a husband and
 wife thus circumstanced, so cautiously,  that they should not be
 abused, yet without the imputation  of criminality to either party;
 and many evils might be thereby prevented, and some great ad-
 vantages obtained.
   I take this opportunity of making another observation on this
 subject, which  affords  but gloomy  reflections.  Formerly, the 
424         INTRODUCTION TO MIDWIFERY.
cases in which the Cesarean operation could come to be consider-
ed were almost universally confined to cities, or very large towns,
where the customs and manners of life most frequently occasion-
ed with every other kind of decrepitude, distortions of the  pel-
vis, and all its consequences.  But within these few years, from
the general dissemination of  manufactures, especially that of cot-
ton, over many parts of the country, these evils have  become
much more frequent;  and as the children employed in them are
obliged to stand, or are confined to one posture  for many hours
together, before their bones have acquired  sufficient  stability to
support them, many have become deformed.  To boys it may be
a great evil and mortification to have bandy legs, yet  this  does
not prevent their becoming fathers;  but girls, under the same
circumstances, must often be precluded from being mothers; nor
could they go through the  process of parturition without infinite
suffering and  danger.  It, therefore, deserves consideration,  both
as it is of great political importance, and as a most interesting
case of humanity, whether some means  cannot be contrived by
which such misfortunes may be prevented.

                         section v.
  In almost  every case in which  the  Cesarean operation has
been performed in this country, the patients have died.  It  may
be of use to inquire, whether  their  death were occasioned by any
disease, with which they were afflicted before the time of labour ;
or were the consequence of the state to  which they  were reduced
from  the occurrences  of labour, before  the operation was per-
formed ; or were the inevitable consequence of the operation.  In
cases of death occasioned  by wounds,  the  following order in
which the danger is produced may be observed  : first, from con-
vulsions, or  immediate loss  of blood ; secondly, from inflamma-
tion ; thirdly, from gangrene; fourthly, from excessive or long
continued suppuration, under which the patietit becomes hectic.
Though almost  all the  patients, on whom this operation has
been performed, died, their death  happened at different periods :
but not one died, either while the operation was performing,  or
immediately after it.   No convulsions were brought on by  inci-
sions; nor does  it appear, that any of them  sunk  through the
loss of blood  accompanying  or succeeding the operation.  Some
died within twelve, others at the end of twenty-four hours, and a
few died on the  third day after the operation.   If we may judge
of the cause of the patient's death by the time of  her  dying, it
might be said, that the death  of those who failed within twenty-
four hours, was probably owing, not to the operation alone, but
to the violence of this,  combined with that of  the  previous dis-
ease ;  but when  they  survived twenty-four or  forty-eight hours,
then their death might be attributed  to  the succeeding inflam- 
ON DIFFICULT LABOURS.
425
mation, in a body predisposed to disease.  If we had the liberty
of selecting a patient on whom to try the merits of this operation,
we  certainly should not choose one who was either very much dis-
torted, or who had the mollities ossium,  or  who was evidently
under the influence  of some dangerous disease, or who had been
several days  in  labour; because the event must very much de-
pend upon her state at the time when the  operation was per-
formed.
  It is not my intention, by this kind of investigation, to lessen
the general aversion to this operation when  it can be avoided ;
but 1 believe we cannot fall  into error by conforming to such
conclusions as  these.   Every  woman, for whom the Cesarean
operation can be proposed to be performed,  will probably die;
and should any one survive, her recovery might rather be con-
sidered as an escape, than as a recovery  to be expected, though
there is always a probable  chance of saving the life of a child.
But as such  an escape may happen  in any case,  in which the
operation might be performed, we  may  and  ought to esteem
every case which can  come before us, as  the individual case  in
which a happy event is to be expected.   These conclusions will
lead us  to the principle of necessity  as the  sole justification  of
this operation, and urge us,  when we  do perform it, and as far  as
it may be in our power, to select  the most eligible time; and
from every motive to  exert  all our judgment and skill  for the
service of the patient, as if  we were  certain  she  would survive.
This operation can seldom be required, and will of course never
be performed on the opinion or judgment of any one person, un-
less  in some  case of great and urgent necessity;  and a concur-
rence of  opinions will  afford the best security against its being
performed unnecessarily; and if it were  to  be  presumed by a
subsequent measurement of the pelvis, and a new consideration
of all the circumstances, that it ever had been performed without
such necessity, that  would prove only that the operation had been
abused, and not serve as a valid argument against its use  when
such necessity really existed.

                        SECTION VI.
  Having never performed  the Cesarean  operation,  nor seen it
performed, 1 offer the description of the case  related in the fourth
volume of the Medical Observations  and  Inquiries,  as the best
example which has been recorded.   The operation was perform-
ed by Mr. Thomson, one of the surgeons of the  London Hospi-
tal.*
  * It is remarkable that the oldest physician or surgeon in London
could not recollect a case of this operation, or had heard it spoken
                             54 
426
INTRODUCTION TO MIDWIFERY.
   " A table being prepared, the patient was placed upon it, lying
 on her back, her head being supported by pillows, and her legs
 hanging down.   The belly appeared prominent  chiefly on the
 right side, the protuberance of the  uterus extending but about
 two or three fingers breadth on the left of the linea alba.   There
 was no difficulty, therefore, to  determine where the incision was
 to be made.
   " Accordingly,  about  a hand's  breadth from the navel on the
 right side, I began the incision in  a  longitudinal direction, and
 continued it about six inches in  length, the middle of which was
 nearly  opposite to the navel;  the skin and  adipose membrane
 being cut through on the outer edge  of  the rectus muscle.   I
 carefully made an  incision through  the tendinous expansion of
 the  abdominal muscles and the peritonaeum,  sufficient to  intro-
 duce the fore finger of my left  hand, when, with a curved  knife,
 conducted on my finger, an opening was made into the cavity of
 the abdomen, and  the uterus exposed.
  " The uterus appearing very solid to the touch, it was appre-
 hended by some gentlemen, that the placenta  might perhaps ad-
 here to that part of the uterus which  lay bare, and which might
 considerably obstruct the removal  of the  child,  or endanger a
 hemorrhage.   With precaution, therefore,  an aperture was  made
 in the centre of the uterus sufficient to admit my finger, with which
 conducting the curved knife, I dilated the wound in the uterus,
 upwards and downwards, to the full extent  of the outward wound.
  " The placenta, which actually  adhered to this part of the
 uterus,  easily gave way,  and receded as  my finger advanced in
 making the opening.
  " The placenta and membranes immediately began to protrude.
 Dr. Ford  at this juncture slipping  his hand into'the uterus, while
 the  sides were kept asunder, brought  forth the child by the feet,
 and immediately afterwards the placenta and membranes were
 extracted  with the greatest ease.  Dr. Ford  took upon h.iself
 the management of the child and separation of the umbilical cord,
 and in a few minutes the  child cried strongly.
  " The uterus being disburdened of its contents, and contract-
 ing amazingly fast, the omentum and bowels began to protrude;
 Mr.  John  Hunter was so obliging  as to  assist me in  retaining
them within the belly, whilst I cleansed away the grumous blood
of by their predecessors ;  yet that two cases, in the same street,
should have  occurred to one gentleman,  within a very short space
of time.
  For a more full and'accurate account of all the circumstances re-
lative to this  operation, see a work lately  published by Dr. Hull, an
eminent physician at Manchester. 
ON DIFFICULT LABOURS.
427
(which was small in quantity) and made the gastroraphy or  su-
ture of the belly.
   " I made four sutures at nearly equal distances from each other,
and about one inch and a half from the edge of the lips of  the
wound.
   " The ligatures being double, pieces of linen spread with com-
mon plaster, and rolled up in the form of bolsters, or compresses,
were applied between them, after the manner of the quilled suture,
and the wound  was thereby  brought  into and retained  in close
contact; and lint and  a common pledget being applied,  finished
the operation.   This woman died about five hours after the ope-
ration.*
   * A uniform fatality, with  a solitary exception, seems  to have
 marked every attempt at the  Cesarean operation hitherto made in
 Great Britain ; and the pride of English surgery has yielded a silent
 deference to the success of the operation in the hands of their conti-
 nental  rivals.  Of nearly thirty cases in England, one only proved
 fortunate ;  while, on the continent, out  of two hundred and thirty
 cases, according to Baudelocque, one hundred and  thirty-nine  wo-
 men  recovered.   The too great exhaustion of the constitutional
 powers of the mother arising from the late period at which the ope-
 ration has been determined  upon, may  be assigned  as  among  the
 causes of its unfavourable termination in Great Britain.  In  the case
 last performed in England, and  published by Mr. Wood in the Medi-
 co-Chirurgical Transactions of London,  the  patient died of exten-
 sive peritoneal inflammation, the rapidity of which termination  wa9
 hastened by the injury the  external organs had received in frequent
 and  imprudent examination, and this in  a debilitated system labour-
 ing under malacosteon.
   Very recently a most instructive history of a case ha9 been com-
 municated to the public by  Dr. Albers :  the operation was perform-
 ed by Dr. Locher of Zurich, Switzerland, and the lives both of mo-
 ther and child were preserved.  I shall present an abstract of the
 account: The patient was a small woman, who, in early life, had been
 afflicted by rickets to a very great degree, and had attained the  age
 of eight years before  she  could  stand  without assistance.   It was
 very  evident she was unable to bring forth a child.   After  she had
 been in labour many hours, the application of the forceps had been
 made in vain; this and other circumstances led to a consultation on two
 indications, viz. the perforation  and the cutting of the child, particu-
 larly as its head presented itself; or, secondly, the Cesarean opera-
 tion.
   " There was, against the former indication," says  Dr. Locher,
 (Medico-Chirurgical Transactions, vol. 9.) " the very probable im-
 possibility of introducing the instruments requisite for the perfora-
tion ; the unavoidable lesion of the parts adjacent, if the introduction
were  found practicable ; and  particularly the assertion of the mo- 
428
INTRODUCTION TO MIDWIFERY.
ther, that still she felt the motion and quickness of the child, which
likewise was distinctly perceptible to our hands, when  laid on the
mother s body.   We, therefore, determined on  the second, under
the conviction, that by it the life of one at least might be saved.
   " The nearest relations who were present, were apprized of the
determination, and, with their approbation, the woman in labojr like-
wise informed of it.  After a few objections, she also soon came  to
a determination, and  we prepared  our apparatus, and  every thing
that was necessary.   After the injection of  a  glyster there followed
stools and urine.
   " At five o'clock in the evening the operation was performed in the
presence of several  professional gentlemen, and in the manner fol-
lowing.   I  caused the patient to be placed  in the position  usual  in
herniotomy, in which the weight of  the  abdomen  presses more
against the  diaphragm, and ordered her to be properly secured.
   " Having performed before a similar operation, I was induced to
make the incision immediately upon the  linea alba, as not a single
blood-vessel of  any  importance had been injured on that occasion.
Immediately beneath the  navel, the skin was pinched up into a fold,
both it and the adipose membrane cut through, and the cut continu-
ed downwards to the length of from eight to ten inches.   The sphere
of the uterus, now appearing, extended  the fat edges of the incision,
so that there appeared a considerable vaulted  surface of the  womb.
There protruded also a portion of small intestine, which, however,
was easily kept back by  means of linen anointed  with fat.  In order
not to cut through the uterus exactly in a place where the placenta
might accidentally be situated, and thus excite a violent bleeding, I
chose a somewhat uneven part of its surface, and there made a lit-
tle incision, so that I could introduce the index of the left hand, to
serve as a guide for the progress of the  knife.   The uterus was then
cut open from six to eight inches along the finger.  Immediately the
child presented itself, together with its membranes, yet without any
water.  The hemorrhage till then was  a mere nothing.   The near-
est part of  the child was an arm.  This, as  there was room enough,
was disengaged  first from  the uterus, and after it carefully one part
of the child after the other in succession, and, last of all, the head.
Already, before the head  was freed from the womb, the infant moved
its limbs, and on the development of the head, to the greatest joy of
the mother and all the attendants, it proved its life by loud cries, so
that not the least thing was required to remove the asphyxia of the
infant.  The funiculus umbilicalis was severed, and the child entrust-
ed to the waiting woman  to  be  cleansed.   In  the right side of the
womb was  found the placenta, which,  lying almost quite free, was
now taken  away.  At this period a violent  bleeding arose from the
bottom of the uterus.  The ligature of a blood-vessel, or any other
styptical application, was not to be thought  of under these circum-
stances ; but the blood was quickly  absorbed from  the uterus  by
means of a sponge, in order to leave  the organ to its own contrac-
tion, and to close the wound of the integuments.   To this I was the
more induced, as a couple of years previously, on dissection, I had 
                  ON DIFFICULT LABOURS.              429

found in a person, who died eight days after the operation, the uterus
quite contracted, and the labia of the wound in the same almost en-
tirely united.  I, therefore, joined the external teguments with tave   ,
sutures, covered the wound  with lint, and applied some adnes,v®
plasters, confining  the whole with a couple of compresses and a broad
bandage.                                        xt •  i_   c • *•
   " The mother was now transferred to her bed.   Neither lamting,
nor any other accident, befel her.   On the contrary, her joy and ea-
gerness at seeing her child,  and having it by  her, were  so powerful,
that even whilst dressing the wounds we had much trouble to keep
her easy.  She now was presented with some good broth, which she
ate with great appetite, and the  greatest tranquillity was enjoined
her.   An emulsion with laud,  liquid. Syd. and Tinct.  Cinnam.  was
then prescribed for her.
   " At ten o'clock in the evening I again paid the patient a visit.  She
found herself quite tranquil, and complained  of nothing  but a burning
in the wound.  During  the  night, she  enjoyed,  at intervals, quiet
sleep, which had  often  been interrupted  by the cries  of the child,
 for which reason it was removed to another room.  The blood be-
 gan to flow from the vagina.   The urine passed in the  natural way.
 In the morning she took her coffee. The belly appeared considera-
 bly protuberant and tense,  but not very  painful to the  touch.   The
 superior part of the dressing,  which was soaked with a serous fluid,
 was removed, and a new one very loosely applied ; the internal re-
 medies  were continued, externally a friction of ol. anod. with hyos-
 ciamus and  laudanum applied, and emollient clysters  administered.
 The  second day passed well,  and without any material  complaints,
 and also the third.  The lochia flowed in due order, the belly grew
 softer ;  yet, in spite of repeated  clysters,  no stool  ensued.  The
 tongue became foul, for which reason, besides the former emulsion,
 a decoction of tamarinds with  salts and  manna was given.   On ac-
 count of the exuberant evacuation of serum, and the appearance of
 suppuration with smell, the  external dressing was daily renewed ; as
 for  the rest, the real  dressing was kept on.  In the night, between
 the third and fourth day, abundance of flatulencies were developed,
  followed  toward the morning by a stool.  The  belly was soft, the
  patient, upon the whole,  well, quiet, and  without fever.   On the
  right side of the belly appeared the greatest tension,  and the great-
  est pain was felt.   Every thing was continued as before.
    " On the fourth in the morning, she found herself very well. From
   the very moment of the operation till now, partly for the sake of ob-
   servation, partly in case of any immediate  help  being requisite, one
   of my  assistants had remained with her.   Toward noon 1 was  sent
   for, and requested to repair  as  quickly as possible to the patient,
   who was apparently dying.   The better I  had left the patient in the
   morning, the more unexpected and strange was this message to me.
     " On my arrival, 1, indeed, found the patient in a very indifferent
   situation.  She experienced violent convulsive  spasms, particularly
   in her head.  She  had a staring look,  cold  extremities, cold  sweat
   on her brow ; the urine had been discharged involuntarily.  She re-
   collected nobody, could neither speak nor  swallow : her breath was 
430
INTRODUCTION TO MIDWIFERY.
    much oppressed, the pube low and contracted ;  her complexion sa-
    turate ; yet the  abdomen was  not much collapsed, which must have
f   been the case had  gangrene existed.  None of the persons present
    were aware of the cause, that in such a promising prognosis, had oc-
    casioned a change so sudden and so distressing to the physician.  She
    had still taken some soup, and  then said, she felt  very squeamish.
    Under these circumstances, and the patient not being able to swallow.
    I had no means left but to make her smell volatile essences, and apply
    antispasmodic frictions, especially about  the neck, to remove the
    convulsions and spasms, and restore the faculty of swallowing.  This
    was effected after the space of  a couple of hours, when an analeptic
    mixture was given to her  every hour, and  every two hours, some
   musk.  Clysters and external  frictions, especially  round  the neck,
   were continued.   Toward evening, the evil, rather than increase,
   seemed to abate.   Her speech  returned, her warmth became equal,
   the skin  moist, the pulse softer.  Her weakness  was very great.
   Being almost fully convinced, that too great exertion in speaking, and
   too great joy, in short, that passions had brought on this alteration, I
   prohibited all visits, and left the patient without any other company
   but two persons to watch her.  The night was passed with varying
   symptoms, yet more tranquilly, and without fever or other accidents.
   The clysters look effect, recollection returned, the belly became ra-
   ther more distended and painful.   On my visit in the morning of the
   fifth day, she called out to me, " I have suffered severely; but at
   present I find myself very well."   Most of the symptoms, indeed,
   had ceased,  so that the highest state of quietude  was once  more to
   be recommended.  The belly was soft; on the application of clysters
   there followed evacuations ; the natural complexion  and warmth re-
   turned ; she felt  much ease and  comfort from changing beds.   As
   there appeared a  violent suppuration, or rather a copious oozing of
   a strong smelling serum, the dressing, all but the ligatures, was taken
   off, and put on again loosely in the same manner.  The ligatures all
   were in the  best order, and duly kept the labia of the wounds toge-
   ther.   The  interior treatment was not at all changed.  From this
   time the patient daily improved  ; every  day  the external  dressing
   was renewed.  The belly collapsed  visibly ; the uterus contracted
   more and more ; the lochia were discharged as they ought;  the milk
   appeared in the breasts, though but in a small quantity, so  that this
   concern was entirely left to nature.
     " On the tenth day after the operation, the  ligatures began to form
   small pustules, and  thence give way.   Two of them, which were
   the least tied, were removed, and the three remaining ones were left
   to hold as well as they could.  The internal remedies were still con-
   tinued,  and  especially  the clysters.   Four or five  days later, the
   three other ligatures were likewise taken off, and the wound treated
   as a simple sore, and kept together, and  supported by adhesive plas-
   ters only.   Good  fare, wine, &c. aided her strength.
     " The same treatment was continued till the 20th of March ; no
   disastrous accident occurred.  All the functions of the body went
   on in the best order.  The wound was cleaned and healed conside-
   rably from day to day.   The patient remained without all medicines 
ON DIFFICULT LABOURS.
431
till the 27th,  when, on account of the uncleanhness of the  prim*
viae, some purging medicine was thought proper for a couple ot days.
The patient now daily spent a few hours out of bed, began to work,
mind her child, and in short,  except from the sore, which was not
very large, suffered not the least inconvenience.  In the seventn
week after the operation, the menses re-appeared, though somewhat
irregularly; since  that they have  occurred at due periods.   Irom
day to day  her strength improved, so that, in the eighth  week, she
transacted most of  her domestic concerns, and never more was con-
fined to her bed during the day.  In the twelfth week she paid me
a visit in the best health, at  my house,  together with her admirably
handsome and stout babe.
  " It  appears surprising, that in the middle of this  wound,  a little
spot, not exceeding two or three lines in length and breadth, in spite
of all the remedies applied for the purpose, will  not  close,  and
when thought to be healed up will  again open, yet without any de-
triment to the mother.   The child, now eight months old, mayhke-
wise be exhibited as a pattern of health, strength, and beauty,  i .J 
432
INTRODUCTION TO MIDWIFERY.
CHAPTER XIV.
CLASS  THIRD.
PRETERNATURAL LABOURS.
                TWO  ORDERS.

                  FIRST ORDER.

  Presentation of the Breech, or Inferior Extremities.

                  SECOND ORDER.

Presentation of the Shoulder, or Superior Extremities.
                         SECTION I.
  The technical terms which are used to specify  all the other
classes of labour, relate to some circumstance in which the mo-
ther is wholly  or  chiefly concerned.   But the  term preter-
natural applies  merely to the position of the  child, and this
kind of labour  may occur in a woman in perfect  health, when
all the changes incidental to the state  of parturition are made
in the most favourable manner, and in  whom there is the best
possible formation.  In short, there may be no deviation or ir-
regularity of any kind, excepting only that the head of the child
does not present.   Should the presentation of any  other part
but the head be combined with a hemorrhage, or any other cir-
cumstance of dangerous  importance, either  to the  mother or
child, the title  of  preternatural would" be generally lost, and
the labour referred to some other class.
  The presentation of children at the  time of  birth may be of
three kinds : first,   with the head ; secondly, with the breech,
or inferior extremities ; thirdly,  with the shoulder, or superior
extremities.  With the first of these,  the  labour, as far as re-
lates to the position of the child, is called natural; but with the
two latter,  preternatural.   Preternatural labours have been
subdivided, by  systematic writers,  into a much  greater number
and variety ; but as all distinctions are to  be made and  regard-
ed according to their utility in practice, and as no possible ad-
vantage can be derived  from their  multiplication,  but on the
contrary  much confusion, it will be found expedient to abide
by  these distinctions only.  For though there may be a differ-
ence, in one respect or other, in every labour of  this kind, and 
ON PRETERNATURAL LABOURS.          433
of course a necessity  for  some change  in  our conduct,  yet
notice cannot possibly be taken of every alteration, and these
distinctions will be  found sufficient for all the general purposes
of practice.
  Great pains have been taken to  discover  the causes of the
preternatural presentation of children, and with the best inten-
tion;  that of pointing out the errors and irregularities by which
they were supposed to be produced, in order to prevent them.
On this part of our  subject, though there have been many  dif-
ferent opinions,  I think  it  has been generally presumed, that
preternatural presentations happen more  frequently to women
in the lower ranks of life, than to those in a more  affluent con-
dition :  the  accidents  and  exertions,  to which the former are
chiefly liable, being considered as the causes.  Before we con-
sent to this inference, it would, however, be necessary to exa-
mine  into the truth of the assertion.  1 believe it has never
been  satisfactorily proved, that preternatural presentations are
really more  common in the lower, than in the higher, ranks of
life ;  the number of the former being, almost beyond any com-
parison, greater than those  of the latter.  No station of life is
exempt from these presentations, though they  rarely  occur in
any, especially those of the second order; and it is wonderful,
that those women who have had such accidents, at different pe-
riods  of uterogestation, as would be deemed  most likely to pro-
duce  them, have escaped them.  But though preternatural pre-
sentations seldom occur when they are dreaded and expected,
it is remarkable  that some women are  peculiarly subject to
them ; not once only, which might be considered  as  the effect
of some accident, but exactly to the same presentation, whether
of the superior or inferior extremities, in several successive or
alternate labours.   It seems doubtful, therefore,  whether we
ought not to exclude accidents as the common causes  of these
presentations, and search for the real cause in some more intri-
cate circumstance ; such as the manner after which the ovum
may pass out of the ovarium into the uterus ; some peculiarity
in the form  of the cavity of the uterus, abdomen, or pelvis ; in
the quantity of the  waters of the ovum at some  certain  lime
of pregnancy; in the  circumvolution of the funis round  the
haunches or lower part of the back of the child ; or perhaps
in the insertion of the funis into the abdomen  of the child, which
is not in all cases confined to one  precise part, but admits of
considerable variety.
                        SECTION II.
           On the signs of preternatural presentations.
  Several presumptive signs of the preternatural presentation of
children have been mentioned; such as  an  unequal  distention
                             55 
434          INTRODUCTION TO MIDWIFERY.

of the abdomen during pregnancy; some peculiarity in the mo-
tion of the child ; the sudden rising of the child, when the woman
is in a recumbent  position,  so  as to affect her stomach, or to
incommode her breathing, which is not unusual when the child
presents with the breech;  the slow progress of the first stage of
a labour ; the early rupture of the membranes^ or the elongated
form which the membranes containing the wafers assume, while
the os  uteri is dilating.   But  these symptoms and appearances
will be found very uncertain; nor can we confide in any mark
or indication,  until we are able to feel  and distinguish  the part
which really presents. It will often be in our power, before the
membranes are broken,  to discover that the presentation of the
child  is preternatural; and  sometimes, though not constantly,
to say  what the presenting part is.  But  when the membranes
are broken, a small share of skill and circumspection will enable
us to determine what that part is ; especially if we have accustom-
ed ourselves to handle the limbs of new-born children.   By its
roundness and firmness, the head  may be  distinguished from
any other part; the breech may be known by the cleft between
the buttocks, by the  parts of generation, and by the discharge
of the meconium ;  though the last circumstance does not always
happen  even  when the  breech  presents,  till  the labour is far
advanced, and sometimes occurs likewise in presentations of the
head.   The foot may be known by the heel  and the want  of a
thumb ; and the hand by its flatness, by the thumb and the length
of the fingers.  In some cases I have found the  hands  and the
feet lying together; but  this cannot create much embarrassment
to an intelligent practitioner; though there is  reason to believe
that an error or mistake in judging a superior to be an inferior
extremity, has  sometimes been productive of mischief.   1 do not
mention the marks by which the  back, belly or  side might be
distinguished,  because these, properly speaking, never constitute
the presenting  part;  that is,  though they may sometimes be felt,
they never advance foremost into  the pelvis in the commence-
ment, at least, of a  labour.

                        SECTION III.

  On the management of the first order of preternatural labours.

  In the first order of preternatural labours may be included the
presentation of the  breech, of a hip, of the knees, and of one or
both legs.
  When  a labour  is so  far  advanced that the os uteri  is fully
dilated, if no part of the child can be felt, it  will be prudent to
watch carefully when the membranes break, as there is a chance
that the presentation  may be of such a kind as may require the
child to be immediately turned ; and if no part of the child can 
ON PRETERNATURAL LABOURS.
435
be  felt,  by a common examination, after the membranes  are
broken, it  will be justifiable to acertain the presentation  by the
introduction of the hand.   Should the head or inferior extremi-
ties, be found to present, the hand may be withdrawn, and we
may suffer the labour to proceed without any further interposi-
tion ; but if it should be that kind of presentation which requires
the child to be turned, we shall have an opportunity of perform-
ing the operation  before there is any contraction of the uterus
sufficient to obstruct the delivery.
  In the first order of preternatural labours, two very different
methods of practice have been recommended.  By the favourers
of the first  method, we have been directed, as soon as the presen-
tation was discovered, whatever might be the state of the  labour
to dilate the parts, then to pass the hand into the uterus,  and to
bring down the feet of the child.   Or if these were originally in
the vagina, to grasp  them  and extract  the child expeditiously,
making the labour wholly artificial,  without waiting for the na-
tural expansion of the parts, or for the expulsatory action of the
uterus.   Would it not argue a want of humanity, say they, to
leave the woman for many hours, perhaps a whole day, or even
a longer time, in pain and anxiety, when we have the power of
extracting the child in a very short space of time, by which the vi-
olence of the  pain would be lessened, or its duration at least very
much  shortened ?  Others, on the contrary, have considered  this
practice  as founded on a  vulgar  and pernicious error,  which
makes no distinction between the slowness and danger of a labour.
These have considered the presentation of the breech and infe-
rior extremities as generally  safe; and have taught  us,  that
such cases ought to be, and with security may  be, left to the
efforts of the constitution, no kind of assistance being required,
in the first stage of the labour; the mother, at least, certainly
not suffering more than in a presentation of the  head, and  the
chance of preserving the life of the child being by this cau-
tious proceeding much improved.   Of the superior advantage
of these two  methods, it is only possible to judge, by the gene-
ral  event of cases of  this kind.   If this  should prove, which I
believe is scarcely to be doubted, that less injury  is done to  the
mother, and that there is  a better  chance of saving the life of
the child, by suffering it to be expelled, than by artificial deli-
very, there can be no hesitation to which of the  methods pre-
ference should be given; for the charge of want of humanity
cannot be properly laid against a proceeding which most fre-
quently terminates happy for both.
  From the  manner  of expressing the directions for the intro-
duction of the hand, for the purpose of bringing down the feet,
in  presentations  of  the  breech, or inferior extremities,  we
might conclude, that  it was always to be done with much ease.
• 
436
INTRODUCTION TO MIDWIFERY.
But  on trial,  it is often  found very difficult,  or impossible,
without the exertion of very  great force; and  when  this is
done, or if the feet were originally in  the vagina, though the
first  part of the extraction  might be easy,  we should,  in the
progress, find an increasing difficulty,  which would  bring the
life of the child into great hazard.   The thighs would advance
more slowly than the legs, and the breech than the  thighs ; there
would be some delay with  the body, then with the shoulders,
and lastly, when the arms were brought down, with the head.
These little difficulties and embarrassments, separately consi-
dered, may not be of  much consequence, but collectively, they
occasion great hazard of a compression of the funis continuing
long enough to bring the life of the child into danger, if not  to
destroy it; and this can only be prevented by a  hurry  in 'he
extraction of the  child, which  may lacerate or do  much in-
jury  to the parts of the  mother.   If, on the contrary, we suf-
fer the breech, especially with  the legs turned upwards, to be
expelled by the natural pains, the distention of the pa:ts there-
by occasioned  is so ample, that the body and head follow im-
mediately, or may be readily extracted.  In cases of the pre-
sentation of the breech or inferior extremities, it is, therefore,
now  established as a general rule,  with  men of the  first abili-
ties and reputation, to suffer the breech to be expelled by the
pains, and then to give such assistance as the exigencies of the
case may require.
   In every labour, in  the progress of which we cannot feel the
head  of the child  presenting, or do feel any other  part, the
membranes being unbroken, we must be particularly careful on
no account to break them  prematurely,  that is, before  the  os
uteri  is fully dilated  ; because, whatever the presentation may
be, the child is in no danger till  the waters are discharged ; and
a natural opening or expansion of the parts is always preferable
to an artificial dilatation, however carefully made.   But when
the membranes break spontaneously  before the os uteri is di-
lated, and we can discover the presentation of the breech or in-
ferior extremities, it is proper to leave the dilatation to be com-
pleted by the natural  efforts, though it will  be  effected  slowly
and more awkwardly, than if it was done by the volume of the
membranes containing the waters, or by the head of the child.
The  presentation of the breech is sometimes so untoward that
the scrotum and penis of the child intervene, and are the parts
which are pressed upon the os  uteri during  its dilatation.   In
consequence of this pressure, which is in some cases unavoida-
ble,  those parts become prodigiously  tumefied, and  when the
child is born, appear in a gangrenous state.  In a  few instances
I have known portion of the  skin of the scrotum or prepuce 
«
              ON PRETERNATURAL LABOURS.          43T

slough away, but by the assiduous use of fomentations and ca-
taplasms, farther mischief has always been prevented.
  Though it may be proper, and is perfectly agreeable to the
most respectable modern practice,  to leave the child to be ex-
pelled by  the pains, when the  breech or inferior  extremities
present, unless the circumstances of the mother should require
more speedy assistance :  yet this resignation  of the labour is
only  to be  understood as  proper, till the breech is expelled
through the  external parts, giving time for their dilatation, and
guarding them with as much care  as when the head presents.
For after that time, as there is  great danger of the child being
destroyed by the compression of the funis, though, perhaps, of
no longer continuance, the labour must  be accelerated, but
with skill and judgment.   That compression is also to be les-
sened, or other injury prevented,  by gently drawing  the funis
somewhat lower down, in such a manner that it may never be
on the full stretch.  In  some cases, however,  after the expul-
sion  of the breech,  the continuance of the pulsation in the funis
very satisfactorily proves, that  no  compression of importance
has taken place; the child of course being in no danger,  there
is no occasion to hurry the delivery.
  When the breech or inferior extremities have passed through
the external parts, great attention is to be given also to the po-
sition which the child bears with regard to the mother. What-
ever that might be, the child  would be extracted  with  equal
ease  till we  came to the head;  but if the face were turned to-
ward the pubes  of the mother, the head  could  not  then be
brought away, or its  position conveniently changed, without
much additional difficulty.  As soon, therefore, as the breech is
expelled, if  the back of the child be not turned toward the ab-
domen of the mother, it will be necessary that the practitioner,
while he is extracting, or the body descending, should give such
an inclination to it, that  when it is wholly extracted,  the hind
part  of the head of the child may be turned toward the pubes,
though not  with a  sudden motion or violence, lest the  child
should be thereby injured or destroyed.   The directions given
on this occasion are, that we should make the turn beyond the
mere reduction of the back of the child to  the pubes,  and then
revert it, to  a certain degree, by what may be supposed equiva-
lent to a quarter turn.  But  such rules being very complex,
are more apt to create confusion than to be of use, and are not
founded on  practical observation, but on  an erroneous opinion,
that  the head of the child could be  extracted only, or most com-
modiously, when the face of the child was turned exactly toward
the os sacrum of the mother.  Whereas it is  now well known,
that  the head of the child will pass  through the pelvis, with one
ear to the pubes,  and the other to the sacrum, or in  different 

438          INTRODUCTION  TO MIDWIFERY.

degrees of diagonal direction regarding  the cavity, and that it
is not found to proceed precisely alike in any two labours.
  When the child is brought down as low as  the shoulders, it
has been esteemed by some as a  very injudicious practice, to
bring down the arms of the child ; these being turned along  the
head, preventing,  in their opinion, that  contraction  of the os
uteri round the neck of the child, which would be an impediment
to its complete deliverance.  Others have considered this step as
absolutely necessary in  all cases, the arms,  according to them,
occupying a portion of that space  which would be filled up by
the head only.   If  the  extraction  of the head  with the arms
turned up, be on trial found tolerably easy, there is clearly no
occasion to bring them  down;  but if the head  should remain
fixed in such a manner as to  resist the force which  we think can
be  safely or prudently exerted,  then the arms ought to  be suc-
cessively brought down, but very circumspectly, lest they should
be fractured or dislocated, or come along with a  flirt, or so sud-
den a motion as to endanger the laceration of the perinaeum. Nor
is there afterwards found to have been  any reason for appre-
hending inconvenience  from  the spasmodic contraction of the
cervix or os uteri round  the neck of the child; at least it is not
produced by this cause so commonly  as  by hurrying  the first
part of the delivery.
   When the arms are brought down, should there be much  dif-
ficulty or delay in the extraction of the head, it will be  of great
use to pass the fore-finger of the left hand into  the mouth of the
child, and to press down the jaw towards the breast, (but not to
pull by  it) in order to change the  position  of the head, which
may be easily done, and the extraction be thereby much facilita-
ted.*  But of this  difficulty we shall speak more fully when we
consider the inconveniences produced in this kind of labour, by
the distortion of the pelvis.
   In the extraction of the child,  the  body  is  converted into  a
lever or instrument for that purpose, and this will act in different
cases, or different periods of the same case,  with greater advan-
tage, by changing the direction in which it is used.  Accord-
ingly, in some cases, greater  progress is  made  by acting alter-
nately from side to side, and in  others from  the pubes to the sa-
crum, or in the opposite direction; and that way  is to be pur-
  *  [% placing one or two of the fingers upon the face of the child,
just below the orbits of the eyes, we have a much greater, and pro-
bably safer purchase, to enable us to change the position of the
head.  Accoucheurs do not seem to reflect upon  the condition  of
the lower jaw;, and  that it may,  at this  early state, be  easily bro-
ken or dislocated.   F.] 
ON PRETERNATURAL LABOURS.
439
sued, in which we are sensible of obtaining  the  greatest advan-
tage with the least violence.   When the head is passing through
the external parts, these may be supported with the fingers or
palm of the left hand spread over the perinaeum, while we are
extracting with the right. As the  head advances, the body must
be turned more and more toward  the  pubes, and we must finish
the operation very  deliberately, or the parts  will be lacerated;
an evil  rendered sometimes by precipitation and  imprudent ma-
nagement of almost as much importance as  the loss  of the child
or  mother:  occasioning, at  least,  great misery and distress
through the future part of the patient's life.
   Though children presenting with the breech are commonly ex-
pelled by the efforts of the parent, it must sometimes  happen that
these fail to produce their proper  effect, and the assistance of art
is required.  But assistance is not to be given till, by the  failure
of  the efforts,  it is proved to be  absolutely necessary; that is,
when having given full scope  and due  time to  the efforts,  they
are proved  to be unequal at the expulsion of die child.  When-
ever artificial assistance is  given  in  these cases, it  ought to be
perfectly consistent with the safety of the mother, and if possible,
with that of the child, which must be considered and  treated as
if we were certain  it was,  and would be born,  living.  When,
therefore, we are satisfied and convinced  that  the mother is un-
able to  expel her child presenting  with the breech, if the inferior
extremities cannot be readily brought down, it  will be proper, by
hooking one or more fingers in the groin, to try whether we can-
not give such an addition to the force of the pains, as may be
sufficient to extract without injuring  it; that is, either by hurt-
ing the  neck or joint  of the thigh bone, or  by separating the
bones of which the pelvis is then  composed.  Should  this force,
though continued for some time, be proved unequal to the pur-
pose, it will be found expedient to pass a garter,  a piece of broad
tape or ribband, over one or both thighs, one of which is usual-
ly pressed before the other, as the case will allow;  and then ta-
king both the ends of the ligature in the same hand, we shall  have
the opportunity of exerting great  power, should  it  be  required,
with less detriment to the  mother or child than by  any other
means; with much convenience at  the  same time to ourselves,
and generally  with success.   But if the  breech should  be so
high, that the  feet* cannot  be  brought down, nor  the ligature
passed, or its power be insufficient, of which I  do  not recollect
an instance, and the necessity of delivering the mother should be
 urgent, then a blunt hook or the  crotchet must be fixed over the
thigh or in  the groin of the child,  and  we must manage as in
other cases of extreme  difficulty and danger, as the circumstances
 will allow, but perhaps without following any general rule, and
 without regard to the child. 
540
INTRODUCTION TO MIDWIFERY.
  It has been said,  that children presenting with the breech are
generally born alive, and  some writers have even considered this
presentation of the inferior extremities as  natural, and preferable
to that of the head;  because assistance could  be  more  readily
given when  it was  required.   It  is true that the children will
usually be born  alive if they be small, or  of a common size, and
the true dimensions of the pelvis be unimpaired ;  or if this pre-
sentation occur  to those who have  before had children, the parts
yielding kindly  and with facility according to the progress of the
labour, and  this be not by any cause retarded or interrupted.
But  if it should  be a first labour, and the children large, or some-
what beyond the common size, and the labour tardy, or  require
much assistance from art, they will be more frequently born dead,
inconsequence  of  some casual  but destructive pressure of the
funis,  before the breech is expelled, or afterward ;  and with re-
gard to presentation, that which is most common  is certainly,
for that reason, to  be esteemed natural.  I have considered one
child in three of those born with these  presentations, to be still
born.*
   In all cases, in which the child is expelled or  extracted by the
breech, or inferior  extremities, the placenta is usually managed
without difficulty or danger, and it is generally, though  not al-
ways,  excluded more easily, and in a shorter time  than after a
natural birth.

                         SECTION iv.

On the distinctions  of the Second Order  of Preternatural Labours.

   In the second order of  preternatural  labours, the presentation
of the shoulder,  or one or  both  arms, may be included; and
whichsoever  of these is the presenting part, there is a necessity of
turning the child, and delivering by the feet, for the interest both
of the  mother and child.  In the management of presentations of
this  kind, there is always less difficulty if both arms present, than
if there should be but one  arm; it will therefore be  necessary to
speak  only of the presentation of a single  arm.
   In ancient times  it was the  custom,  in every kind of labour,
except those in which  the  head originally presented, to endea-
vour to return the part presenting,  and  to bring down  the  head;
and if this were found  impracticable,  direcions  were given to
  * [I have reason to believe, that this calculation is too unfavoura-
ble.   According  to M. Portal, a celebrated accoucheur of Paris,
eighty children out of one  hundred in breech  presentations will be
born alive.   In his opinion, though the labour proceed more slow-
ly, yet it is not more difficult.   F.J 
ON PRETERNATURAL LABOURS.          441
bring the child away by the feet, or in any manner its situation
would allow,  or the exigencies of the case might require.   But
we learn from iEtius, who lived probably about the fifth century,
that Philomenes, whose writings, except those preserved by iEtius,
are now lost, discovered  a method  of turning  and delivering
children by the feet, in all unnatural presentations ; and this me-
thod, with  some alterations and  improvements in the operation,
has been practised ever since his time, and considered as the only
one by which the child, presenting preternaturally, could be ex-
tracted, and the life of the mother preserved.   But many  years
ago,  it was my good fortune to discover,  that in some of the
worst kinds of preternatural labours, those in which the assistance
of art is sometimes found to be insufficient and often unsafe, the
powers of the constitution, if not impeded in their operation, are
capable of expelling the child, with perfect safety to the  mother,
and without any additional danger to the child.   Of the  manner
in which this delivery is accomplished by the natural pains, we
shall speak in its proper place.
   Though the necessity for turning  children  and delivering by
the feet, in this second order of preternatural labours, be univer-
sally acknowledged, yet the circumstances  of those women who
suffer them are exceedingly different.   With the view of prevent-
ing or lessening the embarrassment of the practitioner, it is requi-
site, therefore, to make several distinctions,  and we will say, that
it may be necessary to turn the child,
   First, When the os uteri being fully dilated, and the membrane's
unbroken, a superior extremity is felt through them ; or immedi-
ately  upon the rupture of the membranes  and the discharge of
the waters, before there is any return of the pains, or any import-
ant contraction of the uterus round the body of the child.
   Secondly,  When the  membranes break in the beginning  of
labour, the os uteri being  very  little dilated, perhaps scarcely
in a sufficient degree to allow a hand or an arm of the child  to
pass through it, and but just enough to discover the kind of pre-
sentation.
   Thirdly, When the os uteri is fully dilated, the membranes hav-
ing been long broken, and  the  uterus strongly contracted round
the body of the child, which is strictly fixed at the superior aper-
ture of the pelvis.
   Fourthly,  When under any of these circumstances,  there is a
great disproportion between the size of the child and the dimen-
sions  of the pelvis.
   Under each of these distinctions, a variety of other objects
may require the attention of the practitioner, but of every one
of these it  is impossible  to take notice in  the  description  of
any stated  case, as  no two labours ever were in all points exact-
ly similar.
56 
442
INTRODUCTION  TO MIDWIFERY.
  In the practice of every art, some advantages must  remain be-
yond the power of any doctrine to teach or describe, all rules ap-
plying io irencril. and  practice to particular, cases.  These ad-
vantages can only be obtained by the cultivation of our own minds,
by experience, and by the acquisition of that dexterity, which fre-
quent exercise must give to our hands.

                        SECTION  v.
  It is proper, in the first place, to speak of the method of turn-
ing children in those cases which come under the first distinction,
the management of them being more easy and simple, as there is
only one object which demands our care, that is, to change the
position of the child.
   Whenever there is a necessity of turning the child, the pa-
tient is to be placed in the same situation as in a natural birth,
upon her left side,  with her knees  drawn up,  across the bed,
and as near to the  edge of it as possible.  There  have  been
many different  directions and opinions  respecting the advanta-
ges of particular situations, especially that of turning the patient
upon her knees.  But as our aim, in the choice  or preference
of these,  is merely to obtain the free and most convenient use
of our own hands, the position of the child remaining the  same,
however the woman may be placed, the common situation will
generally be found most  convenient.   Yet as that situation
which suits one practitioner may be awkward to another, and
as in the course of  the  operation changes  may be expedient,
every practitioner  must make them when they appear necessa-
ry to himself.   To many it is more convenient to turn with the-
left hand,  than with the right; and from the common position
 of the child, the former is often more commodious ; but every
 person will, of course, recommend that  in which he can act
 with most dexterity and advantage.
   Though in the case we are now supposing the os uteri may
 be fully dilated, it is possible, that the os externum  may be in a
 rigid and contracted state.  For the purpose  of dilating this,
 it will then be  necessary with the fingers of the right hand, re-
 duced into a conical form, to act with a semirotatory motion,
 and with some degree of pressure upon the sides,  and toward
 the perinaeum.   The artificial dilatation of all parts should be
 slowly made, and an imitation 61 the manner in which they are
 naturally dilated;  and we are not to be .satisfied  wih  such a
 degree of dilatation as will barely admit the hand into the vagi-
 na,  because the contraction round the  wrist or arm  would,  in
 some cases, be a hindrance in the subsequent parts of the ope-
 ration ; the dilatation should therefore be sufficient to allow of
 the unembarrassed use of the hand.
    When the hand is  passed through the os externum, it must 
ON PRETERNATURAL LABOURS.
443
be conducted slowly to the  os uteri, which we presume to be
fully or sufficiently dilated.
   If the membranes be unbroken, the hand may then be con-
ducted into the uterus,  and they will be  easily ruptured by
grasping them firmly, or by perforating them with a finger.
The hand must then be carried very deliberately along the sides,
thighs, and legs of the child, till we come to the feet.  If both
the feet should be lying together, we must grasp them in our
hand; but if they be at  a distance  from each other,  we may
commonly deliver with one foot without  much additional diffi-
culty ; though as in some particular positions we cannot always
turn the child, if it be large, by one foot, it is better to make it
a general rule to bring down  both feet together, when they are
in our power.
   Before we begin to extract, we must examine the limbs we
hold, and be  assured we do not mistake a hand for a foot.  The
feet, being held firmly in the hand, must then be brought with a
waving motion  slowly into the pelvis.  While we are withdraw-
ing the hand, the waters of the ovum flow away, and the uterus
being emptied by the evacuation of these, and by the extraction
of the  inferior extremities, we must wait  till it has contracted,
and on the accession of a pain, the feet must be brought lower,
till they are at length cleared through the os externum.   The
operation may then, in one sense, be said  to be completed, that
is, what was originally a presentation of the arm, is now become
that  of the feet, which considered as primary, might have been
left  to the efforts of  the constitution in the manner before de-
scribed.   But as no  person who had undergone the operation
of turning a  child, with  the expectation of a speedy delivery,
would  have patience to  wait  for the expulsion of the child  by
the natural pains, it is incumbent upon us to finish the delivery,
though there  is no occasion  for hurry; and violence would be
equally unnecessary and  improper.
   In the first place, then, observing the direction of the feet,
and knowing  if  the toes of the child be toward the abdomen of
the mother, that this  position  would  be unfavourable when the
head was to  be extracted, we must  gradually turn the body of
the child during its extraction, in  such a manner that the back
of the child may be placed toward the abdomen of the mother,
before  the head is brought into the pelvis.   It was before ob-
served, that this turn of the child has been described with use-
less intricacy, and in  a manner which can only serve to confuse
the practitioner, who will reap all the advantages to be gained
by any kind of turn, if he remember in general, that if the back
of the child be toward (he abdomen of the mother, the head will
pass more commodiously than  in any other direction.   The
opinion of the necessity of changing  the position of the child at 
4i4          INTRODUCTION TO  MIDWIFERY.

this time has been so strongly inculcated,  and so eagerly pur-
sued  that 1 have more than once  seen it attempted with such
a degree of force, as must have destroyed, or done very great
injury to the child, had it been living ; the operation being evi-
dently more dangerous, than the evil it was intended to remove.
Nor is this the only case in midwifery, in which the means, re-
commended for the purpose of preserving the life of the child,
are utterly inconsistent with its safety.
  When the  heels or back part of  the child  are turned  toward
the pubes, the feet wrapped up in  a cloth are to be  held firmly
about the ancles,  and when the pains come on, we must  extract
in a straight direction, or from side to side, or from the pubes to
the sacrum;  taking care that we do not by violence, or by too
large  a  sweep, run the risk of hurting the child, or of lacerating
the external parts of the mother.   In the interval between the
pains, we must rest, and in this manner proceed, assisting the ef-
forts of  the mother only  at the time of her making them,  and
not rendering the delivery wholly artificial.   When the breech of
the child is arrived at, and begins to distend  the external parts,
we must proceed  yet more slowly, giving time for their full dila-
tation, supporting and favouring any  part which may be immo-
derately distended, and  guiding the child in a proper direction,
by turning it toward the pubes as it advances.   The breech being
expelled, the funis soon  appears, and a small portion of it  must
be drawn forth to prevent its being upon the stretch. Then wrap-
ping a cloth  over the body of the child, which must be held as
close to the mother as it conveniently can, and calling for her vo-
luntary  exertions, the child is to be speedily extracted in  a man-
ner already described.*
  When both the arms are brought  down, if that be necessary, it
will be  of service to suffer the body of the child to rest upon the
left arm of the operator, his hand being spread under the breast,
with a finger turned  back over each shoulder.   His right  hand
is to be  laid in a  similar manner over the shoulders of the child,
and these positions will give him great advantage  in the  extrac-.
tion.    But  if the head should  not descend, the operator, with
his thumbs conducted into  the vagina, may press  the head from
the pubes to the sacrum ;  or pass the  fore-finger of his left hand
into the mouth of the child,  and extract as was before advised,
being still careful of the external parts, when the head is passing
through them.
  * When the life of a child was endangered by  continuing in this
situation, Dr. Pugh  advised the introduction of a properly  curved
air pipe into its mouth, but this I have never used. 
ON PRETERNATURAL LABOURS.          445
   Proper attention must be immediately paid to the child, and of
 the management of the placenta we are to speak hereafter.

                          SECTION  VI.
   In the second  distinction  it was  supposed, that together with
 the presentation of a superior extremity, there was at the time of
 the rupture of the membranes, very little dilatation of theos uteri,
 and some degree of contraction of the uterus round the  body of
 the child.
   The directions generally given on these occasions are, that as
 soon as the  presentation is ascertained, the  operator should sit
 down and dilate the os uteri  sufficiently to allow the introduction
 of the hand  ; which  should  then be passed  with  care and expe-
 dition into the uterus, in order to turn the child.  But some prac-
 titioners have judged it more proper to wait till the os uteri is di-
 lated  naturally, if that  be done in any reasonable time,  before
 any attempt is made to introduce the hand and  turn the child.
 As in every  case of the presentation of the superior extremities,
 there is a necessity of turning the child, the sooner the hand can
 be passed for that purpose, the more safe and easy in general will
 the operation be,  as there must of course be less contraction of
 the uterus round the body of the child.   But  as there is some ha-
 zard of doing mischief by every artificial  dilatation of the os
 uteri,  I believe it is better to  wait for the natural dilatation ; at
 least every attempt to dilate  by art should  be made with great
 caution, and only during the interval between the pains,  unless
 they be very feeble.   Yet we ought not to wait in these cases, till
 there is a complete and absolute dilatation of the os uteri; but al-
 ways to consider it as sufficiently dilated, when we presume it will
 readily admit the hand, and then the child should be turned without
 delay.
   If the external parts be rigid and contracted, they must be di-
 lated,  but without violence,  in the manner before directed; and
 the hand, being passed into the vagina,  must then be conducted
 into the uterus,  on that side of the pelvis where it can  be done
 with most convenience; because  that will lead  most  readily to
 the feet of the child.   It is generally better to conduct  the hand
 between the body of the child and the pubes, than between it and
 the sacrum, because in these  presentations the feet lie most com-
 monly  toward  the  abdomen of the  mother.   In every case
 which comes  under the present distinction, there is some degree
 of contraction of the  uterus round the body of the child, though
 trifling when compared with what occurs in  the cases to be de-
 scribed under the next section. If, therefore, we understand, and
 are able to perform the operation of turning the child,  in the ea-
 siest and most difficult cases, we  shall certainly be competent to
the management of all the  intermediate  ones; there  being in 
446
INTRODUCTION  TO MIDWIFERY.
these no new rules, which we are required to follow, but merely
an  accommodation of rules already known to the exigencies of
any individual case.

                         SECTION VII.

  Under the third distinction,  we are to presume,  that, together
with the presentation of a superior extremity,  there  is the worst
possible situation of the child in all other respects;  that is, toge-
ther with  an exceedingly  close contraction  of the  uterus round
the body of the child, the membranes having  been long broken,
and the waters discharged; to  which may, perhaps, be added
very strong pains.
   In this  case, supposing the difficulty  of turning  the child  as
great as it possibly can be, it will follow, that there is no occa-
sion for hurry  or violence, as we  can lose  nothing  by taking
time to deliberate and to act.  Before we proceed to the  opera-
tion of turning, it will  be therefore proper to repeat our examina-
tion, when we have considered the case, in order to  prevent any
error in the first decision we have made upon  the subject, and to
ascertain  the precise  position of the child; and to reflect also,
whether  by some previous management it may not be  in  our
power to  lessen the impediments to  the  operation,  and the par-
ticular as well as  general  state of the patient.  In either  of these
views there are only two  objects which can engage our atten-
tion ; the wrong  position of the child,  and the strong contrac-
tion of the uterus round its body.   The first  of these, in the ac-
count given of the cases which came under the first distinction,
was stated to be of little consequence ; that is, to be manageable
without difficulty, and to be frequently  void of danger either to
the mother or child.   The principal inconvenience will  then be
produced by the  contraction of the uterus, which it must be  our
duty to remove or lessen, before we attempt to perform the ope-
ration of turning the  child.
   The contraction of the uterus, under these circumstances, may
be of three kinds.  There is, first,  the  continued  or permanent
contraction, in consequence  of the  waters  having been  long
drained off, and which to a certain degree takes place in all ca-
ses, when there has been but little or no pain. This may, in fact,
be considered as the exercise of that iuherent disposition in the
uterus, by which its efforts are made to  recover its primitive size
 and situation, when any cause of distention is removed.   There
 is, secondly, the  occasional or  extraordinary contraction of the
 uterus, by which whatever is contained in its  cavity is ultimately
 to be expelled, which returas at intervals, and is so constantly at-
 tended with pain, that the terms pain and action  are  in such cases
 used synonymously.   Thirdly, there is an irregular action of the 
ON PRETERNATURAL LABOURS.
whole or some part of the uterus, which is sometimes unfavoura-
ble to the expulsion of its contents, which produces effects ac-
cording to its peculiarity, and this  is called spasmodic ; a general
term, not wrested from its common meaning, but appropriated
to every kind of morbid, irregular, or excessive action.  Now,
the  difficulty  and the danger  which attend the  operation of
turning a child,  proceed either  from  the extraordinary or irre-
gular action of the uterus ; and in  order to avoid those, as much
as possible, it will be proper to establish  it as a general rule, ne-
ver to attempt the operation of turning the child, while the pa-
tient has very strong pains.
  The consternation of friends, and the sufferings of the patient,
must necessarily raise a suspicion in her mind, that there is some-
thing unusual and dreadful iu her case, and the solicitude thence
arising will often increase the unavoidable inconveniences of her
situation.   The prudent and steady conduct of the practitioner
will, on such occasions, very  much  contribute  to remove the
fears of her attendants, and to give a composure to the mind of
the patient, which will be productive of the most happy effects.
If she should be much heated, it will be also proper to  take away
some blood, and to direct an  emollient clyster, for the  purpose of
emptying the rectum, and of softening  and soothing the parts,
which are in a  very irritable state.  Even the time employed in
these matters will give an opportunity for quieting the violent
agitation of the patient's mind.
  We are not at present in the  possession or  knowledge of any
specific medicine, upon which we can  depend,  for suppressing or
moderating the action of the uterus, when exerted unfavourably,
or  at  any improper time.   Almost the  only medicine  we ever
think of having  recourse to  on such  occasions,  is opium ; and
this, given in two or three times the usual quantity, will in many
cases of this kind  answer our expectations;  though  sometimes,
when given in a common dose, it  has a contrary effect,  and ex-
cites the  uterus to stronger  action;  it may also be  given  as a
clyster; or a pill composed of three grains  of purified opium
may be introduced and suffered  to remain in the rectum.  If the
opiate should fail to quiet the pains, and to compose the patient,
we must wait till the uterus is wearied, or ceases to act of its own
accord, or acts with less violence.   But if the opiate should pro-
duce tlie effect for which it was given,  it will be in about twenty
minutes* after its exhibition, when  we are to consider the calm or
disposition to sleep, as affording us the most  favourable oppor-
tunity for turning the child.
  *  [This is too soon :  the sedative effects of opium may be looked
for rather after the expiration of thirty or forty minutes.  F.] 
448
INTRODUCTION TO MIDWIFERY.
  Throughout the operation,  it is necessary  to  bear in  our
minds the distinctions made  between the different kinds of action
of the uterus.  The hand must  be  introduced slowly,  but  with
sufficient force to overcome  the continued or permanent contrac-
tion of the uterus,  or the operation  could never be  performed j
and the same may  be observed  of the irregular  or spasmodic ac-
tion,  but with perseverance rather  than violence.   But if we*
were to attempt to  overcome the extraordinary action, either the
hand  would be cramped, and we should be  unable to finish the
operation; or if we had power sufficient to overcome the  con-
traction  of the uterus, there would  be the greatest  hazard of its
being ruptured:  the  deduction is therefore  plain, that we ought
not to attempt to introduce  the hand, while the uterus is in ex-
traordinary  action.
  By the examination of the child's hand which presents, we
shall be able to distinguish whether it be the right or the  left ;
and, which is of more consequence, by its position to judge to
which part  of the uterus  the feet of the  child are directed.
For unless the arm or the body be unnaturally twisted, the palm
of the hand is always turned toward the inferior extremities  or
fore parts of the  child.
  It is in no case  necessary,  or in  any wise serviceable, to se-
parate the arm of the child, previous to the  introduction of the
hand of  the operator.    In some cases to which  I have  been
called, in which the  arm had been separated  at the shoulder, I
have found great inconvenience, there being much difficulty in
distinguishing between  the lacerated skin of the child, and the
part appertaining to the mother.   The presenting arm is never
an impediment of any consequence in the operation, and there-
fore,  in  my opinion, ought not to be  regarded, or on any ac-
count removed.
   It  sometimes happens, that the  introduction of our hand is
absolutely prevented by the shoulder of the child, jammed at
the superior aperture of the pelvis.  It will then be  necessary
to pass  the fore-finger and thumb of the right hand in the lorm
of a crutch, into the armpit of the child, pushing the shoulder
toward  the head and toward  the fundus of  the  uterus; at the
same time firmly  and steadily maintaining  the  advantage we
gain as  we proceed, till we have raised  the body sufficiently,  to
allow the admission  of  the hand into the uterus,  and to bring
the feet  somewhat nearer to us.
  * Qui enim urgentibus doloribus,  manus intus dare,  vel footum
dirigere, vel aliquod membrum replicare audent, iis evenire pote-.t,
ut uterus rumpatur, mulierque subita morte rapiatur, cujus partus
post obitum in ventre reperiri solet.—Platneri  Institutiouea Chirur-
gicae,p.  1040. 
ON PRETERNATURAL LABOURS.
449
  When we begin to make our attempts to introduce the hand
into the uterus, though the patient might be in a composed state,
the irritation thereby occasioned will disturb her, and  the ex-
traordinary  action of the uterus be brought on, which  will be
indicated by the consequent pain.   During  the continuance of
this action and pain, we must not proceed in our attempt, but
wait till they cease, laying our hand flattened in such a manner,
that no injury may be  done by our efforts, or by the action of
the uterus itself, upon any inequalities of the knuckles.   When
the action of  the uterus ceases, our attempts to  introduce our
hand  must be renewed, and steadily continued till the action
returns, when we must again rest.  Thus proceeding,  that is,
alternately resting and acting, we shall,  by repeated, and some-
times  long continued efforts,  at length safely accomplish the
purpose of conducting the hand so far into the uterus,  that we
shall be able to lay hold of the feet of the child.   In  some cases
our attempts to introduce the hand are very discouraging, as
we are sensible of little or no progress ; but the  hurry  or vio-
lence are never to be increased  on account of fhe greatness of
the difficulty.  We  must persevere, and be  persuaded,  that
prudent  attempts will not be fruitless, though they  may fail to
answer our expectations immediately ; as each  apparently un-
profitable attempt contributes at  least  to ther efficacy of a  suc-
ceeding one.
  The strongest contraction of the  uterus is sometimes at the
cervix, and when this is passed, ample room is afforded for the
discovery of the feet toward the fundus, without much  trouble.
But the contraction is very irregular, being in some cases in the
centre, or uniform  throughout; whilst  in others, the uterus is
drawn into lines, as if a cord had been  passed round it exter-
nally with great strength,  so as even to  be painful to the hand.
In some cases the uterus is also contracted into a globular, and
in others into a longitudinal form.  These different contractions
render some difference in our conduct necessary; but if we have
a true general idea of the  various kinds  of contractions, as be-
fore described, the little increase or peculiarity of difficulty will
be readily managed.   In  a globular contraction  of the uterus,
when our hand has passed beyond the cervix,  there will be no
trouble in coining at the feet, and the child will usually  be turn-
ed very easily ; but in the longitudinal contraction, the feet being
at a great distance,  there  is more difficulty, though  it is not al-
ways  necessary to go up to the fundus; for when we  come to the
knees, these being cautiously bent, the legs and feet will be  brought
down together.
  In whatever way  we  lay hold of the  feet,  we must  examine
them before we begin to  extract; for  though  one  arm be in the
vagina, the other may be high up in the uterus, and mistaken for
                             57 
450          INTRODUCTION TO MIDWIFERY.
a leg.  We must also remember that it is necessary  to extract
slowly ; for if we should attempt to hurry  the operation, the feet
may slip out of our hand, and  immediately recede  to the fundus
of the uterus, or to the part from which they were  brought,  and
lay us under the painful necessity of returning with the hand, to
bring them down again.  When we have laid hold  of the feet, if
we proceed slowly, the child commonly turns without much diffi-
culty.  But when the feet are brought into the pelvis, if the turn-
ing of the child be not perfected,  or cannot without much diffi-
culty, it will be of great use to fix the noose of a  garter or  rib-
band round one or both  ancles, which  may be conveniently  and
readily done by forming it upon  our wrist, and then  sliding it
with the fingers of the left hand, over the  right hand containing
the foot or feet, without quitting our hold of them ;  and dexterity
in forming and fixing this noose, may be of great use in the sub-
sequent parts of the  operation.  When the noose is  fixed  and
drawn tight round one or both the  ancles,  we may pull by both
the ends of it with either of our hands, at the same  time grasping
the feet and extracting with the other hand, till  they are brought
slowly through the external orifice.  Should there  be much diffi-
culty in the operation after the feet are brought low into the va-
gina, we may conclude, that  it is occasioned by the body of the
child being fixed  across the superior aperture of the pelvis.  To
remove this impediment, it may be necessary to take the two ends
of the noose into our right hand, and passing the finger and thumb
of the left in the form of a crutch into  the  armpit of the child, as
before described, we must extract with our right hand, and at the
same time raise the body of the child with the left, till the child is
disengaged, and there is sufficient room for the entrance of the
hips into the pelvis.  There will then be no further  difficulty, and
we must deliver as was directed under the  First Order of Preter-
natural Labours.

                        SECTION  VIII.
   Iii presentations of the superior extremities, when the waters
have been long discharged, and the shoulder of the child is jam-
med at the superior aperture of the pelvis,  it was said to be expe-
dient and necessary  to pass the finger and thumb in  the form of
a crutch, into the armpit of the child, in order to raise the body
toward its head, and toward the fundus of the uterus, till it  was
sufficiently moved out of our way to allow of the introduction of
the hand into the uterus.   But, in some cases, when  we are first
called, the shoulder  is so far  advanced into the pelvis, and the
action of the uterus is at the same time so strong, that it is impos-
sible to raise or move the child, which is so forcibly impelled by
the pains, as to overcome all  the  power  we are  able to exert.
This impossibility of turning the child had, to the  apprehension 
ON PRETERNATURAL LABOURS.
451
of writers and practitioners, left the woman without any hope of
relief.   But, in a case of this  kind  which occurred to me  about
twenty years ago, 1  was so fortunate  as to  observe, though it
was not in my power to pass my hand into the uterus to turn the
child, that by the mere effect of the action of the uterus, an evo-
lution took place, and the child was expelled by  the breech.
   Of the first testimonies that prove the possibility of this  evolu-
tion which I have called spontaneous,* the public  has long been
in possession.   The cases  in which  this has  happened, are now
become so numerous, and supported not only by many examples
in my own practice, but established by such unexceptionable  au-
thority in the practice of others, that there is no longer any room
to doubt of the possibility  of its happening, more than there is
of the most acknowledged fact in midwifery.  As to the manner
in which this evolution  takes place, I presume, that after the long
continued action of  the uterus, the body of the child is brought
into such a compacted  6tate, as to receive the full  force of every
returning action. The body, in its doubled state,  being too large
to pass through  the pelvis, and the uterus pressing upon its infe-
rior extremities, which are the only parts capable of being moved,
they are forced gradually lower,  making room as  they are pres-
sed down  for the reception of some other part into the cavity of
the uterus which  they have evacuated, till the body, turning ;<s it
were upon its own axis, the breech of the child is  expelled, as in
an original presentation of that part.   Nor  ha^s there been any
thing uncommon  in the  size or form of the pelvis of these women
to whom this case has happened, nor have the children been small,
or softened by putrefaction,  because one or  more children have
been in this way born alive.f  I believe, on  the contrary, that a
child of the common size, living, or but  lately dead,  in  such  a
state as to possess some degree of resilition, is the best calculated
  * See the London  Medical Journal,  vol. V. for 1785; and the
Journal de M^decine de Paris, pour Afcril et Septembre, 1785, and
many  cases published since that time.  I used the word spontaneous,
though, to some, it appeared objectionable, but I could not fix upon
one better  suited to explain my meaning.  I only intended to say,
that the series of effects  terminating in an evolution of the child,
were  wholly independent  of the practitioner, not that this was pro-
duced from any impulse  or exertion in the body moved.  In the
sense  in which  I use the term spontaneous, it seems to be  proper
according to its common use in medical, though, perhaps, not  strictly
in mechanical language.
  t Dr.  Garthshore, consulting physician of the British  Lying-in-
Hospital, informed me of  a case of this kind, in which the  child was
born  living ; and Mr. Martineau, an eminent surgeon  at Norwich,
informed me of another. 
462          INTRODUCTION TO MIDWIFERY.
for expulsion in this manner.   Premature, or  very small chil-
dren have often been expelled  in a doubled state, whatever might
be the original presentation, when the pelvis was well formed, or
rather more capacious than ordinary ; but this is a different case
to that we are now describing.
   Yet, the knowledge of this fact, however unquestionably proved,
does not free us from the necessity and propriety of turning chil-
dren presenting with the  superior extremities, in  every case in
which that operation can be performed with safety to the mother,
or give us a better chance of saving the child.  Under such cir-
cumstances, the instructions given by former writers, and  the ob-
servations we have before made, must still be considered as pro-
per to guide our conduct.   But, when we are called to a  patient
with a preternatural labour, in which there is little or no reason
to hope for the preservation of the child, or in which we are as-
sured of its death, or  when the operation of  turning cannot be
performed without violence, and  some  danger  to the mother;
then the knowledge of the probability  of a spontaneous evolu-
tion will set our minds at ease; and disengage us from the con-
sideration of making any hasty attempts to perform a hazardous
operation, from which  no possible good can  be derived, except
that of extracting a dead child, and which, at  all events, might be
effected by a method far more safe to the mother.
   The time required  for the spontaneous evolution of the  child,
and the facility with  which it may be made,  will depend upon  a
variety  of circumstances, but chiefly upon the size of the child,
the aptitude of its position, the dimensions of the pelvis, and the
power exerted by the uterus.   If the child be very large, or much
below the common size, the slower I believe will be the evolution,
nor  can it  be made at  all without a strong action  of the uterus.
It is possible, therefore, when we have conducted ourselves on the
ground of expectation  that the evolution would  be made, that
the pains may fall off,  or be unequal to the effect, and we may
be disappointed    It might then  be apprehended, that the diffi-
culty of extracting the  chikj would be infinitely increased.   But
though the  evolution was not perfected,  1  have not found this
consequence; for the child, though not expelled, has been brought
into such a state, that afterwards I could often pass  my hand with
ease, and bring down its feet, though, in an attempt to do this in
the beginning of  the labour, I had been foiled.  In one  case in
which  the evolution did not take  place,  I  could not bring down
the inferior extremities, but I had  no difficulty in fixing an instru-
ment upon the curved part of  the body of the  child, or in bring-
ing it away with entire safety to the mother.   It was before pre-
sumed, that the child was dead; and the sole object was, to free
the mother from her danger, and  with her safety, no appearances
of the child, however disagreeable, are to be put in competition 
              ON PRETERNATURAL LABOURS.           468

In cases of this kind, another mode of practice has been recom-
mended, that of separating the head from the body, with a blunt
hook, or other convenient safe instrument; but as I nave^never
practised this method, I give a description of it in a note.
   In the  course of my conversation and  correspondence witn
medical friends, I have been informed of several instances of wo-
men, who have died undelivered, their children presenting with
the arm ; because the practitioners  were not able, by art or by
force, to pass the hand into the uterus, to turn  the chdd, and de-
liver by the feet,  and it  was not spontaneously turned.  Inese
cases have been mentioned tome as objections to the idea of spon-
taneous evolution, but, I apprehend,  without reason.    1 he evo-
lution is supposed to be the consequence of the strong and long-
continued action of the uterus, uninterrupted.   Now the first part
of the operation of  turning a child by art, formerly consisted al-
most wholly in resisting this evolution;  and if the attempts  were
persevered in, would be an absolute bar to its taking  place,  lo
give a full explanation of my opinion, I should say, that a woman
in a state  of nature,  with her child presenting in any manner,
would not die undelivered, if no assistance were afforded to her.
 But if an  equally healthful woman'lived in a  country  somewhat
 civilized, in  which the art of midwifery was in  an  imperfect state,
 much would be thought  requisite to be done,  and violence sup-
 plying the place of knowledge and skill,  she might perish  from
 the ungainly and rude exercise of  art,  rather than from the ne-
 cessity of her case; for by the attempts of art the natural efforts
 would,  in these cases, be defeated.   In the most perfect state of
 society,  all just  and true knowledge in this  art being  founded
 upon observation  of the proceedings of nature, and all sound
 practice upon  the  imitation, the well-judging practitioner would
 recur to tlie consideration of the primitive state; that is, he would
 do nothing, unless it was absolutely necessary for him to act, and
 then  he would act  in imitation of nature.  From a retrospective
 view of the practice of midwifery in all former times, and in all
 countries, every intelligent  person  sees, and is ready to acknow-


    * Hoorneus same  laudatus  adhuc peculiarem novum, eumque
 breviorem modum, fcetum mortuum cum brachio arct.ssimi in vagina
  uteri haerente, invenit atque descripsit: qui in eo consist*, ut quaudo
  ad pedes pervenire nequit, collum, utpote quod id  fcetibus valde ad-
  huc  tenerum est, vel scalpello a reliquo trunco resecet, vel unco
  idoneo quam cautissime auferat: hoc enim facto vel sponte mox pro-
  rumnit ex  utero foetus, vel tamen, dum brachium propendens attra-
  hitur quod medico tunc loco habena. inservit, quam facdhme excu-
  titur ■ caput vero deinde seorsim mox vel  manu vel ahis propositi
  artificiis, si  manus parum esset, ejiciendum.  Heister. Cap. ch.j.
  sect. ix. 
454         INTRODUCTION TO MIDWIFERY.
ledge, that there has been too officious an interposition, and too
great a readiness to give assistance in various ways, for the relief
of many  difficulties attending parturition; which  are not only
fully proved to require no assistance, but which are also now al-
lowed to be surmounted in* a, safer and more effectual way by the
resources of the constitution.  This should certainly put us upon
our guard against hasty determinations, upon what is possible or.
otherwise, in  any case; or upon the use of any means, which
may be destructive to the child, or injurious to the mother.*
  Now I am speaking of the spontaneous evolution in presenta-
tions of the arm, it will not be amiss to observe, that several other
changes of the position of the child  take  place,  at  the time of
birth, particularly the following, of which 1 have  seen more than
one instance.   Having been called to women in the beginning of
labour, and finding by an examination, that the  head of the
child presented, 1 have left  them  for several hours,  till the first
changes were naturally made.  When I have examined them on
my return, I  have found  the arm of the child presenting, the
head being departed out  of my reach.   I do not  know, that any
practical advantage is to be obtained by the knowledge of these
cases; but it is remarkable, that the accident  has   always  hap-
pened  to  women  who  were deformed.  Such cases, however,
should be recorded, and it is possible, that, some time or other,
the knowledge of them may be of use.  It may lead to an ex-
planation of one cause at least, of preternatural labours, f
  * In America and Africa, the native women, whom we may pre-
sume to be healthy, very seldom die in labour, or in consequence of
it.  Properly speaking, they have no midwives.   The same may be
observed of  the women in Lapland, and other northern countries.
Yet the African women, when  transplanted to the West India colo-
nies, not  unfrequently die.  They  are attended by ignorant mid-
wives.   In the East Indies, the midwives of the country are ignorant
and daring, interfering perpetually, and often in the most outrageous
manner,  with the women  in labour, many of whom die, or  suffer
grievous complaints for the remainder of their lives.   In England
the practice  of midwifery  is extremely reasonable, and  it is a rare
thing  for  women to die in  labour,  or in  consequence of  it, unless
when  there  is  some dangerous epidemic disease.   In France, the
practice of midwifery is more  artificial,  and there is, both in that
and other countries on the continent, a very reprehensible fondness
for instruments and operations : we  may therefore  conclude,  that
the abuse of art produces more and greater evils, than are occasion-
ed by all the imperfections of nature.
   t [It is difficult to reject the facts which Dr.  Denman and  other
high authorities have brought forward in support of the doctrine of
the spontaneous evolution of  the  foetus in utero ; and yet it is 
ON PRETERNATURAL LABOURS.
                         SECTION IX.
  To the preternatural presentation of the child, and the circum-
stances before mentioned, there may  be added a distortion of the
equally dangerous to confide  in this resource of nature.  The ex-
planation which has been recently attempted of this occurrence by
Dr. Douglas, though written with an evident leaning in its favour, is
much more consistent with the idea of the expulsion, than of the
evolution of the foetus.  It is to be apprehended that  both views  of
the subject are calculated to produce a degree of passive conduct on
the part of the practitioner, that experience does not warrant   Dif-
ficult as the artificial turning may be, even when made use of early,
and in cases in appearance best calculated for the operation, it is yet
the duty of the accoucheur to attempt it, rather than to place exclu-
sive reliance on a power which nature seldom exerts.   Moreover,
the safety of the child is best consulted by this practice.
   On this interesting subject, Dr.  Gooch has lately published in the
Medical Transactions of the College  of Physicians of London, the
history of a case : and the  account  is the more valuable, as the au-
thor is the advocate neither of the  doctrine of Dr. Denman, nor of
Dr. Douglas.  By such observations as  those of Dr. Gooch, must
the question be ultimately settled.  The  patient  was  a  tall young
woman, at  the full time with  her  first child ; she  had  slight pains
during the night, (Saturday ;) about four in the morning, (Sunday,)
the membranes had  broken—an  arm  descended.  The first thing
 which Dr. G. observed was, that not only the arm was out its whole
length, but that the shoulder had turned forward under the arch of
the^pubts, like the occiput just before  the head is born.   The next
 thing observed  was, that when a  pain came on which  was very
 strong, the side of the thorax pressed down with  great force against
 the perinaeum.   " Struck  by these appearances," continues Dr. G.
 " 1 abstained from turning, and sat down  by the  bed-side, fully  ex •
 pecting what actually took place,  the spontaneous expulsion.   Re-
 solved to know what became of  the arm if this should happen, and
 thus fit myself for a witness on this disputed point, I laid hold of it
 with a napkin, and watched its movements :  so far from going up into
 the uterus when a pain came on, it  advanced as well as the shoulder
 still forwards under the arch of  the pubis, the  side of the thorax
 pressing more on the perinaeum,  and  appearing still more exter-
 nally : it advanced so rapidly, that  in two pains,  with a good deal of
 muscular exertion on the  part of the  patient, but apparently  with
 less suffering than attends  the  birth of the head  in a common first
 labour, did the side of the chest, of the abdomen, and of the breech,
 pass one after the other in an enormous sweep over the perinaeum,
 till the nates  and legs  were completely  expelled.  The head and
 other arm were still to be extricated,  but this was effected with the
 greatest ease :  the child was dead : the mother had not felt it move
 since the day before at noon.  Not  only was the chord without a pul- 
456
INTRODUCTION TO MIDWIFERY.
pelvis.  As there is no  occasion  to repeat  the  management,
which the other circumstances may require, we may confine our
attention to the peculiar difficulties produced by the  distortion.
sation, but  it was empty and  shrunk,  and looked  as if it had been
some time since blood had circulated  through it.  The side  of the
chest which had come foremost, was of a livid green ; the skin
peeled off, and the naked cutis was dark brown."
  The case of arm  presentation published by Dr. Bigelow in the
New-England Journal of Medicine  and Surgery, vol.  10. gives sup-
port to the doctrines of Dr. Gooch.
  In the following account of an arm presentation, kindly commu-
nicated to me by the author, Dr.  A.  H. Stevens, of this city, the
reader will  perceive  a judicious  practice adopted, under circum-
stances of great difficulty and  embarrassment, and, in  like cases, he
will find it advantageous to pursue a similar course.
  *«  I was called in the night of March 9th, 1819," sajs Dr. Stevens,
«' to  a village about ten miles  from this city, to visit a lady who was
represented to have been in labour since the morning of the prece-
ding day.   She  was  healthy, well-formed, and the mother of several
children.   For  three  months  previous to her confinement, she had
been obliged to  keep her bed, in consequence of a strain in getting
out  of a waggon, and her feelings  had led her to anticipate  unusual
difficulty in  her accouchement.   Two medical  gentlemen were in
attendance, one of whom had  been sent for only a few hours before
I arrived    What the original presentation had  been, could  not be
ascertained ; but the cord  was  stated to have protruded, and the
waters to have  been discharged in the first periods of  the labour.
I found the cord and  the right  arm protruded as  far as the elbow,
and  the cuticle  was  detached  upon slight pressure.   There  was no
pulsation in the cord.  Since  the preceding morning  the pains had
been severe, and now they had the peculiar character which  usually
attends the last  stage of parturition ; the external parts  were exqui-
sitely tender.
   " When she consented to an  examination, I found, by the feel of
the  shoulder, the spine, the  ribs,  and the  right side of the lower
jaw, that the child lay with the trunk  across the pelvis with the
head to the left side,  and the buttocks to  the right of the mother ;
the  back to the abdomen, and the  sternum to the posterior surface
of the uterus.
   " As the bladder had emptied itself, and as there was great fulness
of the pulse, it was deemed  advisable to take some blood from the
arm, and  administer a large  opiate, in the hope of gaining a tru.ce
from the unremitting pains,  to  turn the child, and bring down the
feet.  In this  hope we waited from  four o'clock  of  the morning of
the  10th, until seven.   But finding the pains continued, and judging
 that no advantage could result from  further delay, as the pulsation
 had ceased in the cord, and the child  was unquestionably dead, I
 cautiously  introduced a blunt bistoury, and dissected  off the  right 
ON PRETERNATURAL LABOURS.
Some disadvantage may arise from  this cause in the extraction
of any part of the child, but it will be trifling, if compared with
that which attends the extraction of the  head; we may therefore
arm, the woman lying on her back, with her feet over the foot of
the bed, one supported by each of the gentlemen, who assisted me.
I then pushed firmly on the axilla with my thumb,  but  it could not
be pressed back.   I next attempted to introduce my hand and get at
the feet;  a pain came  on,  my hand was then kept quiet; it remit-
ted ; I repeated the attempt, but with no better success : I changed
hands, but the contraction of the  womb increased  by the slightest
movement, and  kept the hand firmly wedged as if in a vice.  In the
hope of making more  room, 1 then opened the chest and removed
the contents ; when introducing first two fingers, and afterwards the
blunt hook, 1 endeavoured by that  hold to bring down the body, but
ineffectually.
  " Another plan succeeded better,  and it is chiefly with  a view of
suggesting this (of which I do not  recollect to have  heard  or read,)
that the present case  has been drawn up.  This  was the making an
incision as  high up on the back as  I safely could, with a blunt bis-
toury passed along the fore-finger ; inserting a  blunt hook into it,
and pulling in a direction obliquely downwards and forwards, so as to
bring  the  buttocks  down,  and  having partly  succeeded, I  made
a second incision, immediately above the hip, introduced  the hook as
before, and extracted the child, breech foremost.  The placenta fol-
lowed and was immediately  removed, in a very offensive state.
  " The  woman bore the  operation,  which lasted until  half past
eight with great fortitude.  The left leg is partially paralysed.
  " Second Day, 5  P. M.—The lochial discharge has been regular.
Has bad several severe chills, succeeded by great heat of the skin,
copious diaphoresis, thirst and dryness of the tongue.  Is occasion-
ally delirious, passes a great quantity of water from the bladder with
difficulty.   Bowels have been opened ; fomentations have been ap-
plied to the abdomen, which is  swollen and  tender to the touch in
the region of the uterus.   Pulse  frequent,  and,  except during the
chills, full.  Seeing a  rigor coming  on,  I advised hot  salt, in  a
woollen  stocking.,  to be applied  to the pit of the  stomach and the
feet;  and a copious draught of catmint tea to be taken.   The chill
terminated sooner than any which had preceded  it.
  " 6 P. M.—Pulse  full and frequent; great heat of skin ; general
and profuse  sweating; delirium.   1 took  3xiv. of blood from the
arm.   ft was agreed to apply spirituous fomentations to the abdo-
men, a poultice of linseed, with solution of the acetate of lead to the
pudenda, and to give of the acetite of ammonia 3ss every two hours.
  " 9 P. M. Symptoms rather improved. She was again bled to 3xii.v
Sinapisms to be applied to the feet.
  " Fifth Day.—Rigors have been less severe :  tongue  furred, and
somewhat  yellow.   Skin  constantly  moist;  occasional  delirium.
Bowels confined.   Agreed to give three grains of calomel at night  -r
                                58 
458
INTRODUCTION TO MIDWIFERY.
be allowed to suppose, that the whole of the child is born, except
the head, which cannot be brought away in the usual manner, or
by the means  before advised.   The  force with which we endea-
vour to bring down the head of the child, must then be gradual-
ly increased, till we are convinced, that a greater degree is incon-
sistent with the safety of the child, or  induces the hazard of sepa-
rating the body from  the head.
  The wish to extract the head of the child speedily, is founded
on the apprehension, justly entertained, that  in this position the
life of the child is in  the most imminent danger, from the com-
pression of the funis.  A vigorous pulsation in the  funis proves,
even at this time, that the child  is not in any danger,  and of
course gives us an opportunity of acting with deliberation.   But
should the pulsation, which was at first lively and  strong,  gra-
dually decline, and then altogether cease, the head must if possi-
ble be speedily extracted, or the child will be inevitably lost, there
being no other way of removing the compression, or  of preser-
ving its life.
   The extraction of the head may then be attempted with two
views, either to save the life of the child,  or  merely to free the
mother from any danger,  which  might arise from  its detention.
When the first is our  aim, the force  with  which we extract must
be moderate, and  consistent with the safety of the child ; it must
be exerted in a proper direction with regard to the pelvis, as was
before observed; it must  be  uniform and commanded; and  if
there be any pains, it must accompany them.  Should the head.
descend in ever so small a degree, we must not act precipitately,
and increase the force in  order to finish  the delivery suddenly ;
but we must proceed  with circumspection, or we shall add  to the
danger which the child is already in,  and run the risk of doing in-
jury to the mother; though when the head begins to advance,
there is seldom much  remaining difficulty, the cause  usually ex-
a solution of Epsom salts on the following morning.  Sinapisms to
the abdomen.
  " Seventh Day.—The medicine operated well.  Tenderness of the
abdomen lessened ; pulse soft and  frequent.   Complains of want of
sleep ;  we prescribed the effervescing draught, with forty  drops of
laudanum.
  " Eleventh Day.—Continues to improve. Has taken an infusion of
hops—agreed to continue it, and to give freely of nourishment.
  " Fourteenth Day.—Better—is able for the first time to move the
left leg, and to move on her knees  from one bed to  another.  Is al-
lowed the use of animal food.
  " Seventeenth Day.—Appetite good—strength  returning—has set
up in bed several times.
  " Mrs. V. has since  entirely recovered."                 F.] 
ON PRETERNATURAL LABOURS.
459
 isting at one particular part of the pelvis.  It has been  said,
 that children have been sometimes born alive, when the strongest
 efforts, and those continued for many hours,  have been made to
 extract the head detained  in this position.  But I have not been
 so fortunate as to meet with any such instances, a short space of
 time  having generally been sufficient to frustrate my hopes, and
 convince me that the child was dead.  Though when the head
 has been detained a considerable time,  a few cases have termina-
 ted more favourably than I could  have expected,  and  I  have
 been  agreeably surprised  with the discovery of some faint signs
 of life, which, by  the  assiduous and careful use of the common
 means, have been improved, and  the  life of the child  at length
 perfectly recovered, as was observed in sect. 1. chap. ix.
   But when we have abandoned all hope of preserving the child,
 and have no other view but simply that of extracting  the head,
 we must be particularly cautious, that through our conduct the
 mother does not suffer either any immediate injury, or that any
 foundation of mischief be laid, which  may show itself at some
 future time.   When we have in vain exerted all the force which
 we think reasonable and proper, and which, in some cases,  must
 be more than  any circumstance would be thought to require, it
 will be expedient to rest, for the purpose of gaining all the advan-
 tage to be obtained by  the compression  of the head.   On this
 account, the mother will actually  suffer no more inconvenience,
 than would have been produced if  the head had originally pre-
 sented, and been locked in the pelvis.  After waiting some time,
 we must renew  our attempts to extract, and thus proceed, alter-
 nately resting and acting with efficacy  and resolution, and if the
 hold  we may  have of the  body or extremities of the child does
 not suit, a silk handkerchief or other band  may be passed round
 its neck, and this will be found a very handy and convenient in-
 strument.
   The  great  impediment  to  the  extraction of the head of the
 child  exists in  the disproportion between it and the pelvis.  Ano-
 ther of no little consequence may be produced by the dislocation
 of the neck, or the laceration of the  skin, either of which would
 lead to the separation of  the  body from the  head; an accident
 one would  wish to avoid,  as it would lay us under the necessity
 of using some awkward instrument, instead of the body of the
 child.   Either of these inconveniences is readily occasioned by
 the impatience or despair  of the practitioner, who is apt to twist
 the neck while he is extracting, or to pull with a sudden motion,
 instead of the  uniform one before recommended.
   In these cases of extreme difficulty,  it will always be of ser-
vice, and often succeed when other means fail, if we can conduct
our thumbs between the head of the child  and the pubes,  and 
460
INTRODUCTION  TO MIDWIFERY.
press the head  forcibly toward the hollow of the sacrum.   It
would also be of service if we were able to pass the finger into
the mouth of the child, to change the position of the head ; but
in the worst cases this is impracticable, the head being obstructed
so high, that the mouth of the child is beyond our reach.   When
these means are not in our power, or fail to answer our purpose,
it will be necessary to leave the head a yet longer time,  that it
may undergo a greater degree of compression and accommoda-
tion to the pelvis, and  then to renew our  attempts to extract it.
  It must be a very great disproportion between the head of the
child and the pelvis,  which is  able to withstand this method  of
proceeding, if we persevere in  it with prudence and steadiness;
because the integuments of the head will burst, or the bones be
bent inwards in an extraordinary degree, or even broken.  Some-
times, however, this method of proceeding fails; or a hemorrhage
comes on ; or the situation  of the mother from some other cause
will not allow us to take so much  time, or proceed so slowly, as
is generally proposed,  and we are compelled  to the use  of such
means,  as promise a  more  speedy completion of the delivery.
Different kinds of forceps  have been advised for this purpose,
but no instrument of the sort  ought to be used on such occasions,
because the  child is dead; and it would be impossible but that
the mother must by their use  undergo the chance of mischief,
without any equivalent  advantage.  It  then  only remains that
we  should lessen the head of the child, and the operation may be
as easily performed in this, as in the natural presentation of the
head.  In the description of  this operation  it  was said,  that it
clearly divided itself into three parts :  1, perforation; 2, evacua-
tion of the brain; and 3, extraction of the head.   It will  not be
possible to make the perforation in the usual place, but we must
take that which offers itself most conveniently.  We may  recol-
lect that there is a small fontanel behind each ear in the head of
a foetus, which is a convenient place for the purpose; or  it may
be done at the basis of the  cranium through the mouth ;  or, in
short, in any part where we can fix and command the use of the
perforator, except perhaps the occipital bone, where we may cut
the  ligaments which join the  neck  to the head, and when we in-
tended to extract, we  should  leave the head behind.   When the
perforation is made according to the rules before mentioned, and
the  brain evacuated, the head  may be readily extracted, either by
pulling by the body of the child, or by inserting a crotchet in the
opening made by the operator as in other cases.   But it will be
scarcely believed, how  seldom this operation is necessary under
these  circumstances, if we  have not been in a hurry,  but have
acted with prudence.   Nor have I ever known any ill consequen-
ces follow  the compression which the soft parts undergo, between
the head of the. child, and the  sides of the pelvis, if proper atten-
tion were afterwards paid to the state of the bladder and rectum. 
ON PRETERNATURAL LABOURS.          461
                          SECTION X.
   Though with cautious management the head of the child  is
 seldom separated from the neck, and though with  indiscretion it
 could  not often be produced, yet the  possibility of the accident,
 when there is great disproportion between the dimensions of the
 head and those  of the  pelvis, especially  in  the case  of a child
 some  time dead, makes  it necessary for us to  be prepared for
 managing the case  if it should occur.   It  has,  moreover, been
 surmised, that under peculiar circumstances it might be eligible to
 separate the  head from  the body, with  the expectation of after-
 wards extracting it with more ease ; but this, however just in the-
 ory, will not, 1 believe, give us any advantage in  practice, espe-
 cially in cases of distortion of the pelvis; at least, so the accident
 seems to have proved, when it has unavoidably happened. Should
 there be a tendency  to a separation of the neck,  the hold it yet
 affords will serve to  assist  us in the perforation more  effectually
 than any artificial contrivance, and in the extraction also of the
 head.
   When the  head of the child has been left behind, the case has
 been considered as frightful, and, which is true, exceedingly trou-
 blesome to manage,  because the pelvis might be expected to  be
 very small in proportion to the  size  of the  head, except in the
 case of a putrid child;  and because it could not,  without  great
 difficulty, be  fixed in such  a manner, as to be conveniently  sub-
jected  to the  action of the instruments which it may be necessary
 to use.  Of these there  has certainly  been contrived a sufficient
 number for the purpose of almost every case.  It is, nevertheless,
 evident to every  practical man, that  the greater part of them
 were the conceits  of ingenious  men  in their closets,  and  either
 could  not be applied, or if applied, could not be  of any service
 in a case of real perplexity.
   The chief obstacle  to  the extraction of the head,  must arise
 from the disproportion  between  it  and the cavity of  the pelvis,
 or it would be excluded by the pains,  or easily brought away;
 and this disproportion can only be removed by lessening the bulk
 of the head.   If this were fixed firmly in the pelvis, there would
 be no  more  difficulty in making the perforation, or in any part
 of the operation, than in a case  in which  the  head  originally
 presented ; but should  the head be disengaged, and lying loose
 at the superior aperture of the pelvis, it would not make due re-
 sistance to the point  of the perforator, which  would  be apt to
 slide, we should be foiled in our  attempt, and  incur  the hazard
 of injuring the mother.   To avoid these inconveniences and mis-
 chief, external pressure must be made either by the hands of an
 assistant, or with a napkin passed round the abdomen  with suffi- 
462
INTRODUCTION TO MIDWIFERY.
 cient firmness  to keep  the  head  steadily  fixed; and this being
 done, the operation of perforating and lessening the bulk of the
 head, may be performed without any chance of failure or mischief.
 In the very few cases of this  kind to  which I have been called,
 the difficulty has not, except in one instance, by any means been
 equal to what I expected from the representation of different wri-
 ters.   It is a case to be prevented or  avoided,  if possible;  but
 when it does occur, there is neither that danger in the case,  nor
 that difficulty in the operation, which  ought to  terrify a  practi-
 tioner who has  common resolution, and who gives himself time
 for a little reflection.  We  may, however, believe, that  in some
 cases, every attempt to extract the head has been  in  vain, and
 the patients have been resigned to their fate; of which  there is
 one instance in  Mauriceau, another in Chapman, and some in
 other writers.  Yet even in  these cases, though the patients have
 most frequently died, after a certain time the action of the uterus
 has come on, and  at length expelled the head ;  in one case, If I
 am not mistaken, so late as  the  twentieth  day after the accident
 had happened.   The degree  of distention of the uterus, occa-
 sioned by the mere head of a child, would not, indeed,  be so
 great as to make us very  apprehensive of  fatal consequences on
 that account; and if the uterus be in a  healthy state, a substance
 of that bulk and kind might be managed either by common pu-
 trefaction, reducing its size, and  dividing  it into portions, or it
 might, by repeated efforts,  be expelled, especially if the pelvis
 were of any reasonable size.  But should  the head of the child
 be retained, it is probable, that the placenta would  also remain,
 and the two circumstances combined would add  to  the  danger
 produced  by each ; so that we must revert to the  former conclu-
sions, that the head  ought not to be separated from the  body if it
can be avoided; and if separated, ought  not to be  left in the
uterus, if it can possibly  be extracted  by  any means not abso-
lutely injurious to  the patient. 
ANOMALOUS, OR COMPLEX LABOURS.
CHAPTER XV.
CLASS  FOUR  TH.
ANOMALOUS, OR COMPLEX LABOURS.
                  FOUR  ORDERS.

                     ORDER FIRST.
           Labours attended with Hemorrhage.

                    ORDER SECOND.
           Labours attended with Convulsions.

                     ORDER THIRD.
           Labours with hoo or more Children.

                    ORDER FOURTH.
Labours in which there is a descent of the Funis Umbilicalis
              before any part of the child.
                        SECTION I.

                       ORDER FIRST.
             Labours attended with  Hemorrhage.
  It is necessary to premise, that no practical advantage can be
derived  from the arrangement of these labours into one class.
This is merely of use for the convenience of doctrine, and to  pre-
vent the multiplication of classes ; for there is not the least re-
semblance between the different orders of anomalous or complex
labours, which do not,  therefore, admit of any general definition
or character.
  Uterine  hemorrhages, from  different causes, very frequently
occur in practice, and always require great attention ; but those,
which we are about to consider in this place, are such as depend
upon the states of pregnancy and parturition.  These have ever
been esteemed as constituting a very important part of the prac-
tice of midwifery, on account of the immediate and great danger
with which they are often attended ;  and because the safety of
the patient, in these cases, more frequently depends upon the judg-
ment and skill  of those under whose  care she is placed, than in 
464
INTRODUCTION TO MIDWIFERY.
 almost any other circumstances.   The subject, therefore, requires
 to be treated with  the utmost circumspection ; and though much
 industry hath  been employed  upon it,  there is reason to believe,
 that the knowledge of many things, of which we are at present
 ignorant, is wanting for the  perfection of the rules of practice.
   The  knowledge, however,  which we do possess, it is incum-
 bent upon us to place in the most  advantageous point of view,
 that it may be converted to use ;  that we may be enabled to do
 what reason and experience dictate  to be necessary and proper;
 that we may determine upon the  time most  suitable for acting;
 and be warned, moreover, against relying on  such  things as are
 useless,  or doing what is needless or hurtful.
   The word hemorrhage does not apply with  propriety to  all
 discharges of blood from the  uterus, some of these being natural
 or  salutary.   The menstruous discharge is natural,  but if it
 should be excessive in quantity, "too frequent or irregular in its
 returns, or prolonged beyond its usual time,  it  might be called
 hemorrhage.   Every discharge of blood which  occurs during
 pregnancy, however small,  may be  called  hemorrhage, because
 it is not  natural at that time, though the greater discharge, the
 more decidedly proper would be this term ; and the case is.simi-
 lar with the  small discharges, which pretty generally attend the
commencement, or which occur in the course, of labours.   The
 same observation may be made of those discharges,  which hap-
pen between the birth of the child, and the expulsion of the pla-
centa ; these being often profuse, and not very unfrequently dan-
 gerous.   But the discharges which happen after the expulsion of
the placenta, cannot be called hemorrhages,  unless they are ex-
cessive in their degree; because some loss of blood is  at that
time necessary and natural.  We may then say, that all effusions
 of blood, which are inordinate in  quantity,  or irregular in the
time of their appearance, maybe denominated hemorrhages; and
 these, which are the objects of our present consideration, may be
 divided into four kinds.
   1. Those which  occur in early pregnancy,  or in abortions.
  2. Those which  occur in advanced pregnancy, or toward the
full period of uterogestation.
  3. Those which  happen between the birth of the child and the
expulsion of the placenta.
  4. Those which  follow the expulsion of the placenta.
  Under one or other of these distinctions will be included every
 kind of hemorrhage, which  depends upon pregnancy or parturi-
 tion ; and this  arrangement will not only convey a clear idea of
 the subject, but be  of use also in practice.   Yet it is necessary to
 observe,  that there may be a combination of the three last kinds,
 or any two  of them, in the same  patient; but whether they be
 separate or combined, the modes of treatment  may be accommo- 
           ANOMALOUS, OR COMPLEX LABOURS.        465

dated to each case with equal propriety  and advantage, as far as
it may be reducible to the general denomination.
  Greater accuracy is, nevertheless, required in the description of
what is meant by early or advanced pregnancy, or we may enter-
tain different notions of,  and use different  terms for, the same
thing.  Perhaps no precise line can be drawn for this purpose, as
contingent circumstances may cause a  variation  in different wo-
men ; yet the best, which the nature of the subject admits, is pro-
bably to be taken from time.   We will  then say, that all expul-
sions of the  fcetus, before the termination  of the sixth month of
 {>regnancy, may be called abortions ;*  but all expulsions in  the
 ast  three months shall be considered as labours, premature or
regular.  There is a practical reason for this distinction.-]-  Before
the  termination of the sixth month, these cases, generally speak-
ing, neither require nor  allow of manual assistance; but in  the
last three months, they admit of manual assistance, if it be re-
quired, though not with equal ease; for the longer the  time which
is wanting to complete  the period of uterogestation,  the greater
the  difficulties will  be, which attend any operation, that it might
be thought necessary to perform.   It is  also to be observed, that
expulsions of the  fcetus sometimes happen so critically, as to ren-
der it an extremely difficult thing to decide, to which of the dis-
tinctions they ought to be referred; and in  these,  if we knew any
method of treatment between that enjoined for abortions, and at
the  full period, such,  for instance, as  puncturing  or breaking the
membranes containing the waters of the  ovum, that would be most
eligible.   But on this, as well as many other occasions, there is
room to observe, that when every doctrinal distinction  has been
made, no  absolute rule can be formed for the conduct of the prac-
titioner, in every individual case which may occur, or in  every
possible situation in which a patient may be placed; but he know-
ing in general what ought to be done, and in particular  what ought
to be avoided, must ever be at liberty to exercise his  own judg-
ment in the application of every rule.
  * Foetus praematura ejectio.—Linnaeus.
  Sanguinis ex utero gravido profluvium, cum fcetu immaturo vel
mola subsequendi.—Vogel.
  Partus morbosus et symptomaticus.  Fcetus ejicilur potius quam
paritur.—Harv.
  | [Another division has been  adopted  by some writers, which
possesses the advantages of greater minuteness and accuracy :  1st.
miscarriage, which occurs to the end of the third month ; 2d. abor-
tion, which occurs between the end of the third  month and the close
of the seventh ;  and, 3d. premature labour, which occurs  between
the  end of the seventh month and the regular period.  F.J
                             59 
466
INTRODUCTION TO MIDWIFERY.
                         SECTION II.
             On the frequency of abortion in women.
   It would be curious, and might be of some utility in  practice,
to ascertain whether  women,  on account of their menstruation, or
their erect position, or the structure of the ovum, or the process
by which  this is  connected  to  the uterus,  or from any  other
cause,  are naturally more  liable to  abor ions than  animals; or
whether  frequent  abortions in women  may not be considered as
an attributive, either  of habits superinduced by modes of educa-
tion or of living, or of accidents which might be avoided.  There
is  great  room to  lament their frequent occurrence in the  more
civilized,  perhaps  luxurious scenes of life, and in  those  constitu-
tions that are extremely  delicate, and  winch  are  indeed hardly
found equal to the continuance of the human race.   Yet in  those
situations which  might be presumed to be most unfavourable to
the sex, among the lowest ranks  of life, abortions, except  from
violent external accidents, rarely  happen ; so  that  there is  good
reason for believing,  that women in a state of nature would not
be more liable to  abortion  than other  creatures.   According to
the opinions nevertheless of many  sj'stematic writers  on this
subject, every action in common life  has been assigned as the
cause of abortion : yet this is rarely the  case; but in general that,
about which the patient was  employed, when the first symptom
appeared, is fixed  upon as the particular cause, though probably
she was before in such a state, that abortion  was inevitable.   If
this opinion were just, the event  ought rather to be imputed to
some previous indisposition, or to the excess of some actions, for-
gotten perhaps when the  causes of abortion actually took place,
than to the exercise of the body on common occasions.  Greater
practical  benefit will be  obtained, if we seek for  the causes of
abortion  in the general infirmity of the constitution, or  in  some
particular  state of the uterus, or  its appendages,  or in  want  of
necessary attention to this situation, than by imputing it to  these
accidents.  As far as  the constitution   may  be altered, by the
reduction of the  general strength, by  excessive  irritability, by
plethora or febrile disposition, so as to be unable to perform its
functions, or to perform them with ease, propriety, and regulari-
ty, we may esteem every  cause capable of producing such a state,
as a primary cause of abortion.   It does not,  however,  often
happen, that simple weakness is a cause of abortion; for women
who prove with child in very weak and reduced states of the body,
particularly in consumptions, in which  there is a  great  aptitude
to conceive, have, of all women, the least disposition to miscarry ;
yet a  state more feeble and more irritable could  with difficulty
be pointed out.  But the weakness  and  irritability are at that
time of a particular kind, not arising from, connected  with,  or 
          ANOMALOUS, OR COMPLEX LABOURS.        46?

influencing the uterus, which proceeds in the performance of its
functions, as regularly as if the whole constitution was in perfect
health ; and such  patients are generally kept in a state of quie-
tude.  We may hence conclude, that either weakness or irrita-
bility in general is seldom  a cause of abortion; but some weak-
ness, or imperfection originating in, or affecting the uterus  or its
appendages ; or a  peculiar  kind of irritability, thence proceeding,
distinguishable enough  in the  female character by a careful ob-
server, which creates impatience of mind and restlessness of body;
in which every occurrence is the parent of ungrounded fear and
solicitude, and every office is performed with hurry and vexation.
As an abundance of  acrimonious, or some other humour, or
some quality of the body,  may transfer  this state to the mind,
so the mind often reverberates this state to the body, the continu-
nance of which will often prevent, or impede the regular perform-
ance of any process.  It  is  therefore  often found of as  much
importance in  these cases, to  give composure and  steadiness to
the mind  of a patient, by leading her to hope  and cheerful ex-
pectation,  by  soothing and comfortable conversation, as it is to
administer medicines to the body.
   With respect to that state of the uterus causing abortion, the
opinion originally entertained  and still pursued, as far as can be
collected from the medicines usually prescribed, was, that it fail-
ed to perform its office on account of its excessive lubricity, as if
the ovum, before loosely attached, slipped out of the uterus; but
this idea will  not  bear examination,  being supported neither by
the reason of  the  thing, nor by  the occurrences of practice.  It
is remarkable,  that women, who are in the habit of miscarrying,
go on in a very promising  way to a certain time,  and then mis-
carry, not once, but for a number of times, in spite of all the me-
thods which can be contrived, and all the medicines which can be
given ; so that, besides the force of habit, there  is sometimes rea-
son to'suspect,  that the uterus is incapable of distending beyond
such size, before it assumes its disposition to act, and that it can-
not be quieted till it has excluded the ovum.  What I am about
to say will  not, 1 hope, be  construed as giving a license to irregu-
larity of conduct, which may often be justly assigned as the im-
mediate cause of abortion; or lead to the negligent use  of those
 means which  are  likely to prevent it.  But from the examination
 of many ova  after their expulsion, it has appeared, that their lon-
 ger retention  could not have  produced any advantage, the foetas
 being decayed, or having ceased to grow, long before it was ex-
 pelled.  Or the ovum has been  in such a state, as to have become
 wholly unfit  for  the purpose which it was designed to  answer ;
 so that if we  could believe there was a distinct intelligence exist-
 ing in every part of the body, we should say, it was concluded in
 council, this ovum can never come  to perfection,  and it shall be 
468
INTRODUCTION TO  MIDWIFERY.
expelled.  Nevertheless, in some cases, the ovum, though blight-
ed or extinguished, if the expression may be allowed, will, though
it cease to grow,  remain inoffensive in the uterus to the  period
of legitimate pregnancy, or may be expelled at any intermediate
time.
  Conception probably depends upon the  perfect  state of one or
both ovaria, and  will therefore  sometimes take place, when the
uterus  is considerably diseased.*  But the progress depends upon
the state of the uterus, and chiefly upon that of the fundus;  fori
have known several instances of women, who had  both excrescen-
ces and induration about the os uteri,  who have conceived and
pone on to their full time without any material  inconvenience, till
the time of labour approached.
   The imperfections  observable  in ova  are  of  different kinds',
and found occasionally in every part; and there is usually a con-
sent between the fcetus and the shell of the ovum, as  the placen-
tal part and the membranes may be called, but not always.  For
examples have occurred, in which  :he fcetus  has died before the
termination of  the third month, yet the  shell being  healthy has
increased to a certain size, has remained till the expiration of the
nintli month, and then been expelled, according to the genius and
constitution of the uterus; though  frequently it has been found
to have undergone great changes, as, for instance, in many cases
of hydatids.  But if the  shell becomes diseased, then  the foetus
being  deprived of its nourishment, is of course destroyed, and
both are expelled, as any other extraneous body would be, though
not immediately  on the accession of the mischief.  There is rea-
son to believe,  that the part of the ovum most commonly diseased
is not that which passes from the ovarium, but that production
of the uterus,  which is prepared  for the reception of  the ovum
after its passage  from the  ovarium, and  which may be  called the
connecting membrane  of the  ovum.   When that  process,  by
which the two  membranes are cemented, goes on  without inter-
ruption, I believe the connection is completed between the sixth
and the tenth week from the time  of conception.   But when an
abortion is about to happen, there is usually between this and the
outer  membrane  of  the ovum an  affusion of  blood,  which  often
insinuates itself through the cellular membrane  of the placenta
and between the  membranes, giving externally to the whole ovum
a tumid and unequal appearance, often not unlike  a lump of co-
agulated blood, for which  it has  been frequently mistaken,  and
then it is popularly  called a false conception.   It  is  probable,
that either the connecting membrane  is imperfectly formed, or
  * [I have already adverted to the importance of a perfect state of
one or other of the ovaria, as essential to conception.  F.] 
ANOMALOUS, OR COMPLEX LABOURS.
469
 there is  some difficulty, and  a failure in the completion of the
 union  between it and the ovum;  and according to this opinion
 the causes of abortions are generally to be sought for in the fe-
 male only, contrary to what I formerly suspected.

                         SECTION IV.
                On the treatment in Abortions.
   All  the means  which can  be advised with any prospect of
 success, in the treatment of patients disposed to abortion, whe-
 ther the cause exist in the constitution or in the uterus, may be
 considered as preventive or curative.   In either of these views
 we must chiefly  recur to  the constitution ;  as in the first case,
 it is the  great object of our attention : and in the second, as
 the principal chance of producing any  salutary change in  the
 uterus, is through the medium of the constitution,  on the regu-
 lation  of which our success must ultimately depend.   Should
 a separation of the husband from  his wife's bed be thought ne-
 cessary, it must be chiefly so about the period above mention-
 ed, unless when  there have  been frequent miscarriages at  any
 other precise time,  when particular attention,  in this  respect,
 will be required.
  As women, with different constitutions and different states of
 health, are subject to abortion, every mode of treatment must
 be accommodated  to the constitution of each patient,  and to
 the disease of which there may be any indication.  In plethoric
 and febrile habits, it may be proper to take away small quanti-
 ties of blood, soon after the suppression of the  menstruous  dis-
 charge, and occasionally afterwards ; to enjoin a spare, or even
 a vegetable diet, and to give cooling medicines; in  some habits,
 in which the  uterus may be supposed unwilling to distend  be-
 yond a certain degree, or where the degree of irritability is ex-
 treme, to prescribe opiates in small quantities often  repeated ;
 and sometimes tepid bathing.  In debilitated and  languid con-
 stitutions, a strengthening diet must be allowed, and wine, es-
 pecially claret, in an  indefinite  quantity at such  times as the
 patient may be more sensible of depression, or the want  of sup-
 port, of which no one but herself can be sensible.  Every kind
 of medicine,  which proposes to give vigour and  energy, will
 also then be proper; as the cortex cinchonas in any convenient
 form, and preparations of iron in  the  officinal  or extemporane-
 ous forms, or  mineral waters of the same quality, but in small
 quantities.  The shower bath,  dashing cold  water upon  the
 loins, the cold bath, sea-bathing especially, are  pretty constant-
ly recommended for the general purpose of improving the health,
not only in those who have a disposition to abortion, but in those
 also who are accustomed to bring forth dead children, or who 
470         INTRODUCTION TO MIDWIFERY.
are prone to hemorrhage at the time of delivery ; and experi-
ence has shown, that they may, in many cases,  be continued
through  the whole time of  pregnancy,  with safety and advan-
tage.*  For the great purpose of establishing permanent strength
in those who have had long continued ill health,  or who are in
a habit of meeting with these untoward accidents,  nothing seems
better calculated, or is found to be more  useful, than travelling;
not taking a hasty journey, but wandering about by easy stages,
for many months, by which the evils that appertain to the too
refined scenes of civilized life are done away, the mind becomes
soothed and composed, and the  corporeal advantages of a natu-
ral state are, in some measure, acquired.
   When the health cannot be  confirmed,  so as  to enable the
constitution to bear the common exigencies of life,  it has been
thought advisable to remove patients from them, by  confining
them occasionally to their house, to a floor, or a single room ;
or even  to a  horizontal position,  throughout pregnancy; at
least till  the period when they  were accustomed to miscarry
was past, and the injunctions in  this.respect  must accord with
the debilitated or irritable state of the patient.  Some instances
of advantage from this method I  have known, particularly in the
early part of pregnancy.  But if we were to consider abortions
as originally proceeding from weakness,  or too great a degree
of irritability,  confinement to a room,  or any  treatment by
which both those evils are likely  to be increased, seems a strange
and unlikely method of preventing mischief; and from what I
have seen of the general issue of such  strict  practice, much
cannot be said  in its favour, the event being usually deferred,
but not hindered.   In the  management  of  some cases of this
kind, 1 have thought  myself entitled to credit,  but I  must also
acknowledge,  that 1 have  been frequently  disappointed; yet
from some general improvement of the health,  or for some rea-
son, not obvious or easy to discover, the patient,  wearied with
the fruitless attempts of art, and deserting all rules, has another
time escaped the abortion, which 1 had before  in vain attempt-
ed to prevent.
   With respect  to that state of the uterus itself,  which may be
considered as  the  cause of  abortion, should there  have been
any indication from the  discharges being irregular or profuse,
if they be of the sanguineous kind ; from their  quality  or de-
gree, if of that kind which passes under the general name of
weakness: it is first  to be  determined, whether  they be symp-
  * [Too much can scarcely be said in behalf of cold bathing, and
cold lavations, for these purposes.  F.] 
ANOMALOUS, OR COMPLEX LABOURS.       471
toms indicating a certain state of general health, or any morbid
disposition of the uterus.    Should they even be of the latter
kind, it is in general only by application to, and improvement
of, the constitution at large, that we have the power of making
any  material  alteration in the state of the uterus.  Something
may, however, be done by local applications of various kinds,
especially by injections, but their activity must not be such as
to make too quick an alteration, by suppressing suddenly any
kind of discharge, to which the  part itself,  or the constitution,
may have been  long accustomed.  For it must be observed,
that  disagreeable as these discharges are, their sudden suppres-
sion  by the use of powerful  astringents, often occasions very
serious or dangerous diseases ; and such discharges seem to be
really of secondary use  That  is, if we suppose a certain state
of the uterus, the discharge may be absolutely necessary for its
relief, while it remains in  such a state,  and the state is to be
changed previous to the suppression of the discharge; else,  in-
stead of removing, we shall add to the existing disease, or pro-
duce one of a different and worse kind.  In such states os the
uterus as dispose to  abortion,  I have seldom dared to advise
any more active  application than  the  Bath or Buxton waters,
which may be injected into the vagina, in the interval between
the two periods  of menstruation, or even for a longer time.   I
say  into the vagina, because 1 do not approve of daily or fre-
quent attempts to introduce any instrument within the os uteri,
on this account,  or for the relief of any disease.   It must, how-
ever, be mentioned,  that some have assured me, they have ad-
vised the  use  of astringent injections, even  those composed of
zincum vitnolatum or alum,  and other medicines of that class,
not only for the  cure  of common weakening  discharges, but
with much advantage also in  pregnancy, when there was a pro-
pensity to abortion.

                        SECTION III.
     On the symptoms preceding and accompanying abortions.
   The circumstances attending abortions, and  the symptoms by
which they are  threatened  or accompanied, are very unlike in
different patients, as  are indeed all the effect? arising from uterine
disturbance.   But there is  generally alternate  pain  and ease in
the  back,  abdomen, and inferior  extremities,  with a sense of
weight and weakness in the  region of the uterus, frequent mic-
turition, and a tenesmus ; but the most certain sign of a threaten-
ed abortion is a  discharge of blood, which proves that some part
of the ovum is already loosened from the uterus.
  When such discharge  happens during pregnancy, especially
at an early period, it has been a received opinion, that abortion 
472
INTRODUCTION TO MIDWIFERY.
was inevitable, because  it was  presumed, that  the separation
which it proved could not be repaired.  It must be allowed, that
under  such  circumstances  there is  always too much  reason to
apprehend an abortion; yet experience has fully shown,  that
women, who have had not one, but  repeated discharges,  and
sometimes to a profuse degree,  with  considerable and  regular
pains, have gone to their full time,  without  any  imperfection in
the child,  or any detriment to the mother; the pain ceasing, and
the loosened part, by some operation beyond human skill, having
been cemented and reunited to the uterus, which  reunion, I  pre-
sume, may take place, or be completed in ten or twelve  days
after the cessation of  the discharge.   There seems to be just so
much chance of preventing an  abortion, when there  has  been
one or more discharges of blood, as to make it worth  our while
to use the  common means for that purpose ;  keeping the patient
cool and composed  by medicines and general treatment, which
must in such cases be the principal aim,  and by means suited to
her constitution or any peculiarity in her situation.
   There is an almost endless variety in  the  manner, in which
abortion happens.    Some  women abort  with sharp  and long
continued  pains,  which  denote that  some part of the ovum is
firmly adherent to the uterus ; others,  with little or no pain, the
ovum gliding out of the uterus almost  imperceptibly; some with
a profuse and alarming hemorrhage, others with  very  little.  In
some, the  ovum has been soon and perfectly expelled; in others,
after a long time, first the child,  then  the placenta, whole,  or in
small portions, or part of it dissolved.   But whatever other pain
or trouble may  attend, the  hemorrhage  is the only  immediately
alarming  symptom ; I say immediately, because every practi-
tioner must be convinced, that sometimes abortions either occa-
sion local  diseases, or the time of abortion is an era, from which
we may date the  commencement of some dangerous  disease of
the uterus, or its  appendages.  It has also been   imagined, that
the safety  of the patient very much depended upon the complete
and speedy expulsion  of the placenta; and when  it was retained,
very active deobstruent  medicines,  as  they were  called, were
supposed to be necessary, and strenuously given  for the purpose
of expelling it, lest it should  become putrid,  and  some of the
putrefied  particles be absorbed  into the  constituton.  1 believe
the whole of this supposition is groundless, having seen many
instances of its being expelled in a  very putrid state at  different
periods of pregnancy, when the patient was in  perfect  health ;
and if she had any  disease, the putridity of the placenta clearly
seemed the consequence,  not the cause,  of the disease.   At ail
events, much less mischief may be expected from  the retention of
a putrid placenta at this period of pregnancy, than from attempts
to force it away by  the medicines usually given for that purpose,
or by manual assistance. 
           ANOMALOUS, OR COMPLEX LABOURS.       473

   The degree of hemorrhage in abortions is  not always in pro-
portion to  the  period  of pregnancy, but it  depends upon the
difficulty with  which the ovum may be expelled;  sometimes
upon the cause, and often upon some peculiarity in  the consti-
tution, as happens in the various degrees of the menstruous dis-
charge.
   A notion of there being something mysterious in uterine he-
morrhages, different from those from any other part of the body,
has been entertained, and supposed  to occasion the necessity
of a peculiar treatment.  But it is now agreed, that the general
principles,  which  guide us in the treatment of hemorrhages
from any other part of the body,  are with equal propriety ap-
plicable to  those from the uterus.   We must  however recollect,
that in uterine hemorrhages, depending on pregnancy, there is
an additional circumstance, which we are ever to bear in mind;
that they are ultimately to be suppressed by the action of the
uterus, contracting its cavity into a less compass, of courae les-
sening the  dimensions  of the vessels, and expelling whatever
may be contained  in its  cavity.   In this  view,  uterine hemor-
rhages do certainly differ from those of any other part of the
body, because they in general, immediately or presently cease,
or are much abated, on the exclusion of the ovum.
  Hemorrhages of all kinds are  moderated, or wholly stayed,
by the formation of coagula at the orifices of the open vessels;
or by the contraction of the coats of the vessels themselves, by
which their orifices are  lessened or closed.  The latter of these
effects being stronger and more active in arteries than in veins,
may be a reason for the common observation, that hemorrhages
from arteries,  though in an equal degree, are  less  dangerous
than those  from veins, in which the power of contraction is less
or altogether wanting.   It has  been proved by physiologists,
that both these effects, that is, the formation of coagula, and
the contraction of the vessels, are favoured when the blood cir-
culates most slowly, as in fainting;  not to  mentiou, that the
quantity of blood lost in a given time will depend upon the ra-
pidity or slowness  of the circulation, as well  as upon the size of
the vessel opened.   But in a state of faintness, which speedily
follows all  profuse hemorrhages, three effects are produced at
the same time : the  circulation of the blood is more  slow, or is
altogether  suspended ;  coagula are  sooner  formed  ; and the
vessels contract more efficaciously.  During faintness,  the ad-
vantage arising from the contraction of the  uterus is likewise
obtained ; for  this acts, or makes its efforts to act, in  sleep,
during faintness, and sometimes  even after death.  Fainting
may then  be considered as a  remedy provided by  nature for
averting the immediate danger of all hemorrhages, and to pre- 
474          INTRODUCTION TO MIDWIFERY.
vent their return.  Cordials or stimulants should not therefore
be given to those who  are faint from hemorrhages,  till by the
duration of the faintness we conclude there has been sufficient
time to produce those effects, which would prevent  a renewal
of the hemorrhage, or lessen its danger, if it should return ; and
then cordials are to be given liberally, and repeated  as often as
the circumstances may require.
   The materia medica abounds with articles under  the class of
astringents, many of which are given  indiscriminately  in hemor-
rhages and  profuse discharges of every kind; nor does much dis-
tinction seem to have been  made between those which were found
useful  in hemorrhages as applications,  and those which  were given
internally.  It  has rather been concluded, that what  was  found
useful  as an external application, would, of course, be  profitable
if given internally.   It is, however, clear,  that astringent medi-
cines, properly so called, can have no immediate power of  stop-
ping hemorrhages from the uterus, or any other internal part of
the body, excepting the intestinal canal; but that every medicine
which  slackens the circulation of the blood, becomes  eventually
an astringent.  If the patient, therefore,  be at first plethoric or
heated, it may be proper to  bleed in an  incipient abortion ac-
companied with hemorrhage; though, if she be reduced to a state
of weakness, that  operation would be useless and  improper.  The
saline draughts with nitre, or nitre alone;  or  acids, mineral or
vegetable, may be given as frequently, and  in as  large a quantity
as the  stomach  can bear, as the infusion of roses, which I  have
given with much liberality,  and often found an effectual and very
pleasant medicine ; or the  gum kino with alum; or the plumbi
superacetus  ;  or  the zinci  sulphas.   Even the nausea, which
these and other medicines sometimes produce, has, by no forced
construction, been considered as an  artificial  imitation of faint-
ness, and found serviceable, and medicines have been  given ex-
pressly for this purpose; the safest, perhaps, and not  least effec-
tual of which, is ipecacuanha, in small quantities, often repeated,
so as to keep up a perpetual nausea.   Oil  of turpentine, in pro-
per doses, has been recommended, and certainly is a very power-
ful medicine in hemorrhages,  but  it seems better suited to  those
which  are habitual or of long continuance,  than to those which
are instantly profuse and  dangerous ;  the digitalis  I have not
tried, though from its power of slackening the circulation it pro-
mises to be of considerable  service.   When the discharge is pro-
fuse, cloths wet in cold vinegar may be applied  to the abdomen
and loins, and changed when they grow warm.  In Italy and
other hot countries, and sometimes in  this,  it is a custom to give
ice internally, or to sprinkle it, crushed  into small pieces,  over
the body of the  patient, who must also be exposed to, and suffered
to breathe the cold air, rendered more active by fanning.  On the 
          ANOMALOUS, OR COMPLEX LABOURS.        475

same principle clysters of cold water have been advised.  Injhort,
every application and medicine, actually or potentially cold,  the
coldest water, even ice itself, if it can be procured, may be given
and repeated with probable  advantage,  when  the  exigency oi
these cases requires very powerful assistance.
   Injections of  cold or astringent fluids, such as the liquor alu-
minis compositus,* into the vagina, have been much  recommend-
ed, as being of great service for the  suppression  of uterine hemor-
rhages.  If we attempt to throw up the injections when the blood
is flowing in a full torrent, they will be immediately rejected; and
if they be used  with the view of preventing a  return of the he-
morrhage, which has ceased, it is rather to be expected and fear-
ed that they  would occasion it, by washing away the coagula
probably formed and applied to the orifices  of the vessels.   Itoe
principal good that can be derived from them, seems to be by their
action upon the internal parts as a cold application ; and in this
view lumps of ice  have been  advantageously introduced into the
vagina.   Less  objection may, perhaps,  be made  and equal  or
rather greater  advantage will  attend the  introduction  of lint
sponge,  or any soft substance, moistened  with spirit of wine  or
any astringent liquor, into the vagina, which may serve the pur-
pose of forming coagula, and applying them to the  orifices of the
opened vessels?  But I have generally been satisfied with the ap-
plication of cloths wet with cold vinegar to the external parts, with
 so firm a pressure, that the stream of blood  should  be instantly
 retarded or  stopped.  This might have been originally done  in-
 stinctively,  to remove the immediate dread of the hemorrhage,
 and to give me a tittle time to reflect and  determine how I should
 moceed; but being persuaded that this  is of real  utility,  it is a
 Custom  with me to do it, in  the first instance, in  every  alarming
 or dangerous hemorrhage.                         .  .
    Opiates have been generally recommended as of principal effi-
 racv for the prevention of abortions, and in all cases  of uterine
 hemorrhage; but 1 seldom use them in the latter situation, unless
 with a view of moderating any unusual degree of pain, or of quiet-
 Lsome tumult which preceded,  attended  or followed the acci-
 dent, and then in moderate doses repeated according to the  ur-
 cencv of the case;  having reasoned myself into an opmion that
 fhev do not, in these cases, deserve the high commendation which
 has been given them.   Some pain  is unavoidable and necessary,
 for  the exclusion of  the ovum out  of the  cavity  of the uterus,
  * IA lump of alum alone introduced into the vagina, will often be
found, of itself, powerfully efficacious in suppressing uterine hemor-
rhage.   F.] 
476         INTRODUCTION  TO MIDWIFERY.
whenever  we have given  up the  hope of  preventing abortioe.
The degree of pain proves the degree of action raised for the
purpose,  and we should consider  how  far by lessening the pain
we may lessen the action, and by lessening that action, by which
the ovum  would be expelled, whether  we contribute to the sup-
pression or continuance of the hemorrhage,  or to the more regu-
lar  conduct of the abortion.  But when there are  the  common
symptoms of abortion without hemorrhage,  small doses of Tinc-
tura opii, often  repeated, or a clyster with thirty or forty drops
of the same tincture,  will be of great service; and in these cases
bleeding is frequently required.*
  It was  said that no manual assistance was required in the ma-
nagement of abortions, and no rule can be  more generally true;
yet there are some exceptions.  When, for instance, a  woman
who is miscarrying,  with  a considerable, or an apparently dan-
gerous hemorrhage,  or with frequent repetitions of it, is so far
advanced in her  pregnancy, that it may  be difficult to decide
whether we should deem it an abortion or  a  premature labour;
it may not be safe to rely upon  the use of  those means which
were advised for hemorrhages  in general,  and yet  the operation
of delivering would, if it were possible, be extremely difficult and
hazardous  We may then determine upon an intermediate me-
thod, which is to break the membranes.   By the  discharge of
the waters of the ovum,  which necessarily follows,  the distention
of the uterus is  lessened, of course the size of the  open blood ves-
sels, by which the  discharge had been made,  is diminished, and
the hemorrhage is  abated or suppressed.  In consequence also of
the discharge of the waters,  the uterus acquires a disposition to
act, and an ability to act with more energy, and the whole busi-
ness is sooner completed.  At a  more early period likewise of
pregnancy,  when the hemorrhage is profuse, liable to return, or
of long continuance, on examination per vaginam,  not otherwise
thought necessary, the  ovum will sometimes be found hanging in
the os uteri,  half or more of it voided out of the  cavity of the
uterus, yet eoough remaining to keep up the hemorrhage.  Then,
by  a little motion or slight impulse in different directions, it will
sometimes be cleared of the os uteri, and drop into the vagina.
But great caution  is  to be used in this operation, for if it be done
with violence, it may occasion an  increase of  the  hemorrhage,
or  be a cause of future mischief.   The relation  of the following
unfortunate case which lately occurred may be of use.
   I was desired to see a patient, in the seventh month of her preg-
nancy, who had a very profuse hemorrhage,  which had appear-
  * [Under such circumstances, larger doses of opium than are re-
commended by our author may be given with advantage.   F.] 
ANOMALOUS, OR COMPLEX LABOURS.        477
 ed about six weeks before.  The placenta was over the os uteri,
 and the gentleman first called in finding it impossible, on account
 of the rigid state of the os and cervix uteri either to pass his hand,
 or to hook down any part of the child, either with his fingers or
 any  contrivance,  had  conducted a small piece  of whalebone
 through the presenting part of the placenta, and discharged the
 water of the ovum.   The hemorrhage was immediately very much
 lessened, and did not return again with great violence,  though it
 never ceased.   About twelve hours after the  discharge of the
 water,  pains came  on,  and  a great portion of the placenta was
 forced into the  vagina.   She continued  nearly in this state for
 seven hours, when it was judged  proper to give her some assist-
 ance, by attempting  to extract her child,  and it was then disco-
 vered that a part of the navel-string and an arm were also in the
 vagina.  The child  being small,  it was  thought probable,  that
 it would come away doubled without much difficulty, by gently
 assisting, duripg a pain.  The  body  of  the child did descend
 somewhat lower, but the arm giving way, we desisted  from that
 attempt.  It was then  considered whether  it would be at that
 time possible to pass the hand into the uterus, but  on trial it was
 found impracticable.   The blunt  hook was then passed over the
 spine of the child, which was  brought away, but not without con-
 siderable force.   The instant the child was extracted,  she com-
 plained of  very excruciating pain  in the region  of the uterus,
 which contracting speedily,  was  thought to be after-pain, for
 which twenty-five  drops of tinct. opii were immediately given,
 and  repeated  without  any advantage.   The pain however in-
 creased, she became restless,  and died two hours after the extrac-
 tion  of the child, apparently in a convulsion.
   With a view to the management of similar cases,  which may
 in future occur, it may reasonably  and  properly be asked, was
 this  case well  conducted ?  even allowing,  which I believe is
 true, that what was done was well done.  To this question I
 should answer, no; for as the hemorrhage was very much les-
 sened,  and the danger thence arising removed,  there  was no
 sufficient reason to  justify our hastening the delivery by the
 means which were used, and we certainly ought to have waited
 with more patience.
   In abortions, dreadful and alarming as they sometimes  are,
 it is  a great comfort to know, that they are almost universally
 void of danger, either from  the  hemorrhage, or on any other
 account.  It is perhaps impossible  to explain  it, but the fact is
 undoubtedly true,  that an equal  loss  of  blood, and with appa-
 rently equal and immediate effects, should, in abortions, if pro-
perly managed, and the patient  be in good health when  they
take place, not occasion any  danger; and yet at the full period
of uterogestation be so dangerous that one considers the patient 
478          INTRODUCTION TO MIDWIFER7.

who recovers as having a lucky escape.   It is wonderful also to
observe, how soon women recover from the debility occasioned
by hemorrhages in abortions; and how  long a time is often re-
quired for their recovery after the same circumstance in  ad-
vanced pregnancy.   But though  I reckon there is little or no
danger from mere abortion,  yet when the accident is hi conse-
quence of acute diseases, there is  often extreme  danger;  for
women abort because they are already in great danger, and this
is aggravated  by the abortion.  Without a more accurate dis-
tinction we may still form an erroneous prognostic.  It has been
generally said,  for example, that women who miscarry, or  are
delivered at the time of their having the small-pox, universally
die.   Now if a pregnant woman should, at any period of preg-
nancy, expel her child in the commencement of that disease,
perhaps from the violence of the eruptive  fever, she may not
only escape the danger, but go through the  disease with as
much regularity,  as if she had not miscarried.  But if that pe-
riod of the disease be passed without abortion, and the patient
should go on to the time of the crisis,  and then miscarry,  the
general  prognostic will be too  true; at least the death of the
patient has followed  in every case of this kind which  I have
seen.  Since the first publication  of these observations, I have,
also  been informed of two cases of early abortion,  which have
proved fatal.  In the first, the patient became paralytic imme-
diately after the hemorrhage;  but the death of  the  second,
though she was only in the seventh week of her pregnancy,
seemed to be  occasioned merely  by the hemorrhage, or more
probably by a convulsion.

                        section v.

     On Hemorrhages in the last three months of Pregnancy.

  Under this head will  be included all the hemorrhages  which
occur in the three last months of  pregnancy,  because  from  the
danger with which they are attended, they require, and from  the
situation of the patient,  they  allow of a similar treatment when
required,  though not with equal  facility.   These hemorrhages
are occasioned, 1st. by the attachment of the  placenta over  the
os uteri;  and  this is discovered by our  being able to feel in a
common examination only a fleshy substance within  the os uteri
without any part of the membranes:  2d. by a separation of a
part, or of the whole placenta, which had been attached to any
other part of the uterus ; and this  is known by our being able to
distinguish the  membranes without any  fleshy substance.  The
first of these may be caused by the approach of labour,  dilating
the os uteri, and of course separating,  in proportion to  the de-
gpee of dilatation, the placenta; and the second by accidental 
ANOMALOUS OR COMPLEX LABOURS.       479
violence, or by some infirm or morbid affection  of the uterus or
placenta; and it  sometimes  happens without our being able to
assign any cause, equal to the suddenness and violence of the ef-
fect produced.
   Hemorrhages arising from the first cause have been considered,
and generally are far more  dangerous than those from the se-
cond ;  but these  have nevertheless  sometimes  proved  fatal.
Hence, in the estimate of the,.danger  of uterine hemorrhages at
the time of labour, it is necessary not only  to discover  the cause
and to regard the quantity  of  blood  lost, but, above all other
considerations, to attend to  the effect produced,  which is  infi-
nitely greater and more alarming in one constitution than in ano-
ther, and  varies in all.  If any individual patient, therefore, be
brought into a state of danger by the loss of blood great or
small, from either cause, it seems incumbent upon  us to put in
practice all the means in our power for the removal of the dan-
ger.   For any judgment formed upon the quantity of blood,
really or apparently discharged, will be liable to great errors, as
concealment or accident may deceive us; not to mention that
cases sometimes occur, in which there  may be a greater quantity
of blood lost, than can be known, either by  its being locked up in
the uterus beyond the child,  when the membranes  are broken, of
which I have known some very dangerous  and  some fatal in-
stances ; or by being effused into  the ovum, when  that has an
appearance of being whole.   This observation, of the necessity
of judging principally by  the effect of the loss of blood, deserves
the most serious reflection, because, the time when we are to exe-
cute what reason dictates, or experience authorizes us to do, will
chiefly depend upon it.  It is also of great importance to recol-
lect, that those hemorrhages are far more dangerous, in which an
equal quantity of blood is lost suddenly,  or in  a  short space of
time, than if it flows away slowly or at intervals.  The imme-
diate injury to the constitution is greater in the  former case,  the
vessels requiring some time to enable them to be accommodated
to the quantity of blood remaining in them, in order to carry on
the circulation.  A great and sudden loss of blood also creates a
suspicion  that  the  return of the hemorrhage is to be much
dreaded, because  if it  should  be equally profuse with that which
has already  happened, it  may occasion the death  of the patient,
before we have time to put in practice, or reap the advantage, of
what we suppose to be the only method of removing the danger.
  In hemorrhages the danger is indicated by the weakness and
quickness  of the pulse, or by its becoming and continuing im-
perceptible ;  by a general paleness and coldness of the body, and
by a ghastly countenance; by inquietude, or by continual faint-
ings ;  by a high and laborious  respiration, and by  convulsions.
The two last are usually mortal symptoms; yet  when patients 
480          INTRODUCTION TO MIDWIFERY.
 are reduced to a certain state of weakness, they are liable to hys-
 teric affections resembling convulsions, and to other symptoms
 equally alarming, but by  no means so dangerous.
    When patients  have  suffered much from loss of  blood, they
 will often have a sudden  and violent fit of vomiting; and some-
 times under circumstances of such extreme  debility, that I have
 shrunk with apprehension, lest they  should  have been destroyed
 by a return or increase of the hemorrhage, which I concluded
 would be an inevitable consequence of so violent an effort.   But
 there is no reason for this apprehension ; for though the vomiting
 may be considered as a proof of the injury which the constitu-
 tion has suffered by the hemorrhage, yet the action of vomiting
 contributes to its suppression, and to the immediaio relief of the
 patient; perhaps by some revulsion,  and certainly  by exciting a
 more vigorous action of the remaining powers of the constitution,
 as is proved by the amendment of the pulse,  and  of all other
 appearances immediately after the vomiting, which I have there-
 fore in some cases attempted  by  gentle means to promote.
   A tolerably just opinion may be formed of the danger of uterine
 hemorrhages,  in advanced pregnancy, by the pain  with which
 they are attended.  An equal hemorrhage without pain is always
 more dangerous than if the  pain be regular and acute, and the
 danger is lessened as the pain increases.  In the most dangerous
 hemorrhages,  there is no pain whatever, or none of consequence,
 and patients have often died, or  been brought  into the most im-
 minent danger, that is, into situations from which it was scarcely
 possible for them to recover,  whilst the practitioner was  waiting
for the accession of the pains of labour.  The reason was before
mentioned.  The  pain proves the degree of the action  of the
uterus, and the action of the uterus proves that the  powers of the
 constitution  are not  exhausted.  In very bad cases there is be-
fore delivery an effort in the uterus to act, just  sufficient to cause
 a  renewal  of  the  hemorrhage ;  but immediately  upon the
discharge of  a gush of blood, the effort, together with the  little
pain attending, ceases; and in this manner patients would some-
times proceed  to the moment of their death, unless they were re-
lieved by art.

                         section VI.
 Hemorrhages in which the placenta is attached  over the os uteri.
   Those hemorrhages, which are occasioned by the  attachment
 of the  placenta over the os uteri, are  first  to be considered, be-
cause they are  attended with the greatest dangi-r, and  because
some part of  their treatment will apply in the other  cases to be
described.
   Though the placenta be attached over the  os uteri,  the woman
usually goes through the early part  of her  pregnancy  without 
            ANOMALOUS, OR COMFLEX LABOURS.       481

any inconvenience, or any symptom, at least, which denotes that
circumstance.   But when  the cervix of tlie uterus is distended to a
certain  degree,  or when  the changes previous  to  labour come
on, there must  be a hemorrhage,  because such  distention, or
change, wjll necessarily separate a part of the placenta.*  This
hemorrhage is often, but  not always, in proportion to the space
of the placenta attached over the os uteri, or to the quantity sepa-
rated, for women have sometimes been in as great danger when
the mere edge of the placenta was  fixed upon  the os uteri, as if
the middle had been placed over it; especially  if the part separa-
ted be near the insertion of the funis, where the blood vessels are
large.
  When hemorrhages from this cause once come on,  though all
women  without proper assistance would not  die, none are free
from danger, till they are delivered.  As there is a very doubtful
chance of the  accomplishment  of the delivery by the  pains of
labour, and as  experience has fully proved  the frequent  insuf-
ficiency of all other methods,  intended to suppress  the hemor-
rhage, and how little reliance ought to be placed on them, though
they are always to be tried; it is a practice, established by high
and  multiplied  authority, and sanctioned by success, to deliver
women  by art,  in all cases of dangerous hemorrhage,  without
confiding in the resources of the constitution.   This practice is
no longer a matter of partial opinion, on the propriety of which
we may think ourselves at liberty to debate; it has for near two
centuries met the consent  and approbation of every practitioner
of judgment and  reputation,  in this and many other countries.
(See Mauriceau, and almost every  succeeding writer.)
  There is much comfort  in knowing and possessing a remedy,
to which we can recur, with a more than equal chance  of suc-
cess, in  any case of great and imminent danger.  But though it
should be allowed, that the artificial delivery of the patient, in
every case of dangerous hemorrhage, in advanced pregnancy, is
generally expedient and necessary for the preservation of the life
of the patient;  and though the practitioner, who should neglect
  [* The recurrence of the hemorrhage during each pain  may be
considered as sufficient evidence of the attachment of the placenta
to the os uteri.  But  this  as well as other symptoms being some-
times equivocal, our most certain knowledge is derived from an exami-
nation of the os tincae by the touch.  Having ascertained the existence
of such attachment,  the practitioner will be the more guarded in his
conduct, and scarcely wait,  before he acts, for the debilitating effects
of liemorrhage on the constitution, as he  perhaps may justly do
when the discharge arises from a different situation of the placenta.

                             61 
482
INTRODUCTION TO  MIDWIFERY.
it would be very reprehensible, yet that necessity,  presuming it
to arise solely from the  loss of blood, or that expediency, which
constitutes  the authority for the  operation,  and which  is  now
clear and  distinct to another, may  not appear  to me.   Besides,
should the necessity be acknowledged, and the practice approved,
there  may be much dispute and  difference of opinion  about the
time when the operation ought to be  performed.
   It may be  observed, however, that patients who are reduced
by hemorrhage to a state of extreme weakness, should not then be
delivered by art, even though the  hemorrhage should  have cea-
sed ; but we are to wait till the patient is somewhat  recovered
from her faintness or extreme debility, and then deliver by pass-
ing the hand and extracting the chil I,  without expecting the pains
to return; as  the hemorrhage may return instead  of the pains,
and the patient suddenly die.
   It would be of great advantage in  practice, if some mark were
discovered, or some symptom observed, which would indicate the
precise time when  women with hermorrhages Of this kind ought
to be  delivered.  But though we  do not at present  know any
such  mark  or symptom, and the determination of the  time  is to
be made by the judgment of each  individual practitioner, we
may be permitted to state what we do  know in the most convin-
cing point of view.
   Ad  fitting, then, in the first place,  that women having  uterine
hemorrhages from  this cause, in advanced pregnancy,  are not in
safety till they are delivered ;  that the natural efforts are general-
ly uneqml  to  the expulsion of the child; that the hemorrhage
can only be stayed by the evacuation  of the contents of the uterus,
giving an opportunity to the vessels to  contract  and to close;
that these  salutary  effects may  be produced as certainly by an
 artificial extraction, as by a natural  expulsion  of the  child ; and
 if it be moreover true, that the operation, though  performed be-
 fore it is absolutely necessary, is not attended  with danger, if it
 be performed in a  proper manner,  and with due care;  but that if
 the operation be delayed  beyond the proper time,  it will not an-
 swer the purpose  for which it is  recommended;  we  may from
 these  premises conclude, that a woman under the circumstance  of
 dangerous hemorrhage ought to be delivered by art, if the natura 1
 efforts be unequal to the expulsion of the  child ; that it is  better
 to deliver too  soon, than  to delay  the delivery a moment too
 long; and that in every case of doubt, it is a proof of wisdom to
 decide, and determine upon speedy delivery; at least,  that it be
 not delayed beyond the proper  time.
    If,  however, we were certain that the placenta was attached over
 the os uteri, it would seldom be necessary to deliver  women on
 the first appearance of the hemorrhage; yet that will be sufficient
 to awaken our apprehensions, and set us upon our guard.   Nor 
ANOMALOUS, OR COMPLEX LABOURS.
483
does it often happen that  a  second ^ even a third discharge
obliges us to proceed to deliver immediately: because each return
may not be in such a quantity, as by its violence or continuance
to endanger the life of the patient, or apparently very much to
reduce her strength ; and such an interval may pass between the
returns, as to give time and opportunity for repairing the mischiel
done by one loss of blood, before the return  of another.  Nor is
delivery by art necessary, or usually proper, when the hemorrhage
is abating:   There are cases,  however, in which the quantity of
blood  lost, the  suddenness of the discharge, and the effect pro-
duced,  are such with one hemorrhage, as to  make it evidently
unsafe to trust a return; and whenever  the  countenance,  and
other appearances, indicate  that the constitution is much  impair-
ed, by repeated, though not  profuse discharges, the strength is
by degrees undermined, and danger creeps on certainly, though
insidbusly.   For we may presume, that every constitution is ca-
pable of bearing the loss of a certain quantity of blood,  without
the instantaneous hazard of life,  and this will depend upon the
general  state of the body.   Now, the body may  be  reduced to
such  a stale, that there is barely a sufficient quantity of blood  or
of powers, to carry on the business of life, upon a very nice ba-
lance; and of course the additional loss of a small  quantity  may
 altogether destroy the power of living, and  the patient die of the
 hemorrhage, though  the quantity of blood which shall imme-
 diately precede her death may be small; but unfortunately she
 was able to bear the loss of none.   We should, therefore, though
 careful  not to  act rashly and unadvisedly,  not only be on our
 guard against  the effect of  rapid and  profuse discharges, but
 against those which  are productive of as much danger, on ac-
 count of their returns,  though less  in degree  at  any one  time.
 We should ever call  to mind the possible evil of delay, and re-
  collect that there is little danger in a premature delivery, if  the
  operation be performed with prudence ;  but that the delay of one
  hour will sometimes deprive  us of all chance of success.
    Those who are young in practice, or of timid and anxious dis-
  positions, often suffer much  solicitude  from the apprehension of
  danger, when it  does not exist in these  cases,  which, for  many
  reasons, I consider as highly proper for a consultation, when it

  ^l^LC^s', in which it has been presumed  to be necessary
  to deliver the patient on account of the hemorrhage, the   parts
  have  been in such a state, that the operation  could not,  it was
  thought, be performed  with  safety.  Whenever the case demands
   he  operation, on account of the danger of the hemorrhage, the
  state of the parts will on this account always allow  it to be per-
  formed with safety, though not with equal facility ; and though it
  may be often necessary to determine speedily upon the  propriety 
484
INTRODUCTION TO MIDWIFERY.
 of the operation, this should never be performed rashly, but al-
 ways with the utmost deliberation and  slowuess, even though it
 might admit of haste,  For in hemorrhages a woman ma\  perish
 from two errors in  practice;  from  delaying the  operation  too
 long, and from the rude, violent  or  improper manner in  which it
 may be performed, even at the most eligible time.
    Sufficient notice hath been taken of the danger of precipitating,
 as well as that of delaying the delivery, in cases of hemorrhage.
 With  respect to the operation, the first part,  that is, as far as re-
 lates to the position  of the patient,  the introduction of the hand,
 and the  dilatation of  the  os  uteri,  has been already described
 under preternatural  presentations.  When the os uteri  is with
 great caution sufficiently dilated  to allow of the ready admission
 of the hand, and we come  to the  placenta attached over it, it  is of
 little consequence whether we  begin to separate this till we come
 to an edge, and go  up on the outside of the membranes, which
 may be ruptured at pleasure; or whether we perforate  the  sub-
 stance of the placenta, and conduct  the  hand directly into the
 ovum, though by the latter  method there  is  rather more danger
 of losing the child;  but the determination may depend upon the
 greater or less  proportion of placenta attached over the  os uteri.
 In either case, without regard to the  position of the child, we
 must proceed to, and lay hold  of its foot or feet, carefully distin-
 guishing that  they are the feet, before we  begin to extract them.
 Immediately  on  our beginning  to  withdraw  the  hand,  which
 should be done with a slow waving motion, the waters of the
 ovum Qow away ; and while they are flowing, we must withdraw
 the hand, grasping the feet of the child, till by slow degrees these
 are brought into the vagina.  We  are afterwards to wait till the
 ute us contracts, and then gently bring the  feet through the ex-
 ternal  parts.   It is  not improbable  but we may then have the
 power of finishing the operation very speedily ; but though the
 child were extracted if the uterus did not act, and, as it were, fol-
. low the child, as  there would  be a chance of the hemorrhage re-
 turning, the child should  be withdrawn according to the degree of
 the contraction of the uterus, which will be known  either by the
 application of the hand to the abdomen, or by the pains.  Nor is
 there any occasion  at this time for  hurrying  the delivery, for the
 hemorrhage usually  (eases as soon as the child is turned, in  con-
 sequent e of the compression made upon the orifices of the vessels
 by die inferior parts o'" the child, as well ashy the contraction of
 the uterus.   If the  labour pains be at all  efficient at this time, it
 would be proper to leave the breech of the child to be expelled by
 them ; but if they be  not sufficiently strong for this purpose, as-
 sistant e  must be given, gently extracting by the feet only  during
 the continuance of the pain, not with force sufficient  to bring it
 away, but with the view of aiding the feeble power exerted by the 
ANOMALOUS, OR COMPLEX LABOURS.
pains;  imitating  also  the pains in the manner of  extracting.
When the breech  of the  child has passed  through the external
parts,  the delivery  must  be hastened, as there is then danger of
the child  being destroyed by the pressure  upon the funis.  Yet
under such circumstances there is often a better chance of preser-
ving the child, by  leaving it to be wholly, or in a great measure
expelled, than by extracting it with violence, as hath been before
observed.
  When the child  is born, if the operation were slowly performed,
there is not usually a'hy continuance or return of the hemorrhage,
unless  from the blood previously  discharged,  and  locked up
behind  the body of the child.   This is in spme cases in a very
considerable quantity, and rushes away violently the moment the
child is born, but it ceases almost as speedily, not requiring any
immediate manual  assistance.   But if  the hemorrhage should
continue or return, the case must be managed, as will be recom-
mended, when we speak of hemorrhage with a  retained placenta.
If there be  no hemorrhage, and the placenta  be retained,  we
must be particularly cautious not to hurry  it away;  but in these
cases it is commonly expelled with great ease, and  we have less
occasion to  be solicitous,  because  from the part where it was
originally attached, it more readily admits of  assistance if re-
quired.*
  Should  nothing uncommon happen in the delivery,  children
will often  be  born  alive, in cases  of hemorrhage,  which  were
extremely dangerous to the mother; and there have been many
instances in which the delivery being too long delayed, a living
child has been extracted, after her death.   In all cases of danger,
these in particular, the safety  of the parent, and the preservation
of the child, are events which give inexpressible satisfaction, and
adorn  the reputation of the practitioner.

                         section vii.
On hemorrhages occasioned by the separation of the placenta from
                     any part of the uterus.
   It was before  observed,  that those hemorrhages  which are
occasioned by the  separation of a portion or  of the whole placenta,
originally attached to any part of the  uterus, except the os uteri,
   [* In cases of this nature, the  placenta will generally be wholly
detached  and forced into the vagina immediately after the del/very
of the foetus.   The  contractive power of the uterus is sometimes
very remarkable.   A case occurred to Dr. K. S. Kissam of this city,
in which  the placenta was thrown off  and expelled eQtire from  the
mother, and in about three minutes  aftn-a living child followed. Thi-s
was doubtless an instance of the attachment of the placenta over the
os uteri.   F.] 
486
INTRODUCTION  TO MIDWIFERY.
were not generally so  dangerous as those last  described.  But
if the separation be extensive and sudden,  they will be  equally
alarming, the real danger may be as great, and the same method
of proceeding,  that is, speedy delivery by art, may, though not
so generally, be required.  The separation may be occasioned
by great violence  from external accidents  in  the latter part  of
pregnancy ; or in some intense fit of fainting or of laughter ; and
sometimes the whole or a very large part of the placenta will  be
separated suddenly,  without  any  accident or  symptom which
could give  warning or apprehension, that Such an event was  to
be dreaded.   The  separation of the placenta  may then  happen
previous to the commencement,  and it is less surprising  that it
should sometimes occur during any period or stage of labour.
   When  sudden and violent discharges of blood happen from this
cause to women with child,  in advanced  pregnancy, from exter-
nal accidents, if the patient be kept in a cool and composed state,
the discharge may  cease, and  without any return, the patient may
go on to her full time,  and  be delivered by  her natural pains,  as
if no such accident had happened;  though the child will general-
ly be still born.  Sometimes, however,  the hemorrhage will re-
turn, or it may commence in any stage of a  labour, and our con-
duct must be regulated by the degree and probable consequences
of it, and by the state of the labour when the hemorrhage is first
discovered.
   If any considerable  hemorrhage should come on in  the begin-
ning of a labour, or previous to it, and  if the treatment must in
any  measure depend upon  the  cause, it is  necessary  in the first
place that we should ascertain whether the placenta be attached
over the  os uteri, or be casually separated.  Before there is some
degree of dilatation of the os uteri, be the discharge ever so pro-
fuse, and it may even at this time be excessive, I do not know that
it is always possible to tell with certainty whether the  placenta
present or not.   It may indeed  be conjectured, that the placenta
is there attached, by the cushionlike feel of the cervix  and lower
parts of  the uterus; but when the os  uteri is somewhat dilated,
instead of  the membranes, the  fleshy substance of the  placenta
may  be  readily distinguished.   Yet  every practitioner knows
how very different the state of these parts is in  the beginning of
labour, and how difficult it must sometimes be to distinguish be-
tween  a firm coagulum of  blood  and the placenta ; not to men-
tion that so small a part of the placenta may be attached over the
os uteri,  that unless we could  pass the finger completely round
the circle, which is sometimes almost impossible, it could not be
discovered.   Taking therefore into consideration all the varieties
occasioned by either of the causes of hemorrhage, and knowing
that neither the performance of the operation,  nor the event,  is
materially  different,  whatever  may be  the cause,  provided the 
ANOMALOUS, OR COMPLEX LABOURS.
487
discharge and its effects are equal, we must be careful, that we
are not deceived by attempts to make too nice distinctions. (See
an essay on this subject, written by Mr.  Rigby, an able and ex-
perienced surgeon at Norwich.)
  From a casual or spontaneous separation of the placenta, not
attached over the os uteri,  a  hemorrhage may happen in the be-
ginning of labour, when the os uteri,  for example, is not in any
material  degree dilated ; or when it is dilated to a third or half
its extent, or any other degree.   If the discharge should  be so
great as to require some present measures for the  relief  of the
patient, the methods before advised must  be put in practice, and
the common assistance for promoting the dilatation must be given,
till  we can feel distinctly the membranes  of the ovum,  which are
to be ruptured.  By the discharge of the waters the distention of
the uterus will be lessened,  the size of the blood-vessels of course
diminished, and the hemorrhage in general  immediately removed
or very much abated.   By the suppression or abatement of the
hemorrhage, the action of  the uterus  will be rendered stronger,
and the delivery very  often completed in a short space of time
without  farther assistance,  especially if the patient have before
had children.
  In every case of dangerous or considerable hemorrhage,  when
we  can distinguish the membranes, it  therefore seems to be right
and justifiable to puncture  or rupture  them, and to discharge the
waters;  especially when we  can  determine the  presentation of
the child to be natural.
  But if the hemorrhage should come on in the second stage of
the labour,  that is, after the full dilatation of the os uteri, and the
rupture of the membranes,  when the child's head has entered and
in part descended into the pelvis ;  if the discharge be of sufficient
importance  either to prevent the action of the uterus, or to bring
the life of the patient into hazard,  by its violence  or continuance;
then the assistance given must depend upon the  progress which
the labour has made,  and the situation of  the child, whether it
shall be  turned,  as in preternatural  presentations,  or delivered
with the forceps or vectis;  or when neither of these is practica-
ble, and the exigency  of the case justifies the  operation, by les-
seningthe head of the child ; that is, the life of the parent must
at all events, if possible, be preserved.  But such cases are rare,
and always require accuracy of judgment,  and the greatest cir-
cumspection.
   Hemorrhages of this kind are also sometimes combined with
preternatural presentations of the child.   Then  little more will
be  required, than what may  be necessary on account of the pre-
sentation, except that it be  sooner decided, and more speedily
performed ; remembering  ever,  that  all operations  in  midwifery 
488          INTRODUCTION TO  MIDWIFERY.
are intended to remove, lessen, or prevent natural or adventitious
danger, and not to add to that which before existed.
  This method of proceeding, that of accelerating the labour by
breaking the membranes, recommended in this  kind  of hemor-
rhage, seldom fails to answer the intention of moderating or sup-
pressing the discharge, and  of promoting the labour in such a
manner, as to remove the danger.  The only inconvenience to be
apprehended is, that if the hemorrhage should continue in such a
degree, as to occasion the necessity of artificial delivery, the ope-
ration would be rendered more difficult on account of the previous
discharge of the waters.   But in reply to this objection it may be
observed, that if the uterus should contract round the body of the
child, with so  much force as to prevent  the introduction of the
hand  to turn the child with facility, that  it will probably be  ex-
pelled without any farther assistance, if we wait patiently for the
return of the  pains,  which we  may safely do when the hemor-
rhage is stayed, or very much abated.  But if in common cases
there  be not sufficient force exerted by the uterus for the expulsion
of the child, then there will be no great difficulty in passing the
hand  into the uterus.   It must  however  be acknowledged, that
this is sometimes  amongst the cases, for which no precise rule
can be  laid down, and in which  the practitioner must act, ac-
cording to his own estimate of the danger and difficulty.

                        SECTION VIII.
  Of Hemorrhages which come on  immediately, or soon after the
                     birth of the Child.

  It is often a mortifying reflection, whilst we are conducting a
patient through a labour rendered  uncommonly tedious by the
inactivity or irregular action of the uterus,  that we can foresee
after  the birth of the child an unfavourable separation of the pla-
centa, which cannot be prevented.   All that art has dictated to be
done  in this case is, to suffer the body of the  child  to be wholly
expelled by the action of the uterus, after the head is born; or in
some cases rather to  retard its final expulsion, than to use any
force or hurry in extracting it, and  by this proceeding the lower
parts of the cavity of the uterus will  be restrained  from closing
before the fundus assumes its proper share of action, contracting
irregularly, or closing.   Yet no method, nor  any dexterity  will
be sufficient in all cases to prevent,  after  the birth of the child, a
troublesome, and sometimes a dangerous hemorrhage;  the pro-
per management of which often requires as acute an intelligence,
and as determined a conduct, as any circumstance which relates
to the birth of the child.  As the powers of the uterus  or of the
constitution are sometimes not exerted, or fail to answer the pur-
pose, and as no woman can be properly or safely left till the pla- 
            ANOMALOUS, OR COMPLEX LABOURS.       489

 centa is excluded, it is necessary to consider this subject in a full
 and explicit manner.
   From a  review of what has been  said on the management of
 the placenta by Hippocrates, or in the writings contained in his
 works, it does not appear to have been  the general custom to di-
 vide the funis before the placenta was expelled ; that if this were
 retained beyond the common time, no means, or but very gentle
 ones, were used for the purpose of bringing it away ; and in cases
 of its retention, it  was usual to  introduce medicated substances
 into the vagina, and to give  hysteric medicines for the purpose of
 favouring its  expulsion, which  might happen  on  the fourth or
 any subsequent day, when it might have become  putrid.   The
 introduction of the  hand into  the uterus, for the purpose  of
 bringing away a retained placenta, had not been then advised to
 come into consideration, and cases requiring such conduct would
 probably very seldom occur.  Whether this practice were  gra-
dually altered, or another hastily assumed, it is impossible to say;
but it is extraordinary, that Celsus,* without expecting or relying
upon the natural efforts made to eject  the placenta,  of which he
seems indeed to have had an imperfect  knowledge, should have
directed the practitioner  to  introduce his hand  into the uterus,
immediately after the birth of the  child, to bring  the placenta
away, together  with any   coagula  which might have. been
formed in the cavity of the uterus.  These two contrary methods
have, in different times  and countries, been adopted and recom-
mended by  succeeding writers;  but unfortunately,  the practice
of Celsus prevailed  more universally.  The  Arabians,  though
fond of the study of medicine, seem rather to have preserved, than
improved or extended the learning which they gained, when they
plundered the  eastern part of the Roman Empire.  But in the
fifteenth century, which may be considered as the era of the revi-
val of learning, Pare published, among many valuable works, ob-
servations on the practice of midwifery,  under the title of the Ge-
  * Medicus deinde sinistra manu, leniter trahire umbilicum ita, ne
abrumpat, dextraque eum sequi usque ad  eas, quas secundas vocant,
quod  velamentum infantis intus fuit: hisque ultimis apprehensis,
venulas membranasque omnes, eadem  ratione manu diducere a
vulva, totumque illud extrahere, et, si quid intus praeterea concreti
sanguinis remanet.—Celsus, lib. vii. cap. xxix.
  1 may be permitted to observe, that many of the popular opinions,
on medical subjects, are now the same in this country, as those en-
tertained by the Roman writers.   It is probable, that they were first
introduced by those physicians  and surgeons who attended the Ro-
man armv in Britain, and not acquired by the study of their writings.
                              62 
490          INTRODUCTION TO MIDWIFERY.
nerationof Man.   Pare",* who had an understanding to see, and
to profit by the errors of others,  seems desirous of avoiding all
extremes; for with an injunction  not  to  leave  the placenta  be-
hind, he recommends,  in strong and  repeated  terms, the neces-
sity of extreme caution, not to use violence, lest  we  should  in-
vert, or do other injury to the uterus ;  and there is no doubt,  but
the opinion of so eminent a man must have had its influence upon
the practice  and writings of  others,  particularly of those 01 his
own country.  In the latter end of the sixteenth, and the begin-
ning of the seventeenth century,  Ruysch was in high reputation
as an anatomist at Amsterdam,  and he was empowered  by the
magistrates to inspect  and regulate  the  practice of midwifery
throughout that city.  Ruysch had great  industry and abilities;
nnd his pursuits in anatomy,  and his office,  as president of  the
Obstetric  College,  leading  him  to  the knowledge of many
bad consequences which followed the common  method of mana-
ging the placenta, particularly the inversion of the uterus,  he la-
boured the point with great knowledge and ingenuity  in many
parts of his works ; discountenanced the practice, and forbad the
placenta to be extracted hastily,  choosing clearly to run the ha-
zard of the evils which  might follow the imperfections of nature,
rather than of those which would be incurred by the harsh  and
violent method then  in use.t   For many years after the  time of
Ruysch, the  practice of Celsus was followed in this country, by
some even down to this time,  but not universally; for in a large
manuscript, written on the subject of midwifery by Dr. Percival
Willoughby, Physician at Derby,  in the time of the Civil War, a
copy of which came into my possession  by the kindness of my
very able and intelligent friend, Dr. Kirkland,  there is this obser-
  * Not having the French edition of Pare", I transcribe the follow-
ing from the Latin translation.   Molli si fieri potest umbilici tractu ;
quod si sic non licet, obstetrix oleo inunctum manum, blande in ute-
rum immittat, ducem secuta umbilicum, sicque comprehensas, si ad-
huc hasreant utero, leniter hac et  iliac concutiat,  et sic concussas,
leniter extrahat;  non autem violentius educat ne una sequens uterus
procidat.
  t Prudentius ergo relinquere placentam, donee natura hanc se-
parat, aut donee laxata, magisque libera, manu evellere hanc detur,
quam  lethali festinatione occidere aegram.   Putetne quis, boni quid
contigisse trucidatae mulieri,  quod mortua sit sine placenta?  Quae
cum ilia  poterat  vixisse!  Ruysch. Advers. Anat. Dec.  Secunda.
Some  allowance is to be made  for the arguments of Ruysch, which
were intended to overset the bad practice of his  time.  For if the
placenta  were to be left entirely to nature in all cases, there would
not be wanting many examples of mischief and  fatal consequences
from the  very method which he recommends. 
ANOMALOUS, OR COMPLEX LABOURS.        491
 vation : the after-birthe oft cometh of itselfe, yet it is not amisse
 to assist nature for the producing of it. There bee some midwiues,
 that never offer to fetch the after-birthe, but suffer nature to expell
 it, and their women have done well.   The practice of extracting
 the placenta immediately after the birth of the child was neverthe-
 less common in this country, which I am certain  must often have
 produced  both much  immediate and  future mischief.   It was
 taught in the second school of midwifery established in London
 by Chapman in 1733; by Sir Richard Manningham, in the pub-
 lic  establishment  set on foot for the purpose of teaching mid-
 wifery, in the St. James's  Infirmary,  in the  year 1738; and by
 Smellie,  who I  think came to London about  the year 1742.
 Soon after this time, in 1746, Dr. William Hunter began to give
 lectures in anatomy ; as an appendage to which,  he added a cer-
 tain number of lectures on the  anatomy and physiology of the gra-
 vid uterus, interspersed with many important practical observa-
 tions.  With a mind composed and finely turned for observation,
 with a judgment exceedingly correct, and with unwearied appli-
 cation, Dr. Hunter soon acquired very high  and deserved repu-
 tation ; and the great character he established in the practice of
 midwifery,  for which his  person and manners  weTe admirably
 well calculated, and in which  he  was soon and very much enga-
 ged, give a more than usual  authority to what  he advanced on
 the subject.   Being* an associate with Dr. Sandys  for the care
 of the lying-in department in the Middlesex Hospital,  he  propo-
 sed to Dr. Sandys, that they  should  try the event of leaving the
placenta to be expelled by the action of the uterus, without at-
tempting to give  any assistance.  After much consideration and
 some delay from the dread of censure,  they agreed upon the
 trial; and in the  first  instance,  the  placenta remained twenty-
 four hours.  No  ill  consequence, however,  followed; and the
trials being repeated with success, it became a very frequent, and
 almost general rule, to leave  the placenta to  be expelled without
 any  assistance.  Several untoward and  some fatal  accidents
 having followed this practice, it was altered :t at least it became
 necessary  to admit many exceptions; and  after a variety  of
 changes and observations, 1 believe we are at length arrived at a
 state of practice, with regard  to the management  of the placenta,
 that will with difficulty be improved ;  a practice founded on com-
 mon sense and  observation ;  that the placenta ought to be, and
  * This account I had from Dr. Hunter himself.
  t [By the hazardous experiment of permitting the placenta to re-
main until spontaneously expelled, the celebrated Dr. William Hun-
ter is reported to have  sacrificed the lives of five mothers in  one
year.   F.] 
492
INTRODUCTION TO MIDWIFERY.
 is generally expelled by the action of the uterus, in the same man-
 ner as the  child; feeling ourselves at liberty and called upon to
 assist, only when this  action  is  not equal  to the purpose,  or
 when hemorrhage or other dangerous circumstances demand  our
 assistance.

                          SECTION IX.
                On the exclusion of the placenta.
    In  the course  of  ten or twenty minutes, or a short time after
 the birth of the child, sooner or later, according to the condition
 of the patient at the time of her delivery, the action of the uterus
 returns for  the purpose of expelling the placenta and membranes,
 which collectively have the common name of sectmdines, or af-
 ter-birth.   This  action is indicated by pains in all  respects like
 those  the patient had before the child was born, excepting their
 degree.  When these pains come on, it is customary to take hold
 of the funis, by which if we  pull  slightly,  the evacuation of  the
 placenta out of the uterus will  be forwarded, without the risk of
 doing any kind of injury to the uterus.   The placenta and mem-
 branes form a complete lining to the uterus : but the placenta
 coming away first, and then the membranes, the whole is usually
 expelled in  an  inverted state ; yet not  always, as the separation
 of the placenta is,  in some cases, so speedy, that it drops into the
 vagina,  and pushes the  membranes before it.   But though the
 placenta is generally expelled in a short time after the birth of the
 child,  and with the return of a few pains, it is sometimes retained,
 on account, 1st. of the inaction of the uterus; or 2d. of the irre-
 gular  action of the uterus;  or 3d. of a scirrhous adhesion of the
 placenta to  the uterus.   It may be retained beyond the usual
 time, without any  hemorrhage, but whenever there is a discharge
 of blood, the whole or a portion of it must have been previously
 separated;  and the hemorrhage may continue,  or  increase,  or
 cease and return in these cases, till the  placenta  is extracted  or
 expelled.  Every discharge of blood at this time, properly speak-
 ing, is hemorrhage; but to this term,  together with  the other
 parts of the  definition, we annex the idea of such a loss of blood,
 as, by its continuance or degree, may be  apprehended to occa-
 sion danger, which we are ever to bear in mind; otherwise  on
 every slight discharge of blood, we might be led to make unneces-
 sary attempts to extract the placenta by art.
   A very strenuous and long continued exertion of all the powers
 of the constitution, is often required for the expulsion of the child.
 These  powers, though generally adequate to this effect, sometimes
 fail before it is accomplished.  But experience having shown, that
 difficulties, to our  apprehension insurmountable, are very fre-
quently overcome by the natural efforts, both reason and humani-
ty forbid or  discourage all hasty determinations to pursue such 
ANOMALOUS, OR COMPLEX LABOURS.        493
 measures,  as may  affect the safety of the mother or the child.
 But as there is a leaven of imperfection in all human actions, ani-
 mal as well as moral, we may sometimes be led, by the most com-
 mendable motives, to defer that assistance,  which any particular
 case may require, so long, that after the birth of the child, the
 patient may be in such an exhausted state, and the uterus so com-
 petely devested of all power of farther action, that it  is neither
 disposed nor able to  separate or eject the  placenta;  and she is
 scarcely able to support the necessary consequences of her delivery.
 The mere debility of the patient is therefore  often  a  powerful
 reason why we ought to wait, without making any attempts  to
 hasten the separation or extraction of the placenta; as an imme-
 diate separation, natural or artificial, would render her still  more
 exhausted  and feeble, and greatly increase tlie  danger arising
 from that debility, which before existed.   Sometimes also,  when
 a labour has gone on with great activity, there is, for a consider-
 able time  after,  and from  the moment of the expulsion of the
 child, even though the labour may not have been very fatiguing
1 or slow, a total inaction of the uterus, for which no reason can
 be  assigned.   But  if the  time which passes  between  the  birth
 of the child and the expulsion of the placenta, be employed  in
 composing the patient's mind, in cooling her when overheated, or
 in supplying her with proper cordials when much fatigued and
 wearied  with the preceding  Circumstances, in  short, in restoring
 her to her natural state, it generally happens,  and we may rea-
 sonably expect the action of the uterus to  return, and  make its
 efforts to throw  off the placenta in the usual manner, though
 more time may be required.   But during this  time of waiting for
 the action  of the uterus to return, should hemorrhage come on,
 we  must apply ourselves to the use of those means, by which the
 separation and exclusion of the placenta may be forwarded ; there
 being (in a case of hemorrhage equally urgent) as justifiable  a
 reason for the removal of the placenta, when that is retained,  as
 there was for the extraction of the child.   But every discharge
 of blood is  not a sufficient  reason for the introduction of the
 hand, or for the artificial extraction of the placenta, as some loss
 of blood most frequently precedes, and always accompanies both
 its separation  and exclusion.  We must, therefore, form a judg-
 ment of the necessity of extracting the placenta, by the opinion
 we  entertain of the hemorrhage heing so  profuse as to  endanger
 the life  of the  patient by its continuance  or  probable  increase.
 Sometimes also coagula are discharged in considerable quantities,
 which,  from their appearance, might be  suspected to  have been
 formed in the time  of, or before, labour,  by an effusion  of blood
 into the ovum, from the rupture of some vessel which  ran over
 the surface of the placenta ;  which coagula do not indicate any
 danger.   It is not exactly in order, but  it must, nevertheless, 
494
INTRODUCTION TO MIDWIFERY.
be observed in this place, that when I have been attending wo-
men, who were prone to violent hemorrhages after the birth of
the child in former labours, I have made it a rule to keep them
in an  erect position, till the  waters  were discharged by  the
spontaneous breaking of the membranes,  and the child was
on the point of being born.  By this method it appeared clearly
to me, that the uterus acted more favourably, the placenta came
away more naturally, and the quantity of blood lost  was often
very much diminished.
  When the placenta is not separated or ejected in  due time
after the birth of the child, with or without hemorrhage, means
must be used for the purpose of its exclusion or extraction.   If
there be no hemorrhage, or none of  importance,  it is always
better to wait than to interfere, because slight attempts to  ex-
tract the placenta by pulling by the funis may be just sufficient,
by loosening a portion of the placenta, to occasion or increase
hemorrhage, and not equal to the  extraction of the placenta ;
and such conduct  is a very frequent cause of a degree of  he-
morrhage, which may afterward lay us  under the necessity of
introducing  the  hand into the  uterus, in order to bring away
the placenta, which operation  might not otherwise have been
required.   But after a  certain time,  which is too indefinite a
term if we  were authorized to  employ one more precise, but
certainly not within one,  perhaps two, or even more hours, af-
ter the birth of the child, unless we are compelled by hemor-
rhage or some untoward symptom, only very gentle means are
to be used to favour its exclusion;  and the most  gentle  must
be first tried, as by giving and  frequently repeating  some ac-
tually warm and temperate cordial, which may renew the dis-
position in the uterus to act;  by change of  position to the op-
posite side, should the uterus decline in an unsupported way to
the side of the abdomen; when it is always to be held in a pro-
per direction by a  pillow, or some such means; by  making a
moderate pressure with the expanded  hand upon the abdomen,
to aid the action of the uterus ;  or by pulling very  moderately
by the funis, to try whether it be disposed to come away.  As
the term moderate  has no precise meaning, and what I call vio-
lent, may by another be called moderate, we  will say that so
much force is on no account to be used in pulling by the funis,
as to incur the risk of tearing it from the placenta, or of  in-
verting the  uterus ; and  that  it  is better to make it a general
rule, to prefer the introduction of the hand  into the uterus, to
separate and bring  the placenta away,  than to incur the hazard
of either of these accidents.   It is, however, to be observed,
that when the hand is introduced for this purpose, there is not
always a necessity  of acting ; for the  very  irritation  thereby
occasioned will often excite the uterus to its natural action, and 
          ANOMALOUS, OR COMPLEX LABOURS.       495

the placenta be both separated and expelled, as will be recol-
lected by every one accustomed to this operation.   But the
hand ought never, on any account, to be introduced into the
uterus,  except as a matter of necessity, and then with  the ut-
most care and tenderness ; and when introduced, should never
be withdrawn, till the end for which it was introduced is, if pos-
sible, accomplished.
  In writings,  and in conversations on this  subject,  the intro-
duction of the hand,  for the purpose of bringing away a retained
placenta, is often mentioned as a slight thing; but 1 am  persua-
ded, that every  person, who attends to the consequences  of
practice, will think it of importance, and that, if possible, it al-
ways ought to be avoided.
  To promote the separation and exclusion of the placenta, the
application  of the half-closed hand  to  the  abdomen,  so as  to
make a moderate pressure,  is sometimes of use by aiding the
uterus in its contraction, but this assistance cannot be given in
the worst cases, that is,  when the uterus is not at all contracted,
or contracted irregularly.  The respiration of the patient ha9
also an evident effect upon the uterus and placenta, of which
we shall be sensible, if  we retain the funis in our hand, in the
act of expiration, when it descends, and in the act of  inspira-
tion,  when  it is somewhat retracted.   By supporting the funis
with just so much force as will prevent its retraction in the act
of inspiration, we shall soon be sensible that the funis is length-
ened,  which will prove that the placenta is descending; and
the purpose of extracting the placenta will be completed, with-
out the use of any other means : but this method requires much
time  and attention.  Sometimes, also, the  exclusion of a de-
scending placenta may be favoured by pressing it, with one fin-
ger carried along the funis toward the sacrum or  ossa pubis,  in
such a  manner, as to bring down an edge instead of the whole
mass; but this is not the case of which we are speaking.
   In all cases of dangerous hemorrhage, when the placenta  is
retained, it was said to be equally justifiable and necessary  to
extract the placenta, as it was  to deliver the woman of her
child under the  same circumstances.  But  this general  rule
requires explanation, and some skill in the application.  When
there is a present hemorrhage,  so important as by its violence
or continuance to threaten danger,  the placenta ought to be
immediately extracted out of the cavity of the uterus.  This is
not an opinion, but a rule of practice.  But if there have alrea-
dy been hemorrhage, so profuse as to occasion danger, and the
common consequences of loss of blood, as fainting and the like,
have  already followed;  the placenta  ought  not  then to be ex-
tracted,  nor the patient disturbed, nor any change made, till
she is somewhat revived from her extreme debility; as the dan- 
496         INTR0DUCTI0N~TO MIDWIFERY.
 ger would be thereby increased, and the patient die, during of
 immediately after the operation, as I have seen and known in
 several instances.  In  other words,  the extraction of the pla-
 centa is to be considered as a remedy  for a  present or an ap-
 prehended  dangerous hemorrhage,  but cannot remove the ef-
 fects of one which has already ceased.
   In cases also in which there is no hemorrhage, if the placen-
 ta be not  ejected, or  if none or but very feeble efforts be made
 by the uterus for this purpose, a time will come when we must
 determine upon its extraction, or leave it behind; and the latter
 being unsafe and unjustifiable, the mere retention will be suffi-
 cient authority for us to extract  it.   Upon this point there can
 be no dispute, except as to the time ; and we  will say, leaving
 the matter at large, for the exercise of individual judgment,
 that, if  the placenta be not expelled at the end  of  four  hours
 from tlie birth of the child, it  is generally  wise to determine
 upon extracting it; and the determination of choosing that lime
 is, I believe, to  be founded on the opinion, that the parts have
 not closed since the expulsion  of the child.   I can, however,
 recollect many examples  of a retained placenta, without a he-
 morrhage, to which I have been called at any time within twelve
 or even twenty-four hours after the birth of the child, in which
 the placenta has been very easily managed when the exigencies
 of the case required it.*
   In this place it is necessary to mark another  distinction.—
 Though the placenta may be retained for many hours after
 the birth of the child,  if we be convinced of some degree of de-
 scent, especially  if we can feel that part of it into which the funis
 is  inserted,  we have no occasion to be alarmed, or to hurry its
 exclusion,   unless there  be an existing hemorrhage.   Then the
placenta may be suffered to  remain, till it  is  excluded by the
 action of the uterus, or as it descends, the most gentle assistance
 may be  given by pulling by the  funis, to extract it, without any
 apprehension of danger, whether it  be  detained  two,  or even
 twenty-four hours ; because we have at all times, under such cir-
 cumstances, an easy and certain  command of it.
  * [Whatever may have been the success attendant on cases of this
character, the practice of thus permitting the placenta to be retain-
ed cannot be justified.  As a fixed principle of conduct on the part of
the accoucheur, the  placenta ought  not to be left to the expulsive
efforts of nature longer than two hours.  Nor will the prudent prac-
titioner  ever leave  the patient until the  entire propulsion of the
secundines.  In Dr.  Merriman's private practice, the retention of
the placenta has not occurred oftener than  once in three hundred
labours.  F.] 
           ANOMALOUS,  OR COMPLEX LABOURS.        497

  In the case of a lady of the highest rank, to which I was call-
ed in consultation, we suffered the placenta to remain twenty-
two hours  before it was extracted, but there was no hemorrhage;
and the part of the placenta into  which  the funis is inserted, was
very perceptible.

                          SECTION X.
                On the extraction of the placenta.
  Whenever we have determined upon the necessity and proprie-
ty of extracting  the  placenta  by art, we must proceed in this
manner.  The patient being placed in  a convenient position, as
when we deliver  with the forceps or vectis, and  every thing in
order, the  funis, which is  our guide, is to be  held with a mode-
rate degree of tightness.  The  external parts are usually in such
a state,  as  not to require much dilatation; but  if this should be
necessary,  it must  be done tenderly, and in the  manner  before
directed, with the right hand or  left, as may be found most con-
venient ; as must also the os or  cervix of the uterus, should either
be contracted.  When  the hand  is in the vagina, the funis is to
be  slowly  followed into the uterus, which though in a state of
total inaction before  may then  be irritated to a sufficient degree
of action, to separate  and  expel the placenta, without any further
assistance  on our  part.  But  if the spontaneous  action of the
uterus should not  come on, we must proceed  with the hand to
the placenta, which  may either  adhere with  its  whole surface,
or it may be partly, or even wholly separated and lying loose in
the cavity  of the uterus.  Should there  be a total adhesion, we
must search for  the edge of the placenta, on  the outside of the
membranes,  cautiously distinguishing between the placenta and
the uterus.    When the edge of the placenta is raised, the further
separation  must be made  with the blunt ends of the fingers, and
the closer  and  firmer  the adhesion, the slower  the separation
ought to be made; not proceeding rashly, or affecting dexterity,
but giving  our heads time to guide our hands, as if the operation
were performed under inspection.   By slow proceeding, aud by
demurring a short time if we meet with more than ordinary diffi-
culty, the  separation  will be  perfected ; or,  when  the greater
portion  is loosened, if we  grasp it slightly in the hand and bend
it backwards, the remaining part will often peel from the uterus,
without trouble; but this  requires much caution.   Should the
placenta be found partly separated, we must proceed in the same
manner.  But whether on the  introduction of the hand we found
the placenta separated, or whether it  were necessary to separate
it, we are not to extract it immediately,  but to wait till the uterus
begins to contract,  and then to  withdraw the hand including the
placenta, more quickly or slowly, according  to the degree of
                              63 
498           INTRODUCTION TO MIDWIFERY.

contraction; for the hemorrhage may not be occasioned because
the placenta was  retained,  but because  its retention, or  some
other cause, hindered the contraction of the uterus.  If there be
no action of the uterus whatever,  it is of service to throw the
fingers  gently backwards against the sides or fundus of the uterus,
to  irritate and bring on its action, previous to our withdrawing
our hand.   But when the uterus is  perceived to act,  then gently
withdraw the hand, till the placenta is brought into the vagina.
Whatever was our motive for introducing the hand to  separate
the placenta, when it is brought into the vagina, it ought to be
suffered to abide there,  till the patient is composed, and recover-
ed from her  fatigue, and till the uterus has had time to contract
in such a manner, as to prevent the return of the  hemorrhage,
at least, in  a dangerous way.  For many years  I have made it
a rule to leave the placenta, natnrally, or artificially separated,
to abide in  the vagina one  hour, after it was voided out of the
cavity of the uterus; and I  am convinced by this method  there
is  an  infinitely less  chance of an ensuing hemorrhage, on its
coming  or  being brought away, and less after-pain.   For the
blood discharged in consequence of the separation of the placenta
usually forms into coagula, which  are collected  into  the  mem-
branes as in a net, and the uterus  is left perfectly void of any
thing, 'which can  become of any considerable pain; but many,
I must acknowledge, have  doubted the  propriety of this  prac-
tice.*
   With regard to  those cases in which the placenta is retained
by the irregular action of the uterus, which is, in  some instances,
evident for several weeks before the time of labour, there is  gene-
rally some degree of  hemorrhage, and often a  very profuse one ;
though sometimes there is  no discharge, or none of importance,
only a retention of  the placenta beyond the common time of its
expulsion.  Should all the parts of the uterus act with equivalent
force at the same  time, the  united action would contribute  to the
expulsion of whatever  may be contained in its  cavity.  But if
 one part, the inferior for instance, should act, when the other is at
 rest, a contrary effect might be produced.  The forms which the
 uterus  may assume, in consequence of  this irregular action,  are
 innumerable, but the most common is the longitudinal, which is
 produced when all the  parts, except the fundus, act; or the hour-
 glass form, when the middle of the uterus only acts, by which it
 is  divided, as it were, into two chambers or  cavities.  When it
 was the custom to bring away  the placenta immediately after the
 birth of the child, three reasons were assigned for the  practice ;
 first, that it was a dead  substance,  without any  power like that
[* There does not seem any good reason for this practice.  F.] 
ANOMALOUS, OR COMPLEX LABOURS.        499
which was supposed to be inherent in the child;  secondly, that it
was an extraneous mass, which became pernicious every moment
it remained; and thirdly, that if not  immediately  extracted, it
would be almost impossible to bring it away, the os uteri closing
in such a manner, as absolutely to prevent its exclusion.   These
opinions are proved to be groundless, for both the child and pla-
centa are equally  passive  substances,  expelled  by the action of
the uterus ; and the latter, like a dead child, may without preju-
dice remain in the uterus many hours or even days without doing
any mischief; and the opinion of the os uteri closing so soon af-
ter the birth of the child is without foundation, as this seldom or
never happens; what has been esteemed the natural closing of
the os uteri, being, in reality, an irregular contraction or spasm
of some portion of the cervex, from which we are  assured  with
common care no harm,  and little additional difficulty, can arise.*
  When the uterus is  contracted thus irregularly, as the placenta
cannot be expelled, it must be extracted by art, whenever on ac-
count of a hemorrhage, or of the time  that is past since the birth
of the child, it may be thought expedient  or necessary.  There is
generally no way of judging of this kind or degree of contraction,
unless by the uncertain  information  we may acquire by  the ap-
plication of the hand  to the abdomen,  till we introduce our hand
into the uterus ; and  before this operation, it is always proper to
try whether  the placenta may not be disposed to come away by
any of the gentle means before recommended.  On the failure of
these, and being fully convinced of the necessity, the hand must
be conducted in the  manner before mentioned,  till  we  come to
that part which is partially contracted, whether  it be at the cer-
vix, or in the cavity  of the uterus.   The hand must then be re-
duced into a conical form, in the way directed for the dilatation
of the os uteri  or external orifice in  premature labours.   Should
the spasm be  in such a degree, as to make a perfect closure of the
uterus round the funis, one finger must be first  insinuated along
the funis, and this being turned with a semirotatory motion, will
soon make room for a second, and so on, till all the fingers, in a
conical form, may be admitted.  The  dilatation is sometimes to
be made in opposition to a very firm contraction, yet it must be
  *  Scire enim est post natum infantem, in utero  nullum reperiri
tale os ut olim fuerat: sed ita omnino se res haD^t, ut in bursa num-
maria, quae loris  transmissis  constricta, rugosum os format ;  laxatis
autem hinc vinculis, ubique atque lata et expansa.  Ruysch. Advers.
Anat. Dec. Secunda.
  The tenth chapter of the second Decade is full of useful observa-
tions regarding the management of the placenta, given in very honest
and animated language. 
500
INTRODUCTION TO MIDWIFERY.
done steadily and resolutely, though not rashly or violently. Be-
fore the hand is passed beyond the contracted  part, this must be
amply dilated, otherwise it may clip round the  wrist, and impede
the subsequent part of the operation.  When the contracted part
is amply dilated,  the hand  must be carried forwards into what
may then be called the upper chamber of the uterus, in which the
placenta is contained.  Whether this be separated wholly or par-
tially, or be  yet adhering, we must proceed according to the me-
thod before mentioned.  Immediately upon the separation of the
placenta, the hand containing  it is to be drawn out of the  upper
cavity, to that part of the uterus which was before so closely con-
tracted, and held there, till by the pressure behind, we are sensible
of the action of the fundus.   The hand containing the placenta is
then to be withdrawn by slow degrees, till it arrives in the vagina,
where the placenta may  be suffered to remain for one or several
hours; or we may wait till it is wholly expelled by  the pains,  in
order to avoid the hazard of a subsequent hemorrhage.
  When the placenta  is  either expelled by the action of the ute-
rus, or extracted by art, it should  be a general  rule to apply the
hand to  the abdomen afterward,  that we may be assured the
uterus is not inverted ;  but this method  s not always satisfacto-
ry, for in one case to be  afterwards described, though the vo-
lume of the utei us was  felt, apparently contracting properly,
the inverting  uterus, as it  receded,  was mistaken for a regulur
contraction.
   The natural  attachment of the placenta to the uterus is of
such a texture and kind, as very  readily to admit of separation.
But if that part of the uterus, to which the  placenta adheres,
should be in a  scirrhous  or morbid state, the placenta will par-
take of the disease.   On  the examination of the placenta of
different women, there  are not unfrequently  found n.orbid ap-
pearances, some being  disposed to a putrid,  others to a scir-
rhous  or cartilaginous state ;  while  in others  there i9 a  degree
of ossification  in the vessels, and sometimes perfect  concre-
tions.    The adipose substance  often found  upon the placenta
in large quantities is  not of any importance.    The difficulty of
the separation will depend partly upon the placenta itself, and
partly upo., the state  of the uterus.  When there is found, on the
introduction of the  hand into the uterus, an  uncommonly firm
adhesion of the placenta, a perfect separation will be extreme-
ly aiilicult. an : perhaps  sometimes impossible, without the ha-
zard of doing direct injury to the uterus. There is no security
in these cases, but  by taking time  in the operation, confiding
chiefly in slow proceeding, both for accomplishing our purpose,
and avoiding mischief.   It has been said, that it is more justifi-
able to leave a portion of the placenta behind, than to continue
very strenuous  efforts to bring  the whole away,  as these may 
ANOMALOUS, OR COMPLEX LABOURS.       501
give unbearable pain, and become the cause of immediate  or
subsequent injury.  It must be acknowledged, that it is always
a very desirable thing, to bring away the placenta wholly and
perfectly, not only for the satisfaction of friends,  but for the
real good and interest of the patient.   Even the membranes
should be managed with  caution,  for  though  a  portion'or the
whole of these  might be left without danger, they occasion a
fcetor in the discharges,  and often so much pain as to create a
suspicion  of disease.   But without  meaning to give authority
to negligence o>- misconduct,  to rashness or violence, we may
suppose a situation, in which we must submit to some evil, and
in which all that is in our power is, to choose the least.  There
can then be no doubt, but that it is a less  evil to leave a portion
of the placenta behind,  than  to do any positive injury  to  the
uterus, in striving to bring it away.   For it has been found,
when a portion of the placenta was left behind, that an existing
hemorrhage has ceased and not returned, and that this portion
far sooner decayed, or was more  readily  digested or expelled,
than  the whole   1 once saw an instance of a whole placenta
retained till the fifteenth day after the birth of  the child, and
then expelled with  little signs of pu< refaction, ex< ept upon the
membranes; the whole surface, which had aiihered, exhibiting
marks of a  fresh separation, the  recovery of this patient was
very fortunate,  for I have seen several other  cases of a similar
kind  terminate  faffally.   It is  a  conclusion  generally made,
though not always warranted, that, if a woman die with a por-
tion of the  placenta retained, her death ought to be attributed
to it; yet it should be considered, that there may  have been
previous  disease in  the  uterus, and  that the event may have
been previously occasioned by violent, though unsuccessful  at-
tempts to bring it away,  and not by the retention.   Sometimes
the  danger of these cases is known  to the  practitioner only,
who is obliged to act according to exigencies, for which he may
not be particularly prepared ; but if he have before acquired a
just knowledge  of the principles  of the art, explain himself  in-
genuously, determine not rashly, and proceed slowly, he will
not  do any thing for which he can be justly  blamed, and will
generally be successful.
   The funis is commonly inserted about one third of its space
from, or at  the very edge of the placenta, sometimes in  the cen-
tre, and now and then the vessels branch off before it reaches the
placenta; and the ease or difficulty, with which this may br brought
away, somewhat depends upon the insertion of the funis.  The
chalice also of tearing the funis away  rests chiefly upon the force
used to extract  the placenta by it; yet if it be inserted fully into
the placenta, and be in a  sound state, the  force which it can bear
is infinitely  greater than can  be  exerted without the hazard of 
502
INTRODUCTION TO MIDWIFERY.
 inverting or doing other injury to  the uterus.   But if the funis
 be in a putrid state, or if the vessels branch off too soon, it may
 be torn away with a very small degree of  force,  as in the latter
 case it can only sustain what a single branch of the vessels can
 bear.  Hence in a cautious extraction of  the  placenta, we are
 sometimes sensible of a  sudden yielding or jerk in the  funis,
 which,  if the same force be continued,  will be repeated,  till  at
 length the funis comes unexpectedly  away,  and the placenta is
 left in the uterus, or in the  vagina.  Great circumspection and
 slow  proceeding will usually prevent this  accident; but if it
 should happen in our own practice, or we should be called on  to
 assist others,  we must determine whether  the case will allow  of
 farther waiting; whether there be a necessity of bringing the pla-
 centa away immediately, by introducing the hand into the uterus.
 Should there be occasion, on account of hemorrhage or any
 other untoward circumstance, for  the latter  method, which,  if
 consistent with the safety of the patient, ought always to be avoid-
 ed, we may consider the inconveniences produced by the want
 of the funis, which, when it remains, serves  as a guide to conduct
 the hand, and helps moreover to keep the  uterus steady, and  to
 bring down the placenta when separated.  The former of these
 will not be of much consequence to a person accustomed to the
 operation; and the latter will be lessened, if an assistant make a
judicious pressure upon the abdomen with both his hands.  Some
 disadvantage will necessarily arise from this Incident, we should
 therefore be careful to avoid it, when  in our power; but though
 a little embarrassment may be occasioned, even when the placen-
 ta is in the vagina, the importance of the disadvantages produced
 by the separation of the funis  has, I believe, generally been over-
 rated.
                         SECTION XI.
 On hemorrhages which follow the exclusion or extraction  of the
                          placenta.
   The hemorrhage which follows the expulsion or extraction of
 the placenta, may be a continuation  of that  which came on before
 the birth of the child,  or between the birth of  the child and the
 expulsion of the placenta;  or it may  be unconnected with either
 of these, and  be merely a consequence of the separation and ex-
 clusion of the placenta.  This has usually been described by wri-
 ters as an immoderate flux of the lochia, but is with more pro-
 priety  arranged under the class of  hemorrhages; and though
 generally not so dangerous as either of the varieties last describ-
 ed, it is often alarming, and, under  particular circumstances, has
 sometimes proved fatal.
   Tlie  discharge of blood,  which follows the separation and
 exclusion of the placenta, varies in different women, being in some 
ANOMALOUS, OR COMPLEX LABOURS.
503
very small, and in others there is, after every act of parturition,
a disposition to a very profuse hemorrhage, which suddenly re-
duces the patient into a frightful state.  It is a popular opinion,
that the greater these discharges are at the time of delivery, the
safer women will be from the chance  of diseases during child-bed;
and this opinion very much lessens the terror of the by-standers,
when discharges come on with great profusion.  But the prac-
titioner, who knows the possible  effect of sudden and violent he-
morrhages at this time,  especially in patients who were before
much weakened,  cannot feel at his ease, though supported by the
general experience of their being seldom dangerous.  Nor is the
opinion true, that  the greater the discharge,  the safer the patient
will be;  for whatever weakens the  patient extremely, must ren-
der her more liable to diseases of various kinds in child-bed.  For
the prevention of  this  hemorrhage in those who have suffered
from it in former labours, I have recommended their taking some
tonic medicine, as one grain of zincum vitriolatum  two or three
times a day  for several weeks before the time of their delivery,
and the use of the cold bath throughout the latter period of preg-
nancy,  even to the day of their delivery.   But when,  from for-
mer events, there is reason to be apprehensive of hemorrhage
subsequent to the  exclusion of the  placenta, that has been alto-
gether prevented, or very much lessened,  by delaying the time
of the patient's going to her bed, till the child was upon the point
of being born; or even suffering it  to be born while the woman
sat upon the lap of one of her attendants.
  It has often been a matter of great surprise to me, when I have
seen a patient bear a sudden discharge of what seemed an enor-
mous quantity of blood on the coming away of the placenta, with-
out fainting, or showing any signs  of the common consequences
of great loss of  blood; but it may  be explained in this manner.
Should every drop of blood, which circulates in the uterus, be
discharged  in an instant,  it  would be of  no immediate conse-
quence to the patient, the very existence  of the uterus not being
necessary for her  life.   When all this blood is discharged, if the
uterus should contract speedily, so that the  vessels should be re-
duced to a small size, there would not be a continuance or return
of  the hemorrhage, and the patient  would exhibit no signs  of
suffering from that which had happened.   But after the discharge
of the blood contained in the vessels of the uterus, as  before sta-
ted, if there should be no contraction of the  uterus,  then the ves-
sels remaining of the same size,  and the communication between
the body and the uterus being preserved open, as in pregnancy;
the vessels of the uterus would be replenished from the constitu-
tion, and the same effect would be produced in the patient, as if
it were really lost.  Should this second quantity of blood suppli-
ed to the uterus  be discharged, and another be claimed from the 
504          INTRODUCTION TO MIDWIFERY.
constitution, then, according to the quantity demanded, the quick-
ness, and the number of times the  demand was -oade. would of
course be the danger of  the patient.  In  some cases the hemor-
rhage does not follow the extraction of the placenta immediately,
hut comes on after a certain time; and then it may be supposed,
that the communication between the body and the  uterus was
closed, but not being confirmed, was opened again by some effort
too soon made, or more  violent than the situation of the patient
could endure.   These circumstances point out very clearly the
necessity, in the management and  for the prevention of uterine
hemorrhages,  of ever remembering, that the danger attending
them is lessened, and the  safety of the patient,  secured only-by a
proper contraction of the uterus.  Hence in hemorrhages of this
kind, however vehement,  the accession of uterine pain immediate-
ly proclaims, that the danger is passing or is passed.
   With respect to this variety of hemorrhage, two  things are to
be considered ; I st.  by  what method or means it  is to be  pre-
vented ; 2d. how it shall  be remedied, when it does exist.
   When the hemorrhage  depends upon the imperfect or irregu-
lar action of the uterus, excited for the end of expelling the pla-
centa, it may not be  in our power to regulate these.  But as far
as relates to the force used in the separation, or hurry in the ex-
traction of the placenta, we may  always act  reasonably  and
calmly,  and proper conduct will generally  insure success.  It
was  before advised to leave the placenta  in the vagina for  one
hour after its exclusion from the uterus, in common cases, unless
it were sooner expelled by the natural efforts.   Objections have
been  raised to this, because it confines the patient to an uncom-
fortable situation  for a long time; and  it has been said, that it
was cruel to leave her friends  under  anxiety,  with the delivery
incomplete, when we  have the power of readily bringing  the pla-
centa away.  Now, if we are  speaking of a case of real or  pre-
sumed danger,  the argument of uncomfortableness is  not to be
put in competition with a conduct, on which  the increase or di-
minution of that danger may  turn;  nor does the censure  of a
good action make it  degeuerate into a  crime,  or convert that,
which is in its own nature honest and intelligent, to cruelty.  On
the contrary, it may  be the height of tenderness, in me, to en-
courage the patient to bear a small degree of present pain or in-
convenience, by which her safety is  ensured, rather  than by an
officious interposition  to  add to the hazard, by complying with
the solicitation of those who are not qualified to judge.   When
the placenta is  brought into the vagina,  we have then the abso-
lute command of it at our  pleasure ; but the very ease with which
it could be brought away, is often  a good reason why it should
be suffered  to abide,  as it proves that there is no  natural con-
traction of the parts  for its exclusion, otherwise it would be ex 
           ANOMALOUS, OR COMPLEX LABOURS.        505

 pelled without any assistance.  In what other manner a placenta
 remaining in the vagina may contribute to the checking or the
 prevention  of hemorrhage,  except that, by the irritation  made
 upon the os uteri, it urges the uterus to act, it  may be  hard  to
 say ; though I am convinced of the benefit  thence derived.   Nor
 have I/when attending patients who have  been prone to  a he-
 morrhage in former labours,  been satisfied with leaving it in that
 situation  for one hour, but have prolonged the time to two hours,
 or more, unless it should be in the mean  while ejected by the
 pains, which proving the increased action of the uterus, would
 give an assurance of safety.   Moreover, after waiting so long  as
 seemed reasonable and proper, I  withdraw  the placenta very
 gently, not increasing  the  force on  account of every obstacle,
 but demurring and waiting longer.  Even  after the placenta  is
 wholly excluded, if the membranes  stick, I wait yet longer, and
 proceed more slowly, knowing that a few minutes occasion  a dif-
 ference between the loss of one,  and seven or eight  ounces  of
 blood, which sometimes may be of the utmost importance; nor,
 under these circumstances, can  any  harm arise from delay.
   When we have  the management, or are called to cases of pre-
 ceding or present  hemorrhage, the  placenta being  extracted,  it
 should be an unfailing general rule  to examine the patient,  to be
 sure that the uterus is not inverted; or perhaps by slight irrita-
 tion about the os  uteri, to  endeavour  to  bring  on its  action.
 Then all  the means before recommended for  the suppression of
 hemorrhages are to be put in  practice, speedily and  strenuously;
 and we are also to endeavour  to promote the  action  of the uterus,
 if at rest, or to strengthen it if feeble, by moderate pressure  upon
 the abdomen with a very cold hand.
   After the exclusion of the  placenta, on the application of the
 hand to the abdomen, it  is sometimes clear, from the volume of
 the uterus, though  contracted,  that there are very large coagula
 contained in its cavity.  We have been directed by gentle dilata-
 tion of theos uteri, to give these an  opportunity of coming away,
 or even to introduce the hand for this purpose, (see the  quotation
 from Celsus, at page 489.) as  by their  continuance, they  were*
 supposed to keep up the distention of the uterus, and to occasion a
 continuance of the hemorrhage, as  well  as  other mischief. Of
 any advantage said to be  derived from  this  practice I am very
 doubtful, or whether it may not be suspected  to renew or increase,
 rather than to suppress the hemorrhage.   I have never attempted
 it, nor even troubled myself with the state of the uterus, (unless  it
 were inverted,) after the placenta was brought away, but have left
 whatever coagula is contained,  to be expelled by its own  action.
 Some have  b« lieved,  that this sort of hemorrhage was to be pre-
 vented by giving,  after the birth of the  child, without hesitation,
two  or three glasses of wine, or even a stronger cordial, with a
                              64 
506
INTRODUCTION  TO MIDWIFERY.
view of bringing on a speedy contraction of the uterus,  and I
have really thought sometimes with great success.
  The fainting which follows hemorrhages was considered as an
effect produced,  or  as a remedy provided for their suppression.
It was  also said, that  the medicines given  or the means  used,
did service, according to the degree of dullness they occasioned,
and the slackness of the circulation which followed.   We were
cautioned not to remove this faintness by the hasty exhibition of
cordials, lest with the return of the circulation, there should be a
renewal of the hemorrhage; at least till we  had given sufficient
time for the contraction of the vessels and other circumstances to
take place, before the patient revived.   But when the patient be-
comes  cold, and there is apparently the most imminent danger of
her dying, we must presume  those effects are produced,  or no
longer regard them, but give without delay nourishment and cor-
dials in small quantities, very often repeated, and the patient must
be as it  were compelled to live,  by the strenuous and constant
support we give.   Nor is the exhibition of cordials to  be confined
to any particular quantity or time ; we are only  to be guided in
both respects by the continuance  of danger.  Wine, brandy pro-
perly diluted, or any domestic cordial, will  be suitable on these
terrible occasions, and they must be  made actually  warm.  In
some cases, volatiles have a good effect,  and the julap.  vitae of
Bates, which is  composed of warm wine  and the yelks of eggs,
with the addition of a  few drops of oil of cinnamon,  has proved
an admirable medicine.  Yet I  must confess, that the best and
most general cordial is very cold air, at least this is indispensably
necessary ; and  the strongest stimulant  in  extreme  cases is, to
sprinkle the face  repeatedly with cold water, which the patient,
sensible  of the  benefit she receives,  would often require to be
done with great earnestness.   (Chapman  mentions a compliment
paid him by Sir Richard Blackmore, in a case of this kind, which
shows  great accuracy of distinction.  If,  said Sir Richard, you
had used less  cold  applications, this patient would  have died
from the loss of blood; and if you had continued them longer,
you would have extinguished the powers of life.)
   On  the same  ground on which these  medicines  are advised,
opiates, though in some cases  they may  prevent, were esteemed
improper, during the continuance of a hemorrhage, and they
certainly ought not to be given too freely, when  the patient is re-
duced  to a state of great weakness.  Above all,  she  is not to be
disturbed, or raised to an erect position, but the  small portion of
the principle  of life  is to be carefully husbanded ;  and there is
often a power of living in a  quiescent state, or in  a recumbent
position, when the patient would be destroyed by the least exer-
tion, or by being raised to an  erect position.  Whether an hour
or a day be required for  this  purpose, after a profuse hemor- 
           ANOMALOUS, OR COMPLEX LABOURS.      507

rhage, the patient ought not to be raised, or even moved, before
she is quite  revived, and then with the utmost care  and circum-
spection ; for  through want of attention to this  matter, sudden
death  has sometimes happened, when we were not suspicious ot
danger.   But when immediate danger is no longer apprehended,
and the patient has been reduced to a very low state, the views
of practice are changed, and it will not even then be prudent to
replenish the emptied vessels too hastily,  or to stimulate them to
strong action.  In some cases I have really been fearful of chan-
ging the position of the patient for twenty-four hours.
   It is lastly  to be observed, that in the violent and pertinacious
headach,* and other nervous complaints,  which follow profuse
hemorrhages, and sometimes continue for many weeks, it will
be of great service to procure two  or  three stools every  day
previous to the exhibition of the bark, or other  tome medicines,
though the patient be pale and in a weak state.   For the  pre-
sent relief of headach, cold applications to  the temples,  as
white of egg mixed with powdered bay salt, or crude sal am-
 moniac, always keeping the legs and feet warm, will sometimes
 be of service, as will also  occasionally  all  the nervous medi-
 cines in common use.
    These observations  I have written with great pleasure, hop-
 ing they may be of service; and I  may recommend the method
 founded on them with some confidence, having in practice  seen
 innumerable instances of its good effects,  though the  subject
 may yet admit of much improvement.-]-


    * Douleurs du teste apres grandes pertes du amp—Mauriceau.
    t II cannot pass over the important subject of uterine hemor-
  rh-ure so ably treated by our author, without inserting the following
  valuable case, drawn up and communicated to me  at my request, by
  Dr  William Handy, of this city.   It strongly establishes the propri-
  ety of never  abandoning our patient  in any circumstances of debility,
  arisimr  chiefly from excessive loss of blood.   It is almost incredible
  how copious  a sanguineous discharge from  the uterine vessels may
  gometimes take place, and yet, by care and assiduity, the powers of
  the system be restored.
    On the 27th  of August last, at 11 P. M.  I was requested by  Dr.
  Micauley to visit with him, in consultation,  Mrs. A., a lady of about
  forty years of age, then supposed to be in tin- commencement of the
  ninth month  of her eleventh pregnancy.  '1 lie account he gave me
  of her c»<e was as follows : That he was called to her early in  the
  mornine of the 27th of July, when  he was informed that she  had
  been suddenly taken the night before with flooding, unattended by any
  nain   Her friends had given her laudanum, and made use of cold ap-
  plications  which had lessened the  discharge.   The hemorrhage
  continuing, the same remedies were repeated three successive day* 
508
INTRODUCTION TO MIDWIFERY.
                         SECTION XII.
                On  the  Inversion  of the Uterus.
  The inversion of the uterus has been more than once men-
tioned, but the  subject is so important, as to require some far-
ther consideration.
and nights, during which it was supposed she had lost from seven to
eight pounds of blood.  A feverish state  having succeeded, with a
full, hard  pulse, white tongue, dry skin, and redness of the ejes,
she was bled to eight ounces from the arm,  with immediate relief.
She continued comfortable for a fortnight, when, in consequence of
violent pain  in the head, fever, and great restlessness, she was again
bled to ten  ounces, with speedy and great benefit.  She remained
free from any serious indisposition, until Friday,  the 24th of August,
in the afternoon, when the bleeding again  returned, and was arrest-
ed by external applications and  rest.   On Saturday and Sunday the
discharge was small.   On Monday it returned with greater violence,
when she lost about two poiinds of blood.  The pulse was again ex-
cited, accompanied  by headache, general uneasiness  through  the
system, and the several symptoms  of a febrile condition, which at-
tended the first attack.   She was again bled to six ounces, with sud-
den and great relief.   The hemorrhage now ceased.   In about four
hours after, her strength failed, and she was seized  with fainting
fits.
   On visiting her, I found her in a very low and languid state ;  her
pulse 108 in a minute, and very feeble ;  her lips and whole counte-
nance pale ; her extremities cold, with an occasional  dull pain, as
she expressed  herself, in the small of her  back.   She had considera-
ble thirst,  great nausea, and a constant desire to change  her position.
The hemorrhage had now nearly ceased.  The  vagina was filled
with coagulated blood ; but there was scarcely a  perceptible dilata-
tion of the os internum.   Heated  flannels, &x.  were applied to the
extremities ; an  anodyne with forty drops of laudanum was given,
and light cordial  nourishment frequently administered in such quan-
tity as the state of her stomach would bear.
   28th. 6  A. M.—Had a succession of fainting fits until two  o'clock
this morning.  Her pulse is  now depressed, feeble,  and irregular ;
her extremities cold, her  countenance very pale.  Restlessness—■
nausea—no  return of hemorrhage.
   9 A.M.—Continues the  same.—Agreed to meet at noon.—Labour
having commenced, I was called in at about  ten o'clock. She was
still without hemorrhage ; but as  in the exhausted state of  the pa-
tient, the most fatal consequence was apprehended from such an oc-
currence, every preparation was made to  meet it.  On  examination,
a large portion of the placenta was discovered protruding before the
head of the  child, and, in a little more than half an hour, the  whole
of it, enveloped in the membranes, was expelled by the pains. The
n\embranes  were now ruptured, and the  waters discharged ; when 
ANOMALOUS, OR COMPLEX LABOURS.        509
  In every case in which  there was reason to suspect this ter-
rible accident,  especially  when it Had been found necessary to
extract the placenta by art,  we were  generally advised to ap- '
ply the hand to the abdomen, for the purpose of trying whether
the pains, though feeble, continuing to act upon the child, it was, in
half an hour, delivered, having apparently been dead many  hours.
Its size was such as fully to warrant the conclusion, that it bad been
carried the ordinary full time  of gestation.    No hemorrhage en-
sued its birth ;  but the mother  was exhausted nearly to death,  and
immediately sunk into  a state of alarming syncope.  Her pulse was
no longer felt at the wrist, her extremities were of a deathlike cold-
ness, and a cold sweat was generally  diffused over her.  A com-
press,  supported by bandage, was applied to the  abdomen, and by
the diligent use of friction, and warm  applications to the extremi-
ties, she so far revived as to be  able to speak    Her countenance
was, nevertheless, most ghastly ; there was no perceptible return of
circulation at the wrists, a hiccuping followed, and a constant dispo-
sition to syncope. As soon as she was able to swallow, there was given
her, in small quantities at a time,  light cordial nourishment, consist-
ing of panado and gruel with  wine, warm sangaree, and other cordi-
als ; and, occasionally,  beef tea.   These were alternately given to
her once in six or eight minutes,  while several  persons were em-
ployed in chafing,  and  in the renewal of warm  applications to her
feet, legs, hands, and arms.   Her respiration  was laborious,  and al-
though she retained what was taken into the stomach, she had  con-
stant nausea, and when able to speak, which she did with great fa-
tigue,  she complained  of painful oppression and tightness across the
chest,  and, as she expressed it, a confusion in her head.   She is very
drowsy.
   At half past four, P.  M. though there was .10 distinct pulsation, a  .
slight tremulous sensation was communicated to the fingers, on pres-
sure of the radical artery.   Her countenance was still  ghastly, her
respiration laborious and fatiguing; she had hiccup ;  her extremities
and face  were cold, she sighed frequently, and was  very restless.
Her intellect was entire,  her speech distinct, and she  greedily re-
ceived the nourishment which was given to her.
   8 P. M.—Pulsation at the wrist rather more distinct.  Drowsiness
continues, and she sleeps with  her eyelids but half closed.   Tem-
perature of the  skin  a little  encreased, but  still  morbidly cold.
Breathing less painful.   Takes sufficient nourishment, and retains it.
Hiccup less frequent, and she is less restless.   Lochia moderate.
   29th. On entering her room this  morning,  she  observed,  with
great cheerfulness, previously to being  interrogated,  that she  was
much better, and had passed  a tranquil night.   A natural and equal
warmth is restored to the surface, and her skin possesses a healthy
softness.  Had a copious discharge of urine in the night.   Some af-
ter pains.
  My visits with  Dr. M. were  continued until  the fourth  of Sep- 
510
INTRODUCTION TO MIDWIFERY.
the tumour of the contracted uterus could be felt, and if there
were any remaining doubt, to examine per vaginam.  When it
is inverted, instead of feeling through the integuments the vo-
lume of the contracted uterus, there is a considerable vacuity
at the lower part of the abdomen, which gives sufficient reason
to suspect the inversion, and by the latter examination it  is pro-
ved.  In one case which was under the care of a person, who
might have been allowed to be a competent judge, and expected
to act more wisely, when he applied his hand to  the abdomen,
the recession of the inverting uterus was mistaken for its con-
traction; and it was actually inverted, though he entertained no
suspicion of what had happened.
  The reasons advanced to prove the necessity of ascertaining
the inversion are,  1. that the patient may be relieved from her
present  danger; 2. that a part of so  much  consequence may
 tember, when  our patient appeared to be so  far  a convalescent
 as to induce me to retire.   She still complained of an uncomfortable
 sensation in her head ;  her countenance  was pallid,  and there was
 that paleness of the  tongue  and lips  which frequently attends the
 languor of circulation at  the surface, consequent  on an excessive
 loss of blood.  There had been no evidence of a secretion of milk
-since her delivery.
   On the 17th 1 was again requested to see her with Dr. M.  It ap-
 peared that, since my last visit, she had convalesced slowly, although
 her appetite and rest had been natural, and she had repeatedly walk-
 ed from one room to another.   The  confusion in her head, as she
 described it, and pallid countenance  and lips still  continued.  On
 the 15th and 16th she  had  fever,  preceded by slight chills, some
 pain, and a sense of weight and stiffness about the left hip,  and  a
 want of the usual power to move the left thigh and leg.  There was
 now a great enlargement of the  limb from  the hip downwards.  A
 swelling had suddenly appeared, white, elastic, tense, shining, warm,
 with the other concomitants of phlegmasia dolens, except, fortunate-
 ly, extreme pain and tenderness of the diseased limb when touched.
 Her pulse was at  120 in a minute,  and feeble ; skin  dry ;  she had
 thirst, and her body was costive.  The swelling has  been fomented
 with flannels wrung out in hot vinegar, and embrocated two  or three
 times a day with a mixture of ammoniated and soap liniment and lau-
 danum.  Her bowels have been  kept open, and her skin soft by the
 use of neutral salts' combined with mild  diaphoretics.   The swel-
 ling is now  much reduced, she has  but little fever, and her appetite,
 spirits, and sleep, are good.  Complaint in her head diminished.  Se-
 cretion of urine copious.   Her  tongue  and lips  continuing  to  be
 pallid, with some oedema of the diseased leg and foot, and being free
 from fever, in addition to  a small quantity of animal food, and porter
 sangaree, which have been allowed her a few days past, the muriated
 tincture of iron was this day  prescribed.  Sept. 26, 1821.   F.J 
           ANOMALOUS, OR COMPLEX LABOURS.      511

not be suffered to remain  in that state, even if there were no
hemorrhage or other symptoms of immediate danger;  3. that if
it  were not soon replaced, it could not, after a very short time,
be restored to its proper situation.
  The inversion of the uterus is commonly attended with alarm-
ing nervous symptoms ; but  whether this is considered as  the
first cause of the hemorrhage with which it is almost universal-
ly attended,  or merely  of its continuance, or if there was no
dangerous hemorrhage, the  reasons for replacing it speedily
would be of equal force.  Not that all women would die though
the uterus  were inverted,  but they would  probably be in the
greatest and most imminent danger ; not to  mention the shock-
ing state they would be in for the remainder of life  if they es-
caped.   The impossibility of replacing it, if not done soon af-
ter the accident, has been proved  in several cases, to which I
have been called, so early as within four hours, and the difficulty
will be increased at the expiration of a longer time. Whenever
an opinion is asked, or assistance required in those cases which
may not improperly be called chronic  inversions, it is almost of
course, that the reposition  should be attempted; but I have
never succeeded in any one instance,  though the trials were
made with all the force I durst  exert, and  with whatever skill
and ingenuity I possessed ; and I remember the same complaint
being made by the late Doctors Hunter and Ford ; so  that the
reposition of a uterus which has been long inverted, may be
concluded  to be impossible.  It seems as  if the cervix of the
uterus continued to act,  or  had soon acted in such a manner,
as to gird the inverted uterus so firmly, that it  could not be
moved; yet the inverted surfaces  of the back of the uterus,
though lying in contact, have not been found coalesced together,
so as to form one mass, as has been surmised.  All that art can
do in such cases, in which the patients are commonly subject to
profuse  mucous discharges, or  to frequent hemorrhages, but
without any unbearable pain, is to  alleviate their sufferings, to
moderate symptoms, and sometimes to support the perpending
uterus by a flat pessary.  In a plate published many years ago,
there is an exact representation of an inverted uterus of  long
standing, from a beautiful drawing, by Dr. R. Atkinson ; and a
patient lately died  with an inverted uterus, for whom I was
consulted near twenty years ago.
   Besides  the  complete  inversion of the uterus, in  which the
fundus  may  be brought into the vagina, or without  the body,
dissections have shown, that there is what may be called a  par-
tial or semi-inversion, in which the fundus of the uterus has been
bent inwards, but not passed through the os uteri; yet if it descended
 no lower, the case might have remained wholly unknown during
the  life-time of the patients.  This is  accompanied  with symp- 
512          INTRODUCTION TO MIDWIFERY.
toms like those of the complete inversion ;  and had it  been dis-
covered, would have required equal care, and  the same methods
to be used for replacing it.   Many years ago, in a case of retain-
ed placenta, I perfectly well remember feeling a beginning inver-
sion, which was  prevented  by first  restoring   the uterus to  its
place, and then waiting a short time, before I  made any  farther
attempts to  separate or bring down the placenta; keeping my
hand afterwards in the uterus till it was contracted.
   With respect to the causes of the inversion, it has generally
been attributed, solely, to  the force used in pulling by the funis,
in order to bring away a retained placenta.  But there is reason
to believe, that the uterus has been inverted, when on account of
a  hemorrhage, or  some other urgent  symptom, the hand has
been introduced into the uterus while in a collapsed or  wholly un-
conlracted state; and the placenta being  withdrawn before it
was perfectly loosened, the fundus of the uterus has unexpectedly
followed,  and  a  complete  inversion been occasioned.  1  have
also been assured, that in some cases there has been a sponta-
neous inversion;  that the accident happened,  at least, when  no
force, or none capable of producing the effect, had  been used;
and then it was imputed to  the shortness of the funis, giving the
disposition before the birth of the child; or to some untoward
action of the uterus.   But with  this assurance,  or explanation, I
do not feel quite satisfied, because degrees of force must  always
be vaguely estimated ; though if a disposition to an inversion  be
first given  by the force used in pulling by the funis, it may be
completed by the action of the uterus; or  if  the least possible
degree of inversion were given by the shoitened funis, it might
certainly be completed by a very slight additional  force in  pull-
ing by the funis, or by the mere weight  of the  placenta.
   Ruysch, whose animadversions on the conduct of midwives are
sufficiently severe, especially with respect to the hasty or violent
methods of extracting the placenta, to which only he attributes
the inversion of the uterus, afterward acknowledges  that the ac-
cident may, and did happen in his  own practice,  when no vio-
lence was used.   His words are very striking :  Quamvis hoc ma-
lum oriatur nonnunquam ab obstetricibus minus expertis, funicu-
lum umbilicalem  pius quam  par  est attrahentibus, aliquando
tamen  ortum ducit a conatibus post partum remanentibus.  In
the cases,  however, to which Ruy6ch alludes, it seems probable
that there was some preceding partial inversion, and that this was
completed by the subsequent-action of the uterus.
   Uterine  hemorrhages following  the exclusion or extraction of
the placenta, though often  apparently dangerous, very  seldom
prove fatal;  yet  now and then we hear of a patient dying from
this cause.  May it not be suspected, that in such cases there was
an inversion of the uterus, partial or general, which together with 
           ANOMALOUS, OR COMPLEX LABOURS.        513

hemorrhage is always attended with dreadful disturbance of the
whole nervous system ? Whether the uterus be inverted  or not,
should therefore, in the  first instance, be ascertained by the me-
thods before mentioned, in every case of profuse  uterine hemor-
rhage after the birth of the child, and  particularly after the ex-
clusion of the  placenta.
   Seeing then the causes by which an inversion of the uterus
may be occasioned, knowing the immediate danger arising from it,
and, as far as experience has proved, that after a certain time it
cannot be replaced, we shall want no  other inducements to use
all possible care to avoid doing two things, which have not been
uncommon in  practice, though it is evident, that in various ways
they must be injurious ; first, pulling by the funis  prematurely,
or violently, to bring away the placenta; secondly, hasty intro-
ductions of the hand  for this purpose   Should, notwithstanding
all our care,  a case  of this kind occur in our own practice, or
should we  be  called to  one, which had  happened in that of any
other person,  we should find no difficulty, or very little, in resto-
ring the  uterus to  its perfectly proper situation, if, which is of
prime importance in every case  of difficulty or alarm, we main-
tained the composure  of our minds ;  if,  paying due regard to the
state of the patient, we made our attempt without delay, but at
the same time without violence,  or  precipitation.  The only
point of practice, which occurs to me, as likely  to raise any doubt
of the conduct we ought to pursue, is, when together with an in-
verted uterus there is  an adhering  placenta.  It would probably
then be right  to say,  if the placenta  be partly separated, it will
be proper to finish the  separation, before we  attempt  to replace
the uterus; but if the placenta should  wholly adhere, it will be
better to replace the uterus, before we endeavour to separate the
placenta.  The ground of this opinion  is,  that while we are se-
parating the placenta, the cervix of the uterus is speedily con-
tracting, and the  difficulty of replacing it increasing, which is a
far greater evil than a retained placenta.
   Perhaps a  short account of the two following  cases, with  the
former of which I was supplied by my very able and experienced
friend, Dr. Merriman, Physician to the  Westminster Dispensary,
may elucidate this subject.   Owing  probably  to a better method
of acting with  regard to the placenta, the inversion of the uterus
has certainly  been  an accident of very rare occurrence during
the whole of my life ; yet the means of avoiding it, and the me-
thod of relieving it, when it does happen, deserve serious consi-
deration.

                           CASE I.
   In January, 1802,1  was called  with  Mr. Seares, to a patient,
who had been just delivered of her  first child, by a midwife of
                             65 
514
INTRODUCTION
TO MIDWIFERY.
much experience.  In a short  time  after the  birth of the child,
she had endeavoured to extract the placenta by the funis, but she
solemnly assured me with very little force.   A violent and for-
cing pain immediately came on, the placenta  was expelled with
much force, and together with  this the uterus completely out of
the body of the  patient.   When I arrived, which was not many
minutes after the accident, I found  the uterus, with  part of the
placenta adhering, lying without the os externum.  There was a
profuse hemorrhage from those parts of the uterus, from which
the placenta was  detached, and the  patient was  in so exhausted
a state, that we doubted whether she would live till the uterus was
replaced.   No time was lost in separating the remaining  part of
the placenta, and when this was done, the  uterus  being returned
into  the vagina, I introduced  my hand, and carried the fundus
before me,  till I felt it as  it were spring  from my hand, and it
was  completely replaced.  I then slowly withdrew my hand, and
found the cervix  beginning  to contract.  The hemorrhage im-
mediately ceased.
   During the greater part of this time, the patient was in a state
of faintness, from which she was raised  by giving wine  and the
usual cordials.   She recovered without a single bad symptom,
and  has since had several children.

                          CASE  II.
   Mrs.-----had gone  through a very tedious and hard labour
with her first child.   When the head was so low in  the pelvis as
to rest upon the perinaeum,  the pains left her, at least they be-
came very feeble and slow in their returns.  Fearing that she or
the infant might suffer from long delay in  this position, I thought
it right to deliver her  with the forceps,  and the operation was
easy and safe.   This child she suckled for near twelve months,
and then became again pregnant.  During her pregnancy, she
was thin and delicate, but went on to her full time.   Her labour
proceeded naturally till the head  of the child reached the peri-
naeum, when the pains left her, and the uterus remained  so long
inactive,  that I apprehended I must again have recourse to the
forceps.   But while I was thus deliberating, a violent pain came
on suddenly, by which the child was expelled  with such force,
that it was thrown to the extremity of the bed.   The funis, be-
sides its being  naturally short, was passed twice round the neck
of the child.  After waiting a reasonable time for  the placenta,
and no pains coming on, I  examined and felt the  placenta low
in the vagina, but involving with it a large, firm, and round sub-
stance, which I soon discovered to be the uterus partially invert-
ed,  the placenta still adhering to it.   This was the first case of
the  kind I had ever seen, and  it alarmed me; but while I  was
considering what steps it would  be necessary to take,  another 
            ANOMALOUS, OR COMPLEX LABOURS.        515

violent pain came  on,  by which the placenta and uterus were
forced  through the os  externum.  I first detached the placenta,
and returned the uterus into the vagina, but when I attempted to
replace the fundus  of the uterus,  if could not possibly effect it,
for the cervix was so closely contracted, though in this unnatural
state,  that after repeated trials  to  accomplish it, I desisted,  and
left  the uterus in the vagina,  which then resembled a polypus
with  a pedicle of no large size.   The hemorrhage was not pro-
fuse,  and the patient recovered nearly as well as if nothing extra-
ordinary had  happened.   At the end of the month,  I prevailed
upon her to let me  introduce a pessary,  fearing the uterus might
again drop through the os externum, but this she could not suf-
fer to remain.   She suckled and nursed her child, but removing
into the country, I  could obtain  no farther account of her.
   I now attribute my failure to replace the uterus  to the time
which passed  between my first discovery of the accident, and  my
making attempts to replace it; so that, if I were unfortunately to
meet  with a similar case, I  should certainly replace the uterus
without delaying to separate the placenta.*
  * [In this distressing accident, an inversion of the uterus, in order
to guard against the debility and exhaustion of the system, which may
thence arise, an operation has been recommended and advantageous-
ly performed.
  The inverted uterus has been removed, and the patient recovered.
This is not a novel practice : Pare" states a case where he and Mau-
riceau cut away the womb of a woman of thirty years of age who
survived.   Mr. Clarke had a woman sixty years of age under his
care,  who complained of a tumour which hung down from the exter-
nal parts, between the thighs, attended by a discharge of mucus and
of pus, so profuse in quantity  as  to make her exceedingly weak*
Upon  examination of the tumour it appeared to be an inverted uterus,
the whole surface of which was in a  state  of ulceration.   Above
this tumour was the vagina, also inverted,  having partial  ulcerations
upon it.  A ligature was applied round the contracted part of the
tumour, where the uterus terminated and the  vagina began.   It was
tightened daily until  about the eleventh  or twelfth day, when the
parts included  in the ligature were observed,  and the uterus fell off.
During this time,  the patient complained of very little pain.   Adhe-
sions had taken place between the sides of the vagina, so as to pre-
vent the exposure of the cavity of the abdomen, and the  woman re-
covered.
  Mr. Windsor has given us the particulars of a case of excision of
an inverted uterus, in the tenth volume of the Medical and Chirur-
gical transactions of London. Among the suggestions which he makes
at the conclusion of his paper, on the  best method of removing the
uterus in  those  instances of inverted  uteri, where the  palliative
means are not  sufficient to  arrest the fatal tendency of the disease, 
516
INTRODUCTION  TO MIDWIFERY.
he  maintains a decided preference for the excision of the organ to
the removal of it by ligature.  According to Mr. W. it would proba-
bly be best, before excision  is practised,  first to secure the uterus
above by a ligature, in order that any hemorrhage might be more
easily commanded: " in a day  or two the adhesive inflammation
might be powerful enough to prevent any  further danger of hemor-
rhage, and the ligature might then be safely removed."  F.] 
ANOMALOUS, OR COMPLEX LABOURS.       517
        CHAPTER XVI.

ANOMALOUS, OR COMPLEX LABOURS.
        ORDER  SECOND.

Labours attended with Convulsions.
                         SECTION I.

                     General  Observations.

   The rules given by different  writers, for the management of
labours attended with convulsions, seem to have been founded on
less certain principles, and to  have been less confirmed by expe-
rience, than those which have  been given for almost any other
cases that occur.   These rules have, nevertheless, led to two me-
thods of practice, offered with  sufficient confidence, though dia-
metrically  opposite  to  each  other.   According to the  first,*
which has  been most  generally  approved and followed, it was
deemed indispensably  uecessary to  deliver the patient by  art,
as expeditiously as possible, to free her  from the cause of her im-
pending danger.  But according to the second,f it being presu-
med that'the convulsions appertained to the labour as symptoms;
this, if natural in other respects, was to be suffered to go on with-
out interposition, as if there were no convulsions ; while  we were
to be engaged in using the most efficacious means for preventing
their return, or for lessening the effect which might be produced
by them.   Without success, whatever^has been done or omitted,
has occasionally been blamed  or regretted ; and, in consultations
on cases of this kind, I have generally observed, that the person
who advanced bis opinion in the most confident manner, prevail-
ed on the rest to acquiesce in his  sentiments ; the records of ex-
  * La convulsion est un autre accident  qui fait souvent perir la
mere et I'enfant, aussi bien que la perte de  sang, si la femme n'est
ties promptement secourue par 1'accouchement, qui est le meilleur
remede qu'on puisse apporter a Tune et a l'autre.  Mauriceau, vol.
i. chap. 23.
  t Naturae partus, quoad caetera sanus, relinqui potest.—Roederer
Element. Art. Obstetric. Aphorism. 679. 
518          INTRODUCTION TO  MIDWIFERY.
perience having been thought insufficient, or not so duly weigh-
ed as to satisfy our minds, or to justify our forming an irrefraga-
ble rule of practice.
  The true  puerperal  convulsions have not been accurately de-
scribed ; yet there are  some peculiarities in the symptoms prece-
ding  their appearance, and in the convulsions, or the manner  of
their return, which distinguish them from every kind of hysteric
symptom; and perhaps from convulsions proceeding from  any
other cause.   Together with  the symptoms  of  the  epilepsy,*
which they  very much resemble, there is not  unfrequently a
stertor, which has been considered as  peculiar to the apoplexy ;
or the patients, in the intervals between the fits, are obstinately
comatose.  With the foaming at tlie mouth there is also a sharp
hisping noise, prodnced by fixing the teeth, and by the sudden
motion of the under lip, as if attempts were made to retract the
saliva back into the  mouth; and by this noise I have generally
been able to discover the state of a patient in convulsions, though
she was in another  room.   The  intervals  between the  convul-
sions, which are of a shorter or longer duration, according to the
advancement of labour, evidently depend upon the action of the
uterus,  as will be proved merely by  the application of the hand
to the abdomen;  and when they abate,  the patients in some
cases seem as  if they were awakened by surprise,  and soon re-
cover the use of their faculties;  but in others, they lie in the in-
tervals in an insensible state, as  if they were truly apoplectic,
which they are not,  though there have been instances of patients
dying in the first attack, when  there was no token of labour,  as
far as could be judged by  the state  of the os  uteri.  By the de-
gree of the derangement in the intervals  between the convulsions,
the danger of the patient is to be estimated,  as well as by the vio-
lence of the  fits, or by  the symptoms  which  preceded them.   In
the examination of many women  who have died in convulsions,
I have  never seen an instance of effusion of blood in the brain,
though the vessels were extremely turgid ;  but it is remarkable,
that in all, the heart was found unusually flaccid,  and without a
single drop of blood in the auricles or ventricles; and in several
there instantly appeared many large livid spots on the extremities
  * Epilepsia.—Agitatio convulsiva universalis,  chronica, cum op-
pressione sensorum, exituque spurns ex ore.—Vogelius.
  Epilepsia—Musculorum convulsio cum sopore.—Cullen.
  Convulsio—Musculorum  contractio, clonica, abnormis,  citra  so-
porem.—Cullen.
         Species, 2.    1. Idiopathica.
                      2.  Symptomatica.
.* > 
ANOMALOUS, OR COMPLEX LABOURS.       5l9
 and surface of the body.   They all died immediately after the
 diastole of the heart.
   A  woman in labour was put to bed, and made an effort to
 change her situation.  She died instantly in the act of moving;
 but she had previously complained of a piercing pain in her
 head, and loss of sight.
   Another was in such a  situation, that  the child was expected
 to be born in the next pain.   She threw herself back, and died
 instantly.
   Another raised herself in bed to  take nourishment,  about half
 an hour after  delivery.   She  fell  back,  and died immediately.
 She was opened by the celebrated Dr. Jenner.
   There was no effusion of blood in the brain or any other  part,
 in any of these;  but the heart was found flaccid, perhaps some-
 what enlarged, and not  a drop of  blood in either the auricles or
 ventricles.   Yet the late  Mr. Hewson informed me of a case of
 convulsions, in which,  on examination after death, he found an
 effusion of blood, in a small quantity, on the surface of the brain.
 In  a case of convulsions in which the patient died about eight
 hours after delivery, Dr.  Hooper  found a  coagulum of blood
 weighing near four  ounces, lying between the dura and pia  ma-
 ter.   It is  probable that by more  careful attention instances of
 effusion of blood  in cases which  proved fatal, might be found to
 have occurred more frequently than has been presumed.
   It will be convenient to arrange what I have to say  farther on
 this subject, in the following order: first, to enumerate the repu-
 ted causes of convulsions;  secondly, the symptoms which precede
 their  appearance;  thirdly,  the  means  of preventing  them;
 fourthly, the treatment which may be  requisite  when the patient
 is actually in convulsions;  and, fifthly, on the delivery by art.

                         SECTION II.
             On the reputed causes of Convulsions.
   It is remarkable that  puerperal convulsions occur so rarely in
 tr^e country, that I have not been able  to make some very intelli-
 gent men, of great  experience, comprehend  them, they having
 never seen a single example.   The few cases, of which I  have
 been informed, out  of this city, have happened in large towns, or
 among those who might be reckoned in the higher j-anks of life.
 It has also been justly observed,  that  women are far more liable^
 to puerperal convulsions in certain years and  seasons,  than in
 others.  We may therefore conclude, that a  remote cause of
 these convulsions is to be sought for in some change made in the
constitution, by the customs and manner of living in cities and
large towns,  especially among those  who  too zealously devote
themselves to music; or in the  particular  influence  of the air;


                              »                      j- ■
    _________  ____________         _______  __________         . ,.>____________ 
520         INTRODUCTION TO MIDWIFERY.
    though there may also be immediate causes capable of  produ-
    cing these convulsions  in any situation, or under  any circum-
    stances.
      The female  constitution becomes infinitely more irritable
    than usual in consequence of the  changes made  in  the  uterus
    during pregnancy ; every part of the body readily participating
    with the state of the uterus.   This increased irritability, when
    not excessive, and only affecting in one peculiar manner, parts,
    not essential to the economy  of the constitution at large, is so
    far from being  injurious, that it proves eventually salutary to
    the parent or child.  But we may conclude, that in a constitu-
    tion become unusually  irritable from one cause, any  additional
    corresponding cause of morbid irritation may  often excite dif-
    ferent  and more violent effects, than if that  constitution  had
    been at rest, before the application of the second cause.   It is,
    therefore,  reasonable to believe, and the fact is proved by the
    daily occurrences of practice, that the constitution which a de-
    licate mode of education can scarce fail to give, still farther aug-
    mented by habits  of indulgence, and the eager pursuit of plea-
    sure more in advanced age, renders such women at all times,
    and in all situations,  more  liable to every kind and degree of
    nervous effects; that the state of pregnancy  makes  them  still
    more disposed to the same affections, and from slighter  causes
    to convulsions, than those women who, by education  and habits
    of living, are  seasoned, as  it were, against impressions  which
    might affect either their minds or constitutions ; for it is to both
    these we are to look for the causes of convulsions.
      That the state of the  mind does very often  dispose women to
    puerperal convulsions, and  other dangerous nervous affections,
    there  are  numerous  proofs to be  drawn from  the histories of
    practice, and of which  there is a  very interesting case  in the
    Bible,  (1 Samuel, chapter iv.)  and three remarkable circum-
    stances are mentioned; first, the cause, the violent agitation
    and distress of the mother's  mind ; second, her state of insensi-
    bility  at the  time of her delivery; third, that the child was
    born living, though the mother died immediately after his birffl.
    This has been more particularly observed among those women,
    whose unfortunate situations render pregnancy an evil instead
»   of a blessing ; for, from their seclusion from, and deprivation of
Jr the  comforts of, society, their sense  of present ill, or apprehen-
    sion of future distress,  such  women are especially  subject to
    convulsions at the time  of labour, and to  become maniacal after
    their delivery.  It  has also  been observed, that,  from violent
    and sudden impressions on the mind, more generally  from ter-
    ror  than any other, pregnant women have either immediately
    had convulsions, or fallen into a state which showed a great pro-
    pensity to them, though they did not appear before the accession 
           ANOMALOUS, OR COMPLEX LABOURS.        521

 of labour.  (The carriage of a lady, who was going on a party
 of pleasure, was broken down; she was near the time of her ly-
 ing-in, and was very much frightened, though she received no
 apparent injury.  When she fell into labour, this was preceded
 by convulsions, in which she died undelivered.)  In some cases,
 however, from a state of apparently perfect health, and without
 any known predisposing cause, the first tendency to labour has
 produced convulsions,  which have occasionally returned till
 the child was  born, or even after its birth ;  though in other ca-
 ses the convulsions have ceased; and the labour has proceeded
 with great regularity.  But there is often reason to suspect, that
 when convulsions have once appeared, they make to themselves
 new causes of their return, as they have continued for  many
 hours, or even days, after delivery, and the patients  have at
 length recovered.   There is likewise reason to think, that cau-
 ses, seemingly too  trifling to produce convulsions, have some-
 times been equal to the  effect;  as I recollect two instances of
 women   who had convulsions at the time of labour, preceded
 by violent headachs, brought on, as it appeared, by the use of
 some mercurial preparation mixed with  the  powder used for
 their hair.
  But it is not only in weak and very nervous habits that con-
 vulsions  occur, as  they  more frequently happen in plethoric
 constitutions,  and are accompanied with a  strong action of the
 vascular  system in general,  or of some particular part of the
 body.  With  such different constitutions and indications, some
 with symptoms of debility and depression, and others of plethora
 and fever, the method of treatment must of course vary ; and
great judgment will be  required to suit the proper method,
if that can be discovered,  both in the degree and extent  to
 which it ought to be carried,  to  the state of every individual
patient.
  Beside the general affections of the body, which may be sup-
 posed to  give  a disposition to convulsions, affections of different
parts, as  of the intestinal  canal or bladder, if they should be too
muth loaded or distended, may have the same power.*  But in
the female constitution, the uterus is the great source of morbid
 irritability, and of course every cause capable of disturbing this
part beyond a  certain degree,  or in an unnatural manner, may
affect the whole frame, according to the kind and degree of the
original affection, or according to  the previous disposition.  Yet
  * Ad spasmodica, quae ex uteri vitio proveniunt,  pathemata con-
citanda, non opus semper erit, ut materia corrupta et vitiata, utero
inhaerens, proxime et immediate id efficiat.  Hoffmann, de Mai. Hys-
teric.
66 
522
INTRODUCTION TO MIDWIFERY.
all the parts of the uterus do not appear equally liable to be dis-
turbed, for the os uteri is evidently the most irritable part, even in
a natural state, as well as when disturbed by any morbid or ad-
ventitious cause.  (In a case of this kind, which I published  forty
years ago, I observed, " When the os internum began to dilate,
I gently assisted during every pain ; but being soon convinced,
that  this  endeavour brought on, continued, or increased  the con-
vulsions,  I desisted, and left the  work to nature.")  Hence it
appears in pregnant women, on the first tendency to labour, that
the changes which that part undergoes, often occasion a variety
of nervous symptoms; and that these may be brought on, in-
creased, or continued,  if they before existed, by artificial or im-
prudent dilatation of that part in the course of labour, when it is
unusually rigid; or with  an increased degree of  irritability oc-
casioned by inflammation.  (A woman, whose case was  commu-
nicated to me by Dr. Mackenzie, though  the convulsions ceased
after delivery, died on the  fifth day of the puerperal fever.  In
almost every case of convulsions that I saw in the early part of
my practice, there was evidently, after delivery^ greater or less
degree of abdominal  inflammation;  but by the present  practice
of liberal bleeding this has probably been prevented.)
  It  has  been presumed, that the pressure made  by the expanded
uterus upon the descending blood vessels,  causing a regurgita-
tion of the blood to the superior parts of the body,  to  the head in
particular, by overloading the vessels of the brain,  produced con-
vulsions.  This opinion applies to a cause very general  indeed,
and,  if true, must  have had its effects so frequently as not to re-
main  in doubt.  But they sometimes first come  on, or continue
with  equal violence after the birth of the child, when  this pre-
sumed cause is removed.
  It  is said that women  are far more liable to convulsions, in
first than  in subsequent  labours,  which  is true;  and more fre-
quently when the child is dead, than when it is living;  but this
I cannot allow.  For when women have convulsions, the death
of the children ought  generally to be esteemed rather an effect
than a cause;  as  they have very  often been delivered of liv4ng
children  while they were in convulsions;  or of dead, and  even
putrid children, without  any  tendency  to convulsions.  Some
women have also  had  convulsions  in several successive labours;
but,  having had them in  one, they generally, by the  precautions
taken, or some natural change, escape them in future.    Lastly,
I was for many years  persuaded, that convulsions happened only
when the head of the child presented; but experience has prov-
ed, that they sometimes occur in preternatural presentations. 
ANOMALOUS, OR COMPLEX LABOURS.
523
                        SECTION III.
            On the means of preventing Convulsions.
  For the prevention of common accidents it appears reasonable
and proper, that women in pregnancy should avoid all irregula-
rities in their manner of living, and every  situation where they
may be under restraint; or they will be liable to many complaints
and  inconveniences.  (Gregarious  animals, when pregnant or
giving suck, choose a place in the herd, different from what they
take at other times.)   At the time of labour  it is a  rale generally
observed,  that their minds should be kept composed, their appre-
hensions quieted,  their present sufferings soothed by the tender-
ness of their friends and attendants; that they should be encou-
raged with the hope of a happy event, and that the knowledge
of every thing which might agitate or distress them should be
concealed.  But when any  symptoms of disease appear,  beside
these precautions, such means,  as the consideration of any parti-
cular case may indicate to be necessary, are to be  used; and no
symptoms can require more attention than those, which have been
recited as  threatening convulsions.
  Bleeding is  known to lessen, in a very effectual manner, all
the complaints in  pregnancy which arise from uterine irritation,
and to a certain degree, in pregnant women, from most other
causes.  It is therefore, I may say,  universally recommended in
all cases, when convulsions exist, or are to be apprehended.  In
these, the  quantity of blood to be taken away, and the repetition
of the operation, which in the course of a few hours may in some
cases be several times required, must  depend upon the strength
of the patient and the violence of the symptom:  but certainly I
have not seen or heard of any case where the patients sunk from
the  loss of blood ; though when they have been much reduced by
the  previous bleedings, it has afterwards been necessary to sup-
port with  proper nourishment  or- cordials.  But in some very
urgent cases of this kind,  beside the bipod which  may have been
thought necessary to  take  from the  arm,  it will be also found
necessary or preferable,  especially when the head was particu-
larly affected, to use local bleedings, by scarification  and cup-
ping at the nape  of the neck, or by opening the jugular vein, or
sometimes by cutting the temporal artery ;  a thing so easily done
as not to  deter us from the practice, and often so efficacious as
to invite our doing it on  many other occasions.
  When these symptoms have been  preceded or are accompanied
by others, which  denote much disturbance of, or the lodgment or
any offensive matter in the stomach, gentle emetics may be given
with safety and advantage.  A lady had many severe attacks of
this violent pain in the head, in the  latter part of her pregnancy. 
524         INTRODUCTION TO MIDWIFERY.
 In many affections of the brain it has been thought that emetics
 afforded singular benefit.  (See Pitcairn's Praxis Medicina?.)
   Towards the conclusion of pregnancy some women are subject
 to violent cramps in various parts of the abdomen, or inferior
 extremities, together with complaints in the head or stomach.
 Should not these be relieved by the customary means,  bleeding,
 and  afterwards the tepid  bath, may be advised, and from its oc-
 casional use they will often find much benefit.
   Objections have been made to the frequent or habitual use of
 opiates for slight complaints in pregnant women; and there is
 much reason to suspect, that they sometimes, acting perhaps like
 spirituous liquors,  prove  injurious  to the child.  But these ob-
jections do not apply to their occasional  use, when they are
 really necessary.   Yet as, in very large doses, opiates have been
 known to  produce  convulsions, it  seems better to give them in
 these cases, in small quantities often repeated,  than in a large
 dose at one time.
  Nervous medicines of various kinds are usually given on these
 occasions, rather from custom, or with the intention of procuring
 temporary relief than permanent advantage; but  if they could
 be swallowed, no benefit has  accrued  from their  use. On the
 whole, it appears that in  bleeding, and keeping the stomach and
 bowels in a healthy state, in giving opiates, and in the occasional
 use of the  warm bath, we have the principal means which  medi-
 cine affords, as far as can be judged, either by reason or experi-
 ence, of preventing puerperal convulsions, of insuring, in general,
 a safe labour, and a happy recovery. *
  It may lastly be  considered, whether in cases of convulsions
 existing or threatened after  delivery,  and  indeed  at  all other
 times, especially when there  are twins, it might  not be  expedient
 and  beneficial  to make a uniform  pressure by passing a napkin
 round  the body, as soon  as it can be conveniently done, between
 the birth of the first and  second child, in order to give  a support
 equivalent to that which is lost  by the sudden evacuation of
 the child.

                         SECTION IV.
               Of the treatment of Convulsions.
  From the'attack of convulsions without any previous symptoms,
 or from the want of attention to those symptoms, we have more
 frequently  an opportunity of exercising our  judgment  in curing
 than in preventing convulsions.  These, it was before  observed,
 may come on in the beginning, or in the course of a labour; or,
  * Mulieri ex partu convulsione tentatae, si febris succedat, bonum
est.  Hippocrat. Lib. i. de Morbis. 
ANOMALOUS, OR COMPLEX LABOURS.
525
which is more rare, though not less dreadful, soon after the birth
of the child; and some difference of treatment may be requisite,
according to the time of their appearance*  But whenever they
do come on, the danger  is  so  manifest and  so alarming, as to
call for  the immediate exertion of all the powers of medicine for
the relief of the patient.
  The first and most obvious remedy in a case of such violent
agitation of the whole frame, and such obtusion or perversion of
the mental  faculties, is, to take away a proper quantity of blood
from the arm; for the direct good,  which may be expected to be
gained by bleeding speedily, as well as for the prevention of the
mischief, which might  follow  the convulsions.   One  copious
bleeding has sometimes entirely removed the convulsions, which
have not returned, after as well as before delivery; but  should
these  continue with equal force for a  certain time,  it  will be
expedient to repeat the bleeding, or  for the particular easement
of the head, to try the effect of local bleedings.  Leeches are too
slow in their operation, though they may be safely applied, and
affording some relief, should not be neglected ; and scarification,
with cupping, could not be done without much difficulty; so that
the two methods, most  applicable and adequate to the urgency
of  the case,  are, to open the  temporal artery,  or  the  jugular
vein ; and the latter has certainly been  found preferable, perhaps
because the  blood is  thereby discharged- with greater velocity.
For a patient, who was lying in a state which deprived me and
several  physicians  of all  hope of her  recovery, Dr.  Reynolds
proposed, that the  jugular vein should be  opened.   The good
effects were almost  instantaneous ;  the patient recovered, and has
since had  many children.   Objections are sometimes made to
bleeding in this vein, lest there should be a difficulty in restrain-
ing the blood while the patient is so much disturbed  ; but there
is no hazard, and the case does not admit of delay.   The bleed-
ing, from whatever part the blood  may be drawn, is to be repeat.
ed according to the effect  produced, the strength of the patient,
and the violence or continuance of  the convulsions.  (The  late
Dr. Broomfield informed me of a case of puerperal convulsions,
for which  he had  bled  the  patient  without  much benefit.  .In
the violence of some of her struggles the orifice opened,  and a
considerable quantity of blood was  lost before the accident was
discovered ; but the convulsions from that time ceased.)
   In the course of a few hours,  I have by  different  operations
seen more than forty ounces of blood taken away with the hap-
 piest effect;  and in a labour of long duration, when the convul-
sions have continued, aBd been severe, at various times, not less
than sixty  or seventy ounces.
   The state of the  patient will seldom allow of the use of emetics; 
526          INTRODUCTION TO MIDWIFERY.
but, when they could be given, and have produced their effect,
they have procured much relief; and the same observation may
be made of purgative medicines.  But the truth is, from the mo-
ment the convulsions come on,  the patients often lose  all power
of swallowing, even  in the  intervals, and we are compelled to
relinquish internal medicines  altogether.  Yet  in such cases,
clysters,  if they can  be  made to pass,  are usually given ; but,
whether they were purgative in the  first  instance, or afterwards
composed with a due quantity of opium, of oil of amber, the fe-
tid  gums, or  other medicines of that kind, I cannot say that  I
ever saw any good produced by them, at least before the birth  of
the child; and sometimes they seemed to increase the irritability.
  On a supposition that the remote  cause of these convulsions is
in the too great irritability of the constitution at large, and the
immediate cause in  the excitement raised by some new stimulant,
as the labour,  or  the like, opium in any  convenient form has
been  freely given,  and sometimes with  evident  advantage;
though I have seen many cases, in which it had no power to re-
move,  or even to abate, this  disease.   From the  exhibition of
large doses, the patients have sometimes been brought into a co-
matose state, but the moment  they  are  roused,  the convulsions
have returned with  their former violence.  Nor  has more satis-
faction been obtained by the various nervous medicines common-
ly prescribed ; even musk, often repeated in  very large  quanti-
ties, that is, ten grains every  hour,  has  done as little  service  as
the rest. I do not recollect having tried the introduction of from two
to three or four grain of purified opium into the rectum, though  in
many cases of great uterine pain and disturbance, opium used  in
this manner has had a very powerful effect.
  When  the convulsions have  continued or  increased, notwith-
standing the bleeding duly put in  practice,  which indeed sel-
dom is the case, and the use of all the  other reasonable means
which could be devised, the patient may be  put into the warm
bath, in which  she may remain a considerable time, if the con-
vulsions  be  suspended while she is in  it.  There have been in-
stances of women  with convulsions, who have been  freed from
thepi only during the time they  were in the bath ; and I have
heard of one or more cases of their being actually delivered  in
the bath, without any ill consequences,  either to the  mother  or
child.  When  a warm bath could not be  procured, or while  it
was preparing, I have directed flannels wrung out of hot water,
or any suitable fomentation, to be applied over  the whole abdo-
men, and, I think, with advantage; and after the use of the fo-
mentations I  have  also advised some liniment made more sooth-
ing by the mixture of opium, such as equal parts  of oil and tine«
tura opii.
  On every principle, of removing the cause  of  the convulsions, 
           ANOMALOUS, OR COMPLEX LABOURS.        527

of substituting new modes of irritation different from that which
produced the convulsions, of preventing their ill consequences, or
of abating that exquisite irritability which renders patients sub-
ject to them, almost every measure and method has at one time
or other been tried.  Harvey (Exercitat. de Partu.—page 554.)
recommended the irritation of the nose in a comatose patient who
was in labour, and gives an  instance of its success.  Many years
ago 1 was led by accident to try the effect of sprinkling, or dash-
ing cold water  in the face ;  and in that and other cases the bene-
fit  was  beyond expectation or  belief; but  in  some  cases, in
which I used this method with equal care and assiduity, no good
whatever was derived from it.
   I subjoin the following case, to explain the manner of using
the cold  water.  On a patient  in convulsions,  who   had  been
bled,  and for whom many other means had been fruitlessly used,
I determined to try the effect of cold  water.  I sat down by the
bed-side with a large basin before me, and a bunch  of feathers.
She had a writhing of the body, and  other indications of pain,
evidently occasioned by the action of the uterus,  before the con-
vulsions ; and when those came on,  I dashed with some force
the cold water in her face repeatedly, and prevented the convul-
sion.   The effect  was astonishing  to the  by-standers, and  in-
deed  to myself.  On the return of the indications of pain, I re-
newed the use of the  cold water,  and with equal success; and
proceeded in this  manner till  the patient was delivered, which
she was  without any more convulsions, except  once  when the
water was neglected.  The child was born living about fifteen
hours from the time of my being called,  and the patient  reco-
vered perfectly.
   I was  much  mortified to find, that I  had not discovered a
certain and safe method of  treating convulsions; farther  expe-
rience convincing me, that  this often failed.   It  is however a
safe remedy;  and though  it  may not always  have  sufficient
efficacy to prevent or check convulsions, whoever tries this man-
ner of using cold water will soon be convinced, that it  is a most
powerful stimulant.
   Nor has the application of sinapisms to the feet, or  blisters to
various  parts of the body,  afforded any advantage, except, per-
 haps, when the convulsions had ceased, and the patient remained
 comatose.   Latterly it  has been the  custom in cases of convul-
 sions, and in other cases of delirium, mania, and other violent
 affections of the head, to apply and to keep applied to the  head,
 crushed ice; it  is said,  with evident  and very great advantage.
 In the less degrees of  affections of the head, or when ice  could
 not be procured,  folded napkins wet with cold water  have been
 substituted.
    When all the means which reason can  suggest, or  which  ex- 
528          INTRODUCTION TO  MIDWIFERY.
perience has proved, have been tried to their  foil extent without
success, the convulsions may remain, with evident and extreme
danger of the patient dying every time they return ; and having
taken away as much blood as we can venture to do, we shall be
driven by  necessity to wait quietly for the termination  of the
labour in a natural way, hoping  she may struggle through ; or
we shall be obliged to seek further  resources  in the delivery of
the patient by art.  But this part of our subject shall  be consi-
dered in the next section.

                         SECTION  V.

                   On the Delivery by Art.

   If it be necessary to make distinctions  as to  the time  when
convulsions are threatened or have  actually  come  on, with re-
gard to the medicinal treatment, it is infinitely more so as to the
delivery of the patient by art.   We will therefore consider,
   1. Whether delivery by art  be proper or justifiable in the be-
ginning of a labour attended with convulsions.
   Women  sometimes fall into  convulsions before  there is any
discoverable tendency to labour, when there  is not the smallest
degree of dilatation or relaxation of the os uteri, and when there
is no way of judging that it will be labour, except from the state
of pregnancy, the  peculiarity of the convulsions, or the manner
in which they return, for by these they may in general be rea-
dily distinguished from those proceeding from any other cause.
In some cases also, after a long continuance of the convulsions,
the os uteri has  remained  closed ;  and then  it has sometimes
been presumed, that they were not,  properly  speaking, puerpe-
ral.  Yet,, after a long delay, it has  usually happened, that  the
dilatation both of the internal and external parts has begun and
proceeded very rapidly ; so that,  in a short space of time, from
no degree of dilatation,  the os  uteri became  unexpectedly  but
completely  dilated, when  all hopes of delivery had been  laid
aside, and the very existence of the labour had been denied.   (In
a well known case of this kind, the midwife presuming that it
would not be labour, left the patient, who was found dead in the
morning, with her child, also dead, lying in the bed.)
   When women have before had children, the infant and pla-
centa have been sometimes expelled with wonderful  rapidity,
by the mere force of the convulsion acting  upon  the uterus.
But even in such cases the convulsions may continue with equal
danger after delivery, and then they  will require  a nicely dis-
tinguishing and yet resolute conduct.
  Now whether  it be  proper and  reasonable, that  attempts
should be made to  deliver a woman with the  os  uteri in this
state, and  under such circumstances in general,  must appear 
           ANOMALOUS, OR COMPLEX LABOURS.       529

 very dubious to those who consider  how much would then be
 required to be done by art.   But, if we farther reflect upon the
 event of the greater number of cases of women who have been
 delivered by art, under these, and far more favourable circum-
 stances, the greater part of whom  have soon died, their death
 being apparently hastened by the operation, however carefully
 it might have been performed, we  shall be deterred from pro-
 posing it;  and 1 think, be justified in forming this general rule
 of practice, subject, perhaps, to some exceptions,  that women,
 who fall into  convulsions  in  the beginning of labour, ought not
 then to  be delivered by art.
  I presume, that, with all  the assistance which art enables us
 to give, or if the labour be resigned to nature without interpo-
 sition on our part, patients will sometimes, though of late years
 such cases have very rarely happened, die in a deplorable man-
 ner.   I also know that, if the  patient should  die when  no at-
 tempts  were  made to deliver, the omission is always regretted ;
 or, if she should be delivered by art and die, that the operation
 is lamented.  Yet there must be a rule of conduct to be pre-
 ferably  followed, and  with  few exceptions;  and  this is to be
 made, not according to the timidity or boldness of the person
 under whose  care the patient may be;  nor according to  the
 impatience or tenderness of  friends; but according to a judg-
 ment formed  by a sense of duty, maturely weighing all that the
 knowledge of a present case, or the experience of others, has
 enabled us to collect.   (Dr. Ross, who, many years ago, was
 one of the physicians of St. George's Hospital,  was  the first
 person of late years, who had courage  to declare  his doubt of
 the propriety of speedy delivery in all cases  of puerperal con-
 vulsions.   The observation on which these doubts were found-
 ed was merely practical,  and the event of very many cases has
 since confirmed  the justice of his observation, both with respect
 to mothers and children.) But I have not for many years seen,
 or heard of a  patient dying with puerperal convulsions, if bleed-
 ing had been timely and sufficiently performed.   In the very
 fit of convulsion, by which the patient was apparently  killed, I
 have advised  blood to be drawn from the arm, and she has re-
 covered.
  2. Though convulsions often happen in the beginning of a
 labour, and continue to its  termination, the first  stage  is,  in
 some cases, passed over without any unusual disturbance or ir-
 regularity,  and they come on  in the second stage of the labour,
when the symptoms which usually precede them did not appear,
 or rather passed without observation.  The propriety  of deli-
vering by art is then to be determined on other grounds than
 in the preceding statement,  whether the convulsions have con-
 tinued  to,  or commenced at, that  time.  For, if  it should be
                            67 
530
INTRODUCTION TO MIDWIFERY.
thought necessary to deliver by art, this may frequently be do»e
without any peculiar force upon the parts concerned, as the os
uteri will then either be dilated with the membranes whole or
lately broken, and  the child may be  turned without  difficulty,
and safely  extracted by  the feet: or the  head will  have de-
scended so low into the pelvis, as to allow of the easy use of the
forceps or vectis; or things may be so unhappily circumstanced,
as to leave  no other option of the  mode  of delivery, but we
may be compelled to lessen the head of the child, to preserve
the life of the parent.  Whichsoever of these methods may be
thought proper or  absolutely necessary, the rules before given
for the management of difficult  or  preternatural labours will be
sufficient guides for our conduct:  and before any thing else is
done,  the  membranes may be ruptured,  and  the waters dis-
charged ;  from which alone,  in some cases, much benefit has
been derived, by hastening the delivery.   But,  from a review
of what has passed in my own practice, I feel it an indispensa-
ble duty to caution the operator against a forwardness to sacri-
fice the child in cases  of convulsions,  as many  of these,  with
very unfavourable appearances,  have  terminated happily and
safely both to the mother  and  child ; and against hurry in any
operation, as he would thereby lessen his chance of saving the
child, and probably with disadvantage to the mother; and no
good can result  to society, or reputation accrue to the profesr
sion, from a practice by which  neither of their lives is preserv-
ed.   Should the convulsions continue  after the  birth of the
child, the methods before advised must be tried and  persisted
in,, or  new ones adopted, as the state of the case may then re-
quire or allow; and under these circumstances  it will often be
found preferable,  to satisfy ourselves  with giving time, pro-
ceeding gently and  circumspectly with general  care, rather
than  to use incessantly the  more active  means, which it has
been sometimes necessary to recommend.
   With respect to those convulsions,  which  first  appear after the
birth of the child, the exigence of the case must govern the treat-
ment, and  great attention is to be paid to the placenta, which, I
believe, should not then be hastily extracted.  There is in these
an appearance of iffstaut and unexpected danger, beyond what is
found even in convulsions before delivery,  frightful as they al-
ways were.  These convulsions are preceded or accompanied by
 the same symptoms as those  which  come  on in the commence-
 ment or course of a labour; and notwithstanding the delivery,
 they require and allow of the same means being used for the re-
 lief of the patient, provided these are accommodated to her gene-
 ral strength and circumstances.  In convulsions which come on
 after delivery, if women escape from  the first fit, there is a great
 chance of their recovery;  butt  should they  remain comatose, or 
ANOMALOUS, OR COMPLEX LABOURS.        531
whatever their state may be,  the  particular symptoms are to be
considered, and from all that has been said upon this subject at
large, we shall be at no loss to discover what may be applicable
in any individual case of this kind.
   But there is yet room for much  improvement in our knowledge
of the causes, effects, and treatment of convulsions depending on
pregnancy and parturition; though the greatest confideuce may
certainly be placed in sufficient and timely bleeding.
   Before the conclusion  of this subject,  it will not be amiss to
speak of the sudden deaths which sometimes happen soon, or a
considerable  time after delivery,  when there was no apparent
reason for suspecting such events.
   In every case of extreme debility, induced by any circumstance
which might occur at the time of parturition, great caution wai
generally recommended, that patients should not exert themselves
beyond their strength, or do what they seemed able to do with-
out much apparent difficulty.  But from a review"of these dread-
ful accidents, of which, in the course of a long and extensive prac-
tice, I have seen and known several instances, I think they may
be reduced under the following heads.
   First,  when before delivery the patients were subject to frequent
returns of spasm or cramp-like pains in the stomach, spreading
their influence  to the heart, as is shown by the temporary suspen-
sion or interruption  of the circulation,  indicated by the pulse.
These symptoms may  return  after delivery with increased and
dreadful  violence.
   Secondly, when the patient is  very much reduced by loss of
blood  at the time of delivery, the weakness thereby  occasioned
remaining a long time afterwards.   In  these cases,  on making
any extraordinary exertion, the patient is suddenly overcome, and
the powers of the constitution are not able  at that time to reco-
ver vigour of action sufficient to sustain life.
   Thirdly, when without any adequate indication of the mischief
to be apprehended, a faintness and a difficulty of respiration sud-
denly come on, and these increasing, the patient  dies unexpect-
edly.   This event is usually preceded by her spitting a very small
quantity of blood,  and on examining the body after death, an
oozing or effusion of  blood in the  air vessels of the lungs has
clearly shown the cause.
   Fourthly, in  cases  of extreme debility from other causes,
particularly in the edematose swelling of the leg, in which there
is often  a surprising degree of weakness with much  disturbed
action of the  whole frame,  on the patient's making any effort
beyond  her strength,  and perhaps against her inclination, a
fatal  and  sudden faintness is  sometimes brought  on, before
an action to which she seemed competent is completed,  and
death  seems more unexpected and instantaneous under these 
532
INTRODUCTION TO MIDWIFERY.
than any  other circumstances; in some cases,  several weeks
after delivery.
  With regard  to  the first cause of these deplorable events,
without waiting for the return of the  spasm,  it will be proper
to give some very warm cordial immediately after delivery, as
brandy alone or diluted, acting in the manner usually practised,
when patients are suffering from the gout in the stomach.  The
most suitable  medicine is the  confectio opiata, given and re-
peated in a full dose according  to the  exigencies of the case ;
and the stomach should be very often supplied with some actu-
ally warm drink, as weak broth, tea of various kinds, especial-
ly those  made from ginger or pepper, with  actually hot  ap-
plications.
  With regard to  the second  and third causes,  there is no
way of preventing  their effects  so reasonable, as  by taking
care not to fill the vessels too  hastily, by very plentiful nourish
ment, from an impatience  to  restore that strength which the
patient has lost; or pressing her too hastily to a convalescent
state.
  And with respect to the fourth  cause, of which  I  have seen
three instances, we  are to be very circumspect, that we do not
permit, or  persuade patients to make much exertion,  while
they are very weak, but leave them to act according to their
own feelings and judgment.   But of this we shall speak here-
after.
  These observations will not, I fear, be of much  importance,
but we may be truly said to have a very imperfect knowledge
of the subject of sudden death under these circumstances ; and
it deserves more accurate observation, and  greater considera-
tion, than have hitherto been  given it.*
  * [In the treatment of puerperal  convulsions,  special attention
must be paid to  the different  conditions  of the system from which
they may arise.   In  the comparatively few cases which occur in
consequence of  great exhaustion from excessive hemorrhage, or an
irritable habit, rendered more so by a tedious and painful labour, we
shall find the free use of opiates of  saving efficacy.   That species
of convulsions which is apparently of the epileptic nature, is of much
more frequent occurrence, and sufficiently characterized by its pecu-
liar symptoms. Dissection has shown the extreme commotion which
it induces in the vascular system, and points out, that copious blood-
letting is  our principal remedy.   In this form of disease, opiates
must be productive of serious, if not fatal, mischief, unless preced-
ed by active depletion.   By this evacuation we most  speedily  un-
load the vessels of the brain, and fulfil other important indications.
Dr. Hamilton informs us, that no patient to  whose assistance he  has 
           ANOMALOUS^ OR COMPLEX LABQUBS.       533

been called, and  to  whom opium had been administered before his
arrival, ever recovered :  and this is a result that  might be antici-
pated in every case  in which the convulsions were connected with
a congested state of  the brain.   Camphor, as an  internal  remedy,
has been  strongly recommended, and the experience of the best
practitioners warrants our having recourse to it.  F.] 
53£         INTRODUCTION TO MIDWIFERY.
       CHAPTER XVII.

ANOMALOUS, OR COMPLEX LABOURS.
          THIRD ORDER.

Labours with two or more Children.
                        SECTION i.

  The common order of generation, or the continuance of any
particular kind of animal, according to the properties of each
kind, is more frequently invaded by an extension than a failure
of the principle ;  instances of unusual increase  being often
found both in animals and vegetables, though examples of this
oftener occur in some classes than in others.
  With respect to generation,  all animals may be divided into
two classes, uniparient and multiparient.  Of the multiparient,
the number of young produced at one birth seems to be indefi-
nite, and governed by accidental circumstances, as the frequent
intercourse with the male, plenty or want of food, and perhaps
by the casual fixture of the first conception in the first chamber
or partition of the uterus.  It  very seldom, however, happens,
that  animals,  multiparient by nature, bring forth only one fcetus
at a  birth ; and perhaps the uniparient do not more frequently
bring forth more than one, though in every species there are
exceptions to this general rule.   As  to the economy of this im-
portant end of the animal creation, it would probably be found,
that  the female multiparient animals have no exclusive attach-
ment to any  individual male; but that  the female uniparient
have naturally such an attachment.
  In some species  of animals, the  propensity to bring forth
more than their common  number of young is greater than  in
others ; in sheep, for instance, more  frequently than in  cows,
in these than  in lions.   Climate, and state or degree of civili-
zation, seem to have their influence, in this respect, on human
beings: for in the account  of the  women admitted  into the
Middlesex Hospital of this city, in 8636 births, there were only
ninety-three cases of twins, and none of a greater number. Of
that  number there were  3263 boys ; 310  were still born, and
of this number 180  were boys ; and somewhat more than half 
           ANOMALOUS, OR COMPLEX LABOURS.       535

of the twins were boys.   But in the accounts published by Dr,
Clarke of Dublin, (see Philosophical Transactions,) the number
of twins was in greater  proportion to  the births, and there
were several examples of three children.
   It  has been supposed that there is a disposition in  certain
families to this multiplied generation, which may be transferred
either by the male or female ; but if this be the case, there are
no tokens by which this disposition would  be suspected, either
from  the form, size, strength, or other appearance.
  It is not very usual for women to have twins, though these are
to common observation more frequent in particular years than
in others ; and it can scarcely be doubted, but there is some re-
lation in those years between the animal and vegetable creation.
In the course of more than thirty years, I have met with only
one instance of three children,  and never of  more.   I  have
been  informed of several cases of four children, and there have
been  published a few  cases  of five children born at one birth,
but beyond this number there is no well authenticated or credi-
ble case upon record.
  The size of children  born at one birth is generally in a re-
verse proportion to their number,  as is  also the probability of
their  being born alive, or continuing to live.   Twins are fre-
quently born living, and not much, if at all beneath the  size of
a single child; sometimes three have  been born living,  and
been  reared, but not often ;  and when  there have been more,
the chance of all or any  being preserved is very little,  should
the woman go to her full time.  With more than two children,
women  seldom go  on  to the full  period of uterogestation, and
even with two, there is a great likelihood of a premature birth,
especially  in  the first  pregnancy.  It must of necessity  be
somewhat more  complex and sometimes hazardous when there
are two or more children, than in a single birth, but he who un-
derstands the proper management of a twin case, will meet with
no difficulty to embarrass him, how many children soever there
may be ; we shall, therefore, consider and speak of all births of
this kind under the denomination of twin cases.
                        SECTION  II.
                   On the Signs of Twins.
  1. Women are said  to be always of a greater size in  the ad-
vanced  state  of  uterogestation when they are  pregnant with
twins, than when they have a single child. This is a very uncer-
tain sign, and popular opinions being usually  founded  on this
circumstance only, are therefore far more  frequently  fallacious
than true.  But if a woman be unusually large in the early part
of pregnancy, and  increase proportionably  to  the fall period,
there  is  good reason for suspecting* she will have twins.  But a* 
536          INTRODUCTION TO MIDWIFERY.
the term size is indefinite, and what one, not  much conversant in
such matters, may consider  as  large, another may  consider  as
moderate, there can be no  surprise, if conjectures on this subject
often prove to be erroneous.
  2. The abdomen of all  women with child is in general  uni-
formly distended, without  any inequality.  It  sometimes howe-
ver happens, that the tendons, which form  what is called the linea
alba, which leads from the  navel to the  middle of the ossa pubis,
being less distensible than the sides of the abdomen,  which are
muscular, divide the abdomen as it were into two equal parts by
a raphe or indentation through its inferior part.   This presumed
sign of twins is as ancient as the  time when the human uterus,
like that of quadrupeds, was  supposed to be divided into cornua,
a child being thought to be  contained in  each horn.  But as the
form of the human uterus  is now  well understood, and known to
be equally distensible to its contents, whatever  the form of the
abdomen  may  be,  unless  it be constrained by external means,
even less regard is paid to  tho form of this, than  to its degree of
distention, when we are judging whether it  be  probable, that a
woman is pregnant with more than  one  child,  were  it of any
consequence to decide.
   3. Women  with child,  especially  those who have before had
children, are sometimes apprehensive that they have twins, from
a greater, a distant, or some uncommon motion  they feel during
pregnancy.   Some regard must at all times be paid to the repre-
sentations of those who have had experience; though  they may
be ignorant of doctrines; yet I have  seldom  found  these opi-
nions verified by the event.
   4. In the course of a labour, sooner or later, according to the
strength  of  the  membranes  and of the pains,  the waters of the
ovum are discharged at once,  by one large,  or a repetition of
less  discharges,  when there is only one child.   Mention is some-
times made of a second discharge of water, before the birth of the
child, as a sign of twins.   This second discharge may be occa-
sioned by an imperfect first  discharge, or by water collected in a
considerable quantity between the membranes,  on the  rupture of
the second membrane.  When, however,  a child is far advanced
toward birth, a sudden discharge of any considerable quantity
of water from a part beyond the  child does create a just suspi-
cion of there being another  child, the membranes of  the second
breaking by the efforts made to expel the  first.
   5. Extreme slowness of a labour, which has been considered as
a sign of twins, may be produced by a variety of other causes",
 as we have  often mentioned, and of course this must be a very
 uncertain one.   It is true, when there are twins, the first labour
 is almost universally slow, and this slowness  has been  not unrea-
 sonably attributed to the great distention of the uterus. 
ANOMALOUS, OR COMPLEX LABOURS.        537
   But our ignorance of the number of children of which a wo-
 man  may be  pregnant, fortunately does not lead to any errors
 in practice;  because if we knew with certainty that there were
 twins, our conduct with  regard to the birth of the first child
 should not be altered.  It w ould then be our duly, as at all other
 times, to wait for  the expulsion of the first child, if the  labour
 were natural, and  any difference in practice would only relate
 to the second child.
   After  the birth of a child, it was  formerly the custom to intro-
 duce the hand  into the uterus to  bring  away the  placenta, or
 any coagulated blood which  might be collected in its cavity,
 and to ascertain whether  there were another child.   This prac-
 tice has  been for many years justly held both unecessary and
 pernicious, the placenta generally coming away without any, or
 with  very little assistance, and coagula being also safely expelled
 without any or much difficulty;  and the application  of the hand
 to the abdomen giving full satisfaction as to the other intention.
 By this  method we can  often feel  distinctly if there be another
 child, and its limbs, together with the different parts  of the body,
 through  the integuments of the abdomen; but it is generally by
 the degree of distention which remains  after the birth of the first,
 that we judge there is a  second child.   Yet on this principle I
 remember being mistaken in  a  case in which a  young woman
 with  her first child had  an ascites  during pregnancy ;  and the
 error must always be of that kind, to lead us to believe there are
 twins when there are not,  but can never suffer us to overlook the
 case,  or to leave a child remaining  in the uterus, which through
 inattention or ignorance has sometimes happened, though it be
 not always easy to  decide.
  In  another case I remained for  some hours in doubt whether
 there was not another child, from the awkward contraction and
 position of the uterus, the  patient being much deformed.
  In  twin cases, priority  of birth does not  depend  on  superior
 strength, but on convenience of  position; that which is nearest
 the os uteri or the aperture of the pelvis must first be born, whether
 it be strong or weak, living or dead.  When one child is beyond
 comparison strong,  and the other feeble, it is not unusual for the
 feeble one to be killed,  apparently by pressure of deprivation of
 sufficient nourishment, though it may not be expelled before the
 full period of uterogestation ; so that one may come into the world
fat and full grown,  and the other may be very small, withered,
 and compressed so  as to be quite flat.  This dissimilarity in size
 and appearance was once considered as a proof of the  obsolete
doctrine  of superfetation.
                             68 
538
INTRODUCTION TO MIDWIFERY.
                        SECTION III.
               On the management of twin cases.
  It is a constant rule, to keep patients, who have born one child,
ignorant of there  being another, as  long as it can  possibly be
done.
  In far the greater  number of those twin cases  which have
occurred  to me in practice, while 1 have been waiting for  the
circulation in  the funis to cease, or  employed in  tying it, or
waiting for a pain to exclude the placenta, the  patient has com-
plained with more than ordinary eagerness.   On examination,
I have found the second child on the point of being  born, or the
membranes  protruding  with great firmness, so  that instantly on
their breaking, the patient has been delivered with great rapidity,
almost  before  1  had time to give notice to the  attendants, to
prepare for  its reception.   Of course, in labours  like these,  no-
thing particular could be required to be done, as they terminated
with as little trouble, as if there had been only a single child.
Our intelligence and  care can only be exercised on one or other
of these occasions.
   1.  Whatever may be the  presentation of the first child,  and
whatever  method it may be found necessary  to pursue for the
delivery of the patient,  these are to be precisely the same,  and
there  will  be no greater difficulty  than if there were only a single
child.   One circumstance alone  demands attention  : that if the
presentation of the first child be such as to require the child to
be turned, when we have introduced our hand into the uterus, we
must  be'careful not to break the membranes of the second child,
if they be yet  whole; or if we should find them broken, we must
take care to bring down the  feet of the same child.  In all other
respects I think I have found the turning of the  child less difficult,
when there were twins; and if we have been under the necessity
of turning the first child, it will generally be expedient, to extract
or  get  the command  of the second, by repassing the hand  into
the uterus and bringing down its feet into the vagina.
   Should the  second child  present  with the  breech or inferior
extremities, there can be no solicitude about the case.   We must
act as was before advised in such cases,  that is, we must wait for
the expulsion of the child by the natural efforts,  if they be excited,
or be equal to the effect; otherwise we must give  assistance.
   The most fortunate presentation of the second child in a  twin
case,  is certainly with the inferior extremities,  because it may in
this position be extracted without injury or  difficulty,  and if as-
sistance be required,  this may  be given with  safety and conve-
nience.
   In  cases of the second child presenting with the head, the same
observations will hold good.   That is to say, the child will pro- 
ANOMALOUS, OR COMPLEX LABOURS.        539
bably be expelled by the natural efforts; or if farther assistance
be requisite,  the forceps or vectis  may be  as conveniently used
as in other cases, and according to the same rules  and princi-
ples.  As to lessening of the head of the child, this operation can-
not possibly  be needful, if there  were room for the first child to
pass without diminishing its bulk;  unless from  some  very unu-
sual circumstance,  as hemorrhage or  convulsions, threatening
the immediate death of the parent.
   2dly.  When  after the birth of the first child there is a suspen-
sion of the pains of labour, and no efforts are made to expel the
second child.
   The process of the labour with the first child will usually have
its effect on that of the second.  If we were compelled to make
the first labour artificial, it might be,  and often is necessary and
expedient,  to deliver the patient of her  second on the same prin-
ciple, unless  the natural efforts should be efficaciously made very
soon after the birth of the first child; which is not the statement
I now wish to make.  But when after the birth of the first child,
expelled in a reasonable time, and by  the  natural efforts, from
some cause which we  cannot  comprehend to  counteract,  no ef-
forts whatever  are made for the expulsion  of the  second child,
the patient being as much at her ease as if there had been no pre-
vious labour : this is a state of great solicitude  to every person
careful for his patient,  and  of his own character, as he must know
she will be in some degree liable to unpleasant, and even to dan-
gerous symptoms, till the second child is also born, and the busi-
ness completed.  The rules of practice have been  on this sub-
ject  not only various, but directly opposite.  By the older wri-
ters we have been generally taught, that it was necessary and
proper, if the second labour  were  not  speedily finished, imme-
diately  after the first, to extract the  second child, according to
its position  or situation,  by properly  adapted artificial means.
Others, on the contrary, averse on every safe occasion from the
interposition  of art, have advised us to  wait patiently, till the ef-
forts to expel the second child were renewed; unless some symp-
tom  should arise, which should call for more speedy assistance.
The latter appears to  be a more judicious principle on which to
act in general,  and  it is supported by  some facts under the eye
and  direction of very able men, as well as by many popular ac-
counts ; not to mention the guard it provides against the miscon-
duct of those  who may not be perfectly  competent to give that
assistance  which they presume to be   required.   Like all other
general principles in  practice, it requires nice distinctions to be
made in particular cases, otherwise the cause of danger will some-
times creep  on  insidiously, and come by surprise.  No person
can object  to waiting for a certain time after the  birth of the first
child,  provided there be  no  pressing  occasion  for his interpo- 
540
INTRODUCTION TO MIDWIFERY.
 sition, before he determines on the extraction of the second child
 by art.  We can then only debate upon the length of time which
 it may be expedient to wait;  and as we say with regard to the
 placenta, it shall neither be so short as to run the risk of injuring
 the patient by hurry or ra.shness, nor so long as  to increase the
 danger should any exists  nor the difficulty of delivering the pa-
 tient,  if  we should be at length obliged to use art for this pur-
 pose.  Without regard to those who are fond of speculative opi-
 nions, or the determination of those who are guided by a few in-
 stances which  have occurred in practice, I  have  concluded that
 we may safely, and ought to wait for four hours at least after the
 birth of the first child,  before we deliver the patient by art of  the
 second child;  if there be no particular cause for  delivering her
 sooner.  By this  decision  we shall certainly avoid many unne-
 cessary operations, without detriment to the patient,  without in-
 creasing our own difficulties, or hazarding oar reputation;  and
 on particular occasions,  it will not prevent our waning a longer
 time.  There have been  many examples of women passing seve-
 ral days  after the birth of the first child, with perfect security, be-
 fore the  birth of the second, which has.theu been completed  by
 natural pains.
   The proper management of the  patient  after the birth of the
 fir?t child is very obvious.   There is no reason  for alarming her
fears, and the  case  will terminate more favourably  by keeping
 her ignorant of the circumstance, or if it be discovered by cheer-
ing her mind ;  and she will go on better,  and with more resolu-
tion,  by being  assured that assistance shall be  given, if she
should not be delivered naturally before some fixed time.
   3. When hemorrhage, convulsions, or other dangerous symp-
toms come  on, or are threatened immediately after the birth of
the first,  or before the birth of the second child.
   Though there may be many aberrations, every labour has its
denomination from the most important circumstance with which
it is attended, and such circumstance principally governs the prac-
 tice, which it may be necessary  to pursue.  Among these, hemor-
rhages and convulsions stand in the first  place,  and, whatever
may be the nature  of a labour in other respects, that must be of
secondary consideration.  In twin cases, however proper or ex-
pedient it might be  to wait, for a limited time, for the natural ex-
pulsion ot tlie second  child, the appearance of convulsions, or
hemorrhage,  or other dangerous  symptoms,  would  decide the
 matter, and  put the propriety of waiting any longer  out of  the
 question.  The patient, if  these cannot be removed by other
means, must be speedily  delivered  by art.   But I wish to con-
 fine the term speedy to the determination to deliver ; for under all
 circumsiances, the operation instituted for extracting the child, of
whatever kind that may be, ought  to be performed deliberately, 
ANOMALOUS, OR COMPLEX LABOURS.       541
or we shall add to the danger which  before existed.   Whether,
therefore, we be compelled by these dangerous  appearances, or
after waiting a specific time,  four hours for instance,  as was be-
fore stated,  we have  determined on  the propriety of delivering
the patient by art, we must bear in mind this rule, that we never
ought  to proceed with any degree of hurry or  violence,  if they
can possibly be avoided.  We  must never forget, that it is not
the mere delivery of a woman which is of value, but as this may
be the means of freeing her from the immediate danger she is in,
leaving her with the fairest chance of a perfect  recovery, at the
same time preserving, should it be possible, the life of the child

                         SECTION IV.
             On the Management of the Placenta.
   When there are twins, more difficulty is expected,  but not al-
ways found, in the management  of the  placentae, than  in the case
of a single child.
  The  two placenta? are  usually  connected together so as to
form one mass;  but in  some cases they remain single, except
where the membranes cohere, and must then of course be succes-
sively extracted.
  The number of placentae, separate  or connected, is usually in
proportion to  the  number  of children.  Some  deviations from
this observation have been recorded, a  single placenta and a sin-
gle cord having been found in a case of twins, the latter of which
branched off into two, after it had departed to some distance from
the placenta,   (in the Memoirs  of the Royal  Academy there is
an  account of a case of this  kiud; and my worthy  friend, Dr.
John Sims, informed me of a case of twins, in which  the two
funes were so closely twined together, that  they had the appear-
ance of one.)
  When the placentae are separate, that of the first child should
not be  extracted before the birth of the second  child, as a dis-
charge of blood must necessarily follow, and perhaps a hemorrhage;
though sometimes one placenta  has been discharged  before the
birth of the second child, without any  material loss of blood. In
some  cases of hemorrhage, when there was only one child, the
placenta has been expelled before the child, without any detri-
ment, though not without much apprehension of danger.
  When the placentae are connected, they  usually remain per-
fectly attached till after the birth of the second  child, otherwise
there would be hemorrhage.
  If there have been a necessity of extracting the children by art,
it is commonly, but not universally, necessary to extract the pla-
centae also  by art,  but if the placentae are  detained  beyond a
proper time, we  will say two hours, after the birth of the second 
425
INTRODUCTION TO MIDWIFERY.
child, it is desirable, though there may be no very  urgent symp-
tom, that we should inform ourselves of the cause of this deten-
tion, and act accordingly.
  But presuming that two or more children  have been expelled
by the natural efforts, and that  there is no  hemorrhage or other
cause of alarm, then there appears, and actually is, no more rea-
son for giving  assistance to bring away  the placentae  than  if
there  had been only one child ; but we safely may and ought to
wait for the expulsion of the placentae by the natural efforts, as in
a single birth.
  When we do  give assistance,  we must recollect, that  the two
placentae ought to be extracted together or in  quick succession,
as the patient would not be freed  from  the hazard of her situa-
tion, if any  existed,  should  one of them  be retained.   When,
therefore, we give assistance in pulling by the funes, we must be
careful, that each shall bear an equal share  of the force we think
it  expedient to use.   Or if it should be necessary to  extract the
placentae, by introducing the hand into the uterus,, the  hand is
not to be withdrawn, till  both the placentae are loosened and rea-
dy to come away.  The case will then require precisely the same
conduct as that of a single placenta, which there is no occasion
to repeat.
   The uterine discharges are more copious  in  a case of twins,
than in that  of a single child, and they are  in general of longer
continuance.
   In  all twin cases, after the birth of the first child, it is prudent
to apply a napkin round  the body of the patient to  support the
abdomen; and  that may be tightened after  the birth of  the  se-
cond, and  the exclusion of the placenta*
  * [In the Transactions of the  Royal Society, London,  for 1787,
 Dr. Garthshore has published a curious and valuable paper on plu-
rality of births.
  An account of a singular instance of twins, one presenting with the
feet, and the other  with the head, may be seen in the London Me-
dical and Physical Journal, vol. 25.   The labour advancing slowly,
the attendance of Dr.  Clough was requested.  The feet and body of
one child, with the  arms down on each side, protruded through the
external orifice, and Dr.  C. assisted to extract the shoulders.  Still
finding a difficulty, he examined again, and  ascertained that the head
of the second child and that of the first, were in the pelvis together.
By the uterine effects, the head of  the second child  was expelled,
and then that of the first: both had been  long dead.  The mother
recovered.   See also  Merriman's Synopsis.  F.] 
ANOMALOUS, OR COMPLEX LABOURS.
543
       CHAPTER XVIII.

ANOMALOUS, OR COMPLEX LABOURS.
                    ORDER FOURTH.

Labours in which there is a descent of the Funis Umbilicdlis
             before any part of the child.
SECTION  I.
  The funis umbilicalis may in these cases be easily **»»£»*-
ed bv its pulsation from any  part of the child, rf it be living,
and by  sform and continuation,  whether the child be hvmg or
dead   When a considerable fold of the funis drops through the
Eternal  parts,  the  attendants are very apprehensive of danger

fiSSir1^™^ of the Part' but thiS alarm 1S S°°n ^
^htSe^Titmay be reasonably  thought that the funis is
Inn^r than usual, but some incident is generally assigned as the
longer than visual                     ^  ^          of ^
cause  of its descent  oeio               fae  waterg of the ovum>

SEedSfr *t beTcesslve  in^ity, has been considered
especially " ™*     cause.  This circumstance may sometimes
^A^ion^e^t of the funis, but far less frequently
SSh» to  i^ST For, before the  rupture of the mem-
 than has been  im  g         often be  perceived through them;
 ^•^  before thel3, or presenting part of the child; so that,
 &ver the membranes break, whatever might be the quantity
  c^or  or the manner of its discharge, it would be impossible,
 f ttk  funiT must be the part which first descends.  For
 but that the  ,un*V"        So many cautions have been given
 ^^^^^^^^ because, though the funis
   Sthi smite"Sthe child would be in little  danger, before the
  TembranewUere broken.  It has also been-observed that the de-
  membranes we e v            d t0  the same woman in several
  Ssl  ^  ourVTo  thl Tom the uncommon length of the
  fuitis Mother peculiar  circumstance,  some women seem to be
  ««,.t;riil irlv liable to this accident.
  P X descent of the funis makes little or no difference  with re-
  gard to te progress or event of a labour, as far as the mother is 
544
INTRODUCTION  TO MIDWIFERY.
concerned.   The danger thence arising is wholly confined to the
child.   All  our attention, and every measure we pursue,  must
then relate to the prevention of this danger, which can arise only
from the compression  of the funis, and the consequent interrup-
tion or suppression  of the circulation of the blood between the
placenta and child.
   To gain all the assistance which art can afford for this purpose,
we have been led to two points of practice :  first, in endeavouring
to return the descended funis beyond the head, or presenting part
of the  child, whatever that may be; in drawing  it to the sides,
where  it might be out of  the way of compression ;  or, if these
were impracticable, to favour the continuance «>i" the circulation,
by preventing its exposure to the influence  of the open air.   Se-
condly, by passing the hand into the uterus, turning and deliver-
ing the child by the feet, by which it was expected that the labour
would be accelerated, and the danger from the compression of the
funis lessened or wholly avoided.
   When the funis has  descended, the state of the child may be
precisely determined by the funis  itself.   If there be a pulsation
in it, the child is certainly living, though the pulsation may cease
during the continuance of a pain, and return  in  the intervals ;
but, if no pulsation can at  any time be  perceived in the funis, the
child,  we may  be assured, is already dead.   When the child  is
dead, all the efforts of art must be  useless to it, and might be in-
jurious to the mother ;  we  must, therefore, be  satisfied,  with per-
mitting the labour to proceed,  as  if the funis had not descended.
It is only  when the child is livhig, which, as we before observed,
will be proved by the pulsation of the funis, that  any interposi-
tion can either be required, or be of service; yet it is remarkable,
that writers on this subject have instituted their directions in gene-
ral terms, without regard to the state of the child,  whether living
or dead.  It is also to  be observed, that the same directions have
been given under all the various circumstances  in which the mo-
ther may be, though these are sometimes  such as to make it im-
possible for them to  be followed, without inducing some danger
to the mother, or with any prospect of advantage to the child; but
we shall understand this subject better by considering it in the fol-
lowing manner.

                          SECTION II.
   On  the descent of the Funis  when the Os Uteri is but little
                           dilated.
   Should the membranes break in the beginning of labour, more
especially if it be the first,  when the os  uteri is but little dilated,
and the funis descend  before the presenting part of the child, this
would  probably perish long before the os uteri became naturally
dilated, or acquired such a state of dilatability, as  to allow of the 
          ANOMALOUS, OR COMPLEX LABOURS.        545

safe introduction of the hand, if we were disposed to turn the child;
and before we had an  opportunity of putting in practice any of
the methods for  replacing the funis.  With this statement of the
situation of the mother, it appears to be more eligible, and, I be-
lieve, it is generally  consonant to the present practice, rather to
submit quietly  to the  natural event of the case, than by violent
and ill-timed attempts to deliver the patient by art, with very little
or nj hope of saving the child, and not without some danger to the
mother.

                         SECTION III.
              JVlien the Os Uteri is fully dilated.
  The os uteri is understood-to be completely or sufficiently dilated,
when it will allow of the introduction of the hand without much
force.   When the membranes break  in  the advanced state of a
labour, should the funis  be descended  before the child,  it will
even then be necessary to consider, the state of the child, before
we determine on the measures we might find it safe, and think it
reasonable, to pursue.   If the child should be dead, we then cer-
tainly ought to resign the labour to the natural efforts, without any
interposition.   But, if the child be living, and the presenting  part
remain high  up  in the pelvis,  especially if the pains have been
slow and  feeble, it will generally be better to pass the hand  into
the uterus, to turn and deliver the  child by the feet; using, at
the same time, the precaution of carrying up the descended funis,
that  it may be out of the way of compression.  Should the head
be so far  advanced in  the pelvis, as in any conspicuous degree to
render the turning of the child unsafe to the mother;  that is, if
the child cannot be turned without the use of much force, it may
be proper to use our  endeavours to preserve the clnld by other
means, such  as by replacing the funis,  or by accelerating the la-
bour in its present position ; but the turning and delivery by the
feet ought not to be attempted.
   With the first intention we have  been directed to raise the de-
scended funis beyond the presenting part of the child, in the ab-
sence of a pain, as far as we can rCach; retaining it there when
the pains come on, till it shall abide above the presenting part of
the child, when we might presume it was in safety.   But this me-
thod, as far as 1 know, is, on trial, seldom or never found to  suc-
ceed, for the funis is usually forced  down again on the return of
the pains  ; though the success of these attempts  will very  much
depend upon the quantity of funis descended,  or upon its being
in a single fold, or in  several convolutions,  and whether it be on
the forepart or sides of the pelvis, where it can be more commo-
diously managed.
   The late Dr. Mackenzie, than whom I have not known a man
more intelligent in  conversation, or  more excellent in practice,
                              C9 
546
INTRODUCTION TO MIDWIFERY.
informed me of another method, which he had tried.  Instead of
attempting to replace the descended funis in the common way, he
brought down as much more of it as would come with ease,  and
then enclosed the whole mass in a small bag made of soft leather,
gently drawn together with a string, like the mouth of a purse.
The whole  of the descended  funis, inclosed in  this  bag,  was
conveniently returned, and remained  beyond  the head of the
child till thi's was  expelled ; and the bag  containing the  funis
having escaped compression, the child  was  born  living.   But
he very ingenuously told me, that he had afterwards made seve-
ral other trials in the same manner without success.
  Many years ago, Mr. Croft  also  informed  me of a  method
which he had  successfully practised in several of these cases.
When he had in vain  attempted  to replace the funis in  the com-
mon way, he carried up the descended part beyond the head till
he met with a limb of the child, suppose  the  leg or  arm.  On
this  he suspended  the funis, and then withdrawing his hand, suf-
fered the labour to proceed in a natural  way.  There may be
much of accident in the success of these different methods, but I
should believe, whenever it may have been thought necessary to
introduce the hand into the uterus, that it  would be found  more
expedient, to complete  the  business by turning the  child, and
delivering by the feet.
   With respect to  the acceleration of the labour, the means to be
used must  depend upon various circumstances, which  we  will
consider in the next section.*

                         SECTION IV.
                    Farther Observations.
   1. It  is  to be  observed, that every child is not born  dead,
though the funis had first descended, and no means were used to
free it from compression ; but it must evidently have been in the
greatest jeopardy.  The danger of these cases  depends upon two
circumstances; the time which may pass when the funis is in a
situation  liable to be compressed  before  the  expulsion of the
child; and  the degree of compression made upon it,  in  conse-
  * [Mr. Hopkins and Mr. Hogben have  recommended sponge to
be introduced, so as to keep the funis from falling below the child's
head after it has been carried as  far as practicable above the brim
of the  pelvis, either  by the fingers, or by any other  means.  It is
only under the most favourable circumstances that delivery by turn-
ing the child in utero, and bringing it away by the feet, can be  had
recourse to.  Haighton has stated these circumstances to be : "  1st. A
pulsation of the chord, proving the life of the child.  2d. Its head
not having yet entered the pelvis.  3d. Pains not strong.  4th. A
relaxed state of the external parts, to admit of a ready extrication of
the head."  F.] 
ANOMALOUS, OR COMPLEX LABOURS.       547
 quence  either of  the smallness of the pelvis in proportion to the
 head of the child, or of the resistance of the soft parts, or of the
 untoward situation of the funis.   The first is beyond the power
 of art to remedy ; the second will depend upon the state of the
 parts, whether it be a first child, or whether the patient may have
 before  had one or many children, which  is accidental.  If the
 funis should have descended with a  first  child, in  general the
 more slowly the  labour proceeds, the  less will be  the  hazard
 from the compression ; but, unfortunately, the children thus cir-
 cumstanced will commonly perish, though there is a  bare  possi-
 bility of their escaping; and  I have been  mortified,  in some
 instances,  with an assurance in my own mind, that  a very few
 minutes  delay in the expulsion of the child has been the cause of
 the misfortune.   When the funis descends  in  those women, who
 have had many children,  there  is little comparative resistance
 made by the  soft  parts;  and, by exciting the pains  to act with
 more vigour, or by encouraging  the  patient to exert her efforts
 more strenuously toward the conclusion, the  child will be sooner
 expelled, and its life, perhaps, be preserved.  But no attempts to
 save the child are on any account to  be made, but such as can
 be practised without injuring the mother.
   2. When the head of the child presents,  and has  advanced far
 into the  pelvis, if the pains be slow and ineffectual,  and the child
 living, it may be considered whether,  without hazard to the mo-
 ther, we may not apply the forceps or  vectis;  and,  by extracting
 the head sooner than there was  reason to  think  it  would be ex-
 pelled by the natural pains, preserve the child.  With regard to
 turning  the child, and  delivering by the feet in  these cases, the
 operation  can only be performed  before the head has descended
 far into the pelvis; though in a very few  instances 1 have gone in
 this respect beyond the common rules  of the art, and have suc-
 ceeded in  saving the child.
   3. When there is a descent of the funis,  with a  preternatural
 presentation of the child,  our conduct must have regard  to both
 these circumstances.
   Should the breech present, the case will very much resemble
 the presentation of the head;  that is, the  same methods  for re-
 placing the funis may  be tried, and with rather a better chance
 of success.  If these fail, instead of considering the labour as one
 of those which is to be resigned to the natural efforts, it may be
expedient at a proper time to bring down one or both of  the in-
 ferior extremities, taking care that the  funis be not entangled be-
tween the legs of the infant; and there  are few cases of this kind,
in which we may not conduce to the  preservation  of the infant,
by proceeding in this manner when the funis  has descended be-
fore the  presenting part.
  Should the arm of the child present, and such presentation be 
548          INTRODUCTION TO  MIDWIFERY.
complicated with a descent of the funis,  very  little difference of
conduct will be required;  because, for the first reason, we should
determine to turn the child, and deliver by the feet, and the addi-
tional  circumstance  of the descended funis can require nothing
more to be done.  Yet when  the feet of the  child are brought
down,  if the pulsation of the arteries of the funis be lively or  per-
ceptible, it may sometimes admit of a debate  whether it will be
most proper to hasten the delivery,  especially if the os uteri be
not sufficiently dilated ; or to  leave it to  be expelled by the re-
turning pains.   In either case it will, however,  be right to at-
tempt  to return the funis within the os uteri, and,  if it be in our
power, out of the way of compression.
  The general rules already given for the use  of the forceps and
vectis,  and for the management of preternatural labours, make it
unnecessary in  this place to enlarge on this part of our subject.

                         SECTION V.

                        On Monster*.
  This subject  affords  very little room for practical observations,
because the symptoms in early pregnancy are  not different from
those in natural births; and because  the fcetus,  whatever be its
structure, is usually expelled  easily and  regularly at the time of
labour.  We might indeed be mistaken in our opinion of a  pre-
senting part: but as  in any case of  real difficulty, the needful
investigation would discover the  nature of the case; and as we
should have little to consider but the simple exclusion or extrac-
tion of the monstrous  foetus,  without injury  to  the mother, the
general rules of practice would be readily applied to every exi-
gence  arising from this cause.
  Several books have been professedly written on monsters,  but
the snbject, instead of being considered and cultivated as a branch
of natural history, or as leading to physiological  discoveries and
explanations, has, by the manner of treating it, been rendered lit-
 Je more than a theme of superstitious wonder,  of ridiculous false-
hood,  or  of senseless curiosity.   The same observation may be
made on the cases published in almost every periodical work, and
on collections of monsters.   Yet Lord Bacon thought that a his-
tory of monsters was very much wanted for two purposes; " first,
to correct the partiality of axioms and opinions, which are com-
monly formed on common and familiar examples; secondly, be-
cause  from the wonders of nature is the nearest  passage to the
wonders of art;  for it  is no more than  by following, and  as it
were bounding nature in her wanderings, to be able to lead her
afterwards to the same place."  The advantages which might be
derived from the pursuit  of the first  intention are manifest,  but
those from the second seem to  be problematical. 
          ANOMALOUS, OR COMPLEX LABOURS.        549

  It is probable that monsters might be reduced into regular or-
ders or systems, as they all seem to be of one or other of the fol-
low ing kinds :
   1. Monsters from  redundance, or multiplicity of parts.
  2. Monsters from  deficiency or want of parts.
  3. Monsters from  confusion of parts.
  To these might perhaps be added, without impropriety,  ano-
ther kind, in  which  there  is neither redundance,  nor deficiency,
nor confusion of parts, but an error of place, as in transpositions
of the viscera.   But  children born with diseases, as the hydroce-
phalus, or their effects, as in some cases of blindness undoubtedly
from previous  inflammation,  cannot be properly considered as
monsters, though they are often so denominated.
  Of the first order there may be two kinds, redundance or mul-
tiplicity of natural parts,  as of two heads variously placed, and
one body;  of one head and two bodies ;  an increased number of
limbs,  as legs, arms, fingers,  and toes; or  excrescences or addi-
tions to parts,  of no certain form, as   those upon  the head, and
other parts of the body;  and these are usually more or less im-
portant according to their size, or the part where they grow. But
as such excrescences, whatever may be  their size, have, from their
texture, a disposition to enlarge, and to assume a morbid action,
it is become an established rule to extirpate them  as soon after
the birth of the child as it can be done with safety.
  2. Of monsters from deficiency or want  of parts, the instances
are less frequent than those of the former kind,  as of the brain
and back  part of the head;  or  of the  whole head, as in the
acephalus; or of one eye,  as in the monoculus ;  of the lip and
palate, as in the hare-lip ; of one or both arms ; of the fore-arm
or  hand; of one or more fingers ;  of  a portion, or of the whole
of the  spinal  processes of the vertebrae, as  in the  spina bifida;
of the incomplete formation  of the skin,  most  frequent at the
navel, or some part  of the abdomen ;  of the penis,  especially of
the prepuce ; of the internal organs  of generation in  females;
of  one or both of the inferior extremities ; of the heart; of the
liver, spleen, or any of the abdominal  viscera: of the lower part
of  the rectum, terminating before it reaches the anus ; and many
others.
   3. Monsters from confusion of parts, as when the whole body
is in one mass, (usually  called a mole,) in which various  parts
of the child  are found lying together in apparent confusion; of
parts adhering  together,  as of the fingers and toes; of tlie rec-
tum, as in the misplaced opening  or closure of the anus; of the
vagina; of the external or internal parts  of generation,  as in
those  called  hermaphrodites; of the  two  inferior extremities
conected together and terminating in  a point; of the club foot;
and many others. 
550         INTRODUCTION  TO MIDWIFERY.
   As we are ignorant of the manner in which  the primordial
 parts of a regular conception are formed and established,  and
 in  many respects,  of the  order in which the various parts of
 a fcetus are unfolded or enlarged,  it is not  surprising  that we
 should be ignorant  also of  the manner in which  monsters or
 irregular births are  generated or produced ;  though it is proba-
 ble that the laws by which these are governed are as regular,
 both as to cause and effect, as in common or natural productions.
 Formerly,  and indeed till within these fewr  years, it was a ge-
 nerally received opinion, that monsters were not primordial or
 aboriginal,  but that they  were  caused subsequently,  by  the
 power of the imagination of the mother, transferring the  im-
 perfection of some  external object,  or  the mark of something
 for which she  longed, with  which she  was not indulged, to the
 child of which  she  was pregnant; or by some accident which
 happened to her during her pregnancy.  Such  opinions, it is
 reasonable to think, were  permitted to pass  current, in order
 to protect pregnant  women from all hazardous  and disagreea-
 ble occupations, to skreen them from severe labour, and to pro-
 cure  for them a greater  share of indulgence and tenderness,
 than could  be granted to them in  the common occurrences of
 life.  The laws and  customs  of  every civilized nation have,
 in some degree, established  a persuasion, that there was some-
 thing sacred in the person of a pregnant woman, and  this may
 be right in several points of view; but these go a very little
 way toward justifying the opinion of monsters being caused by
 the imagination of the mother. That opinion has been disprov-
 ed by common observation,  and by philosophy, not perhaps by
 positive proofs, but by  many  strong negative  facts ; as the im-
 probability  of  any child being born perfect, had such a power
 existed ;  the freedom of children from any blemish,  their mo-
 thers being in situations most exposed to  objects likely to pro-
 duce them; the ignorance of  the mother of  any  thing being
wrong in the child, till, from information of the fact, she begins
to recollect every accident which  happened during her preg-
nancy, and assigns the worst or the most plausible as the cause  ;
the organization  and colour of these adventitious substances;
the frequent occurrence of  monsters  in the brute creation, in
which the power of  the imagination cannot  be great; and the
 analogous appearances  in the vegetable system,  where it  does
 not exist in any degree.  Judging, however, from appearances,
accidents may, perhaps, be allowed to have  considerable influ-
 ence in the  production of monsters of some  kinds, either by
actual injury upon parts, or by suppressing or deranging the
 principle of growth, because, when  an  arm, for instance, is
wanting, the rudiments of  the deficient parts may generally 
ANOMALOUS, OR COMPLEX LABOURS.
551
be discovered.  (See Blondell  on the Power of the Imagina-
tion, &c.)
  As to the explanation  or correction  of axioms framed on com-
mon and familiar  examples, there are some things of great im-
portance too obvious to  escape notice.  When, for instance, there
has been a defect of brain, or even no  head, there has been found
a system of nerves;  when the heart has been wanting, there has
been a  vascular system, sufficient to  carry on the circulation ot
the blood ; when there  was  neither liver nor spleen, the blood
was equally red as in perfect infants; and an endless number ot
circumstances  as curious is to  be found in the history of mon-
sters.   It appears that physiology might be greatly improved by
a close  and  accurate cultivation  of this subject, and that an able
and diligent anatomist  would not only detect many modes and
varieties of things, hitherto unobserved, but by carefully register-
ing his  observations,  he would at length be able to  form general
conclusions highly important to science, and which would in an
eminent degree increase his own reputation.

                         SECTION VI.

                  On the Extra-Uterine Foetus.

   The  kind  of extra-uterine fmtus,  of which  it is intended  to
speak in this  place, is not occasioned by a rupture of the uterus,
but by a failure of that part of  the process of  conception, when
the impregnated ovum,  instead  of returning through one  of the
fallopian tubes into the uterus,  is either detained in one of  those
tube^, or, not being received into them, drops into the cavity ot
 the abdomen, where it  must  abide.   In these cases, wherever the
 misplaced evum may be lodged, the external surface adheres, and
 a  placenta  being formed,  it acquires sufficient nourishment to
 bring the child to perfection.   But though it be well ascertained
 that this must be the order of proceeding when an extra-uterine
 fcetus  acquires any  considerable size, it is not unreasonable to
 think,  that an ovum  may miscarry in its transition from the ova-
 rium,  and often remain  without  increase in the  part  which re-
 ceives  it, as a simple extraneous body.
    When the period of utero-gestation is in these cases completed,
 or sooner, there is a general disturbance,  similar in many res-
 pects to that of natural labour  ; whichcontinuest.il  the child  is
 dead  when  the tumult is for the present appeased, and the con-
 stitution is at rest.  But after  some time,  either  on account ol
 undue pressure made by the bulk of the child on some part not
 able to bear it, without being excited to some new and  extraordi-
 nary action, or from other causes, fresh but unavailing  efforts are
 made   Or as in the case of any other extraneous  and offending
 body'a common process is  established, which beginning with m- 
552
INTRODUCTION
TO MIDWIFERY.
 flammation, and producing adhesion to the neighbouring parts,.
 an opening is  ultimately made into some part of the intestines or
 vagina, or through the integuments of the abdomen, by which the
 indissoluble parts of the child are at length expelled.  In many
 cases, however, when the foetus has been lodged in one of the fal-
 lopian tubes, this has burst at various periods, and the patient has
 been speedily, though not immediately, destroyed.   But  in some
 cases the extra-uterine foetus, enveloped in its own, or  some ad-
 ventitious membrane, or  covered  with a  stony concretion,  has
 remained  harmless,  except from its bulk, for the rest of the pa-
 tient's life.  (See Collection of Engravings.)
   Various opinions have been entertained respecting the situation
 of the extra-uterine  fcetus. It was commonly believed that it might
 be placed in any part of the cavity of the abdomen, though many
 asserted that it was most generally detained in one of the fallopian
 tubes.*  In support of this latter opinion many facts  might be
 adduced,  and I was inclined to give  my assent; but from some
 cases which have since occurred, I rather believe,  that the fcetus
 when extra-uterine  is  not universally, though most frequently,
 lodged in  one  of the fallopian tubes.   I had for many years a very
 old painting representing this circumstance with much accuracy.
   Many circumstances  in the  animal economy are proved, or
 rendered probable, by these cases :
   1. That impregnation takes place in the ovarium, but is per-
 fected  in the uterus.
  2. That though the fcetus be extra-uterine, the uterus becomes
 considerably enlarged, and performs its proper office by providing
the efflorescent or deciduous membrane for  the reception of the
 ovum.
  3. That the like  symptoms are produced in the early part of
 pregnancy, whether the child be contained in the cavity  of the
uterus, or  be extra-uterine.
  4. That though the child be placed in one of the fallopian tubes,
 or in the cavity of the abdomen, a placenta is formed, different in-
deed in structure,  but capable of supplying the child with  suffi-
cient nourishment to bring it to perfection ; which tends to prove,
that the uterus does  not perform its office by any specific  action
 or quality.
  5. That the disposition to labour comes on,  before or at the
 completion of the period of utero-gestation, which shows that it is
not excited by  distention or any laculty of the uterus, but by some
state or quality of the child.
  6. That so small  a cavity or canal as is that of a fallopian tube
 if capable of being gradually distended to such a size as  to  con-
* See Opera omnia Anatomica, Diemerbroeck, page 135. 
ANOMALOUS, OR COMPLEX LABOURS.
553
tain a fmtus of the growth of five or six months, or sometimes even
nine months,  without bursting ; though in several cases the fallo-
pian tube, which contained the  child,  has been found rent open,
the death of the patient being thereby speedily occasioned, though
the cause had not been suspected.
   7.  That the menses cease during the time of gestation so long
as the child is living.
   8.  That the menses return in  due time and order after the death
of the child, though this may not be expelled ; unless the constitu-
tion be very  much impaired.
   In the records of medicine there are a very great number of ex-
amples  of the extra-uterine fcetus, in all of which there may be ob-
served  some  similarity of circumstances,  though in several  of
them there are many and great varieties; depending perhaps up-
on some casual situation of the child, or some peculiarity in the
constitution of the patient.  Few  practical remarks have been
made upon the subject,  which can be useful to those, who  are in
the  way of meeting with cases of this kind.  Nor has the order of
the  process,  when the extra-uterine fcetus comes to be  voided, been
described with much accuracy.  I therefore wish to observe, that
in every case  of this kind, which I  have seen, there has  been
sometimes great danger, and in all of them much pain and suffer-
 ing  which it is our duty to avert, or to alleviate,  according to
 theindications.  When the process by which an extra-uterine foetus
 is to be evacuated commences,  it may soon be discovered, whether
 the  effort will be made by the intestines or vagina, or through the
 integuments of the abdomen.  If by the former,  the whole pro-
 cess is to  be left without any,  or as little molestation as possible,
 on our part, to the natural action  of the parts, or of the constitu-
 tion •  for though we might apparently in some cases accelerate
 the  process, and  procure perhaps a little temporary relief,  we
 ought  to be careful not to disturb or interrupt the proceedings of
 nature already established,  which art  can in these cases,  as  in
 many others, very imperfectly imitate.   But if an abscess  should
 be formed in the  side or any part of the abdomen,  and through
 the subsequent opening any part of the child should be evacua-
 ted  it will then be expedient to forward the exclusion of  the re-
 maining parts, either by enlarging the opening, or by giving such
 other assistance, as surgery  is very competent to afford.
    Should the extra-uterine  fcetus  be evacuated by the intestines
 or vagina, after the patient  has endured all the  consequences of
 an  abscess formed in very tender parts, there is  first discharged
 a large quantity of offensive purulent matter; then  the same kind
 of matter mingled with hair or membranous  substance; then  the
 small  bones of the fcetus; and lastly the  larger  bones,  the most
 difficult to be excluded of which  are  the  bones  of the  cranium,
                              70 
*» *> ft.
oo4
INTRODUCTION TO MIDWIFERY.
and the larger bones of the limbs;  and if any of these should
happen to lie athwart the opening in the intestine or vagina, their
discharge may  sometimes be favoured by changing their posi-
tion.   When all the bones are evacuated, the affected parts gra-
dually recover from the injury they have sustained without any
remaining mischief, and the patient after a certain time recovers,
and enjoys as perfect health as if no such accident had happened.
  Cases of this kind have been observed in animals, especially in
sheep, in which the extra-uterine lamb has worked slowly  through
the parietes of the abdomen, without endangering the life of the
sheep; and it is  in common observation among game-keepers.
that does, in whom there is a blighted or dead fcetus, become fat
sooner than the rest of the herd.

                        SECTION VII.

                     On  Superfetation.

   By this term, when applied to the human  species, it  was in-
tended to convey an opinion, that a woman who had advanced to
any period of one pregnancy, was capable of conceiving another
child.
   In  all multiparturient  animals, the structure  of the uterus is
evidently such as to admit of superfetation for a certain time after
the first conception ;  and the fact is obviously proved by the va-
rious qualities of the young brought forth, particularly in the ca-
nine species.   In these it appears that the first conception  most
commonly takes place in a cell at the extremity of one of the
horns of the uterus,  and  then  in order till each horn  is filled.
Otherwise, that is if  the first conception  had  taken place  at the
entrance of the horns, no subsequent conception could have hap-
pened, future impregnations being obstructed by the position of
the first-   But in uniparturient  animals, superfetation seems con-
trary to the structure of the uterus, and if in such more than one
young is conceived, whatever their number may be, they must be
coeval;  as from the moment of conception, the uterus assumes a
peculiar  state by forming an efflorescent membrane which lines
the whole cavity; and by secreting a viscid  mucus for the  clo-
sure of the os uteri in such a manner as to prevent all communi-
cation between the vagina and uterus, during pregnancy.
   But if it be allowed that the cases of superfetation which have
been recorded are neither reasonable nor true, there must be some
apparent reason for the opinion : and this seems  to have been
founded  on  the observation  of one child  being prematurely
expelled, while another remained to the full period of utero-ges-
tation ; or of two of very different sizes being born at  the same
birth. 
          ANOMALOUS, OR COMPLEX LABOURS.        555

   It is not unusual in practice to hear that patients who miscar-
ried of one foetus in early pregnancy, had in the case of a  twin
conception gone to the full period with the other.  This does not
seem impossible, but I am persuaded that it is a  much rarer event
than is imagined.   The errors may have  arisen from our taking
the representation of the facts from those who were not competent
judges, the  discrimination of an early abortion requiring more
knowledge and experience than we have  a right to  expect from
those who are not educated to the profession.
   With respect to the other circumstance which has been supposed
to prove  superfetation,  the great disparity of  size between two
children born at the full period of utero-gestation,  both living, or
perhaps  one of  them  dead; the patient may have ceased to en-
large some weeks before her  delivery.  In such cases,  from the
embarrassed situation  of one  child deprived of its due share of
nourishment, or controlled in some way important to its well be-
ing or even existence, the cause of its either not thriving properly,
or being destroyed, may be readily seen.  The dead child having
lost all power of resistance by the pressure of the surviving one,
may be  quite flattened or compressed into any other form; or
partly or wholly putrefied.  A child in this condition may be ex-
pelled with the living one, or it may perchance be detained for
several days or weeks before it is expelled. Of this I have known
several instances; but the following letter, written to  the much
respected lady of Sir Walter Farquhar, containing a detail of the
attending symptoms, in a case of this kind, judging it may be of
some use, I have permission to transcribe it.  It  certainly  does
not explain the  circumstances which have occurred in many of
the cases of supposed  superfetation which  have  come  to my
knowledge.
   " I should have written to you sometime ago ; but for the last
three months of my being with child, I was scarce able to do any
thing, and it was  thought 1 should never recover.   From the
time of my being three months gone with child, every  person
that saw  me,  concluded I must have twins.   Between five and
six months, I met with a great fright that nearly deprived me of
my senses,  and from  that  time  my size gradually decreased,
so that at nine months I was not so big as when between five and
six ; and every two or three weeks was threatened  with losing my
little one.  I believe nothing prevented me from miscarrying but
laudanum, which 1 took frequently, and in large doses.   On the
eleventh  of February I  was  delivered of  a most delightful  girl,
though  her size by no means answered the  expectations which
might have been formed of her from my looks.   Still I remained
in great  torture.  On the 21st my life was  depaired of,  but the
morning of the 25th brought me  great ease;  for on that  day, 
556
INTRODUCTION TO  MIDWIFERY.
there were born  the head and parts of a child that had just the
appearance of a  miscarriage at four  months.  I continued long
very weak and low, but am now, thank God, almost  as  well as
usual."*
  Jamaica, May 30, 1772.
  * [For an able exposition of the arguments against the doctrine of
superfetation, see Dr. Chapman's paper in  the Philadelphia Eclec-
tic Repertory, vol. 1.  F.]                         ' 
MANAGEMENT OF WOMEN IN CHILDBED.
557
                     CHAPTER  XIX.

          On the management of women in childbed.

                         SECTION  I.

  In  the course of the observations which have been made on
various parts of the practice of midwifery, occasion hath frequent-
ly been taken, to  mark and  to consider those resources  of the
constitution,  by which present evils were remedied, and future
danger prevented.  These resources are so conspicious in all the
circumstances attending parturition, and so generally found  ade-
quate to  the effect, that  notwithstanding the  long train of  diffi-
culties and disorders  we have enumerated, it  is a popular, and I
believe j,a  true remark, that often the most healthful part of the
lives of women is  that in which they are employed in  bearing
and nursing children.  As it is however proved, that those opera-
tions of the constitution which are apparently of little compara-
tive importance, do sometimes become the causes  of disease,  so it
might be expected, that those which are evidently of great impor-
tance, though generally exempt from danger, should occasionally
become the cause of peculiar accidents and diseases. The laws of a
religion founded on principles of the most active benevolence, the
feelings of humanity, and the common interests of society, will not
suffer usto behndolent spectators of the distresses of our fellow crea-
tures, from whatever cause they may arise.   But in the situation
which we are now considering, the  passion^ of men are.deeply
interested, there is more than common tenderness mixed .with our
concern for  those who suffer under the circumstance ofr child-
bearing, and  the mind is not at  these times  prepared for'•unto-
ward  events.  Much  industry hath therefore been used for the
discovery and establishment of some method, by which  women
might be conducted  through  the state of childbed with the least
hazard of exciting  those diseases,  to  which  their state was sup-
posed to  render them peculiarly liable;  and more than equal
pains have  been taken to discover the safest and most effica-
cious method of curing those diseases, when they  actually existed.
The intentions of all may have been commendable, but the direc-
tions given  for both these purposes have been various and con-
tradictory.   It  is therefore proper to  inquire into the principles,
on which such opposite practice has been advised, and  we may
then  fix upon that which  seems most reasonable, or has  been
found most successful. 
558
INTRODUCTION TO MIDWIFERY.
   From the Mosaic law we learn, that, in the state of childbed,
 women were obliged, for a  certain time, to live separate  from
 the world, and were exempted from the cares and solicitudes of
 life.   Whatever  was the principle of this law,  whether it were
 established from motives relating to religion or  manners, the
 time thus allotted gave to women the privilege and opportunity
 of repairing their own health and  strength, and  of dedicating
 themselves  with uninterrupted  attention  to the  care  of  their
 children.
   By  the earliest writers in medicine we  are taught,  that the
 treatment most proper for women in childbed was  that which is
 now termed  antiphlogistic.   Without entering upon  a  minute
 detail, it is sufficient to observe that in the pursuit of this method,
 we were generally directed  to confine, for a certain number of
 days,  every patient  lately delivered, to the same strict regimen,
 as if she actually had or was in  danger of having an inflamma-
 tory fever,  or had  received a  wound  of the most dangerous
 kind.  (See Celsus.)
   This absolute restraint from every customary indulgence, and
 consignment to a regimen  appropriate to the bed of sickness,
 was a  mode of showing tenderness, of the propriety of which it
 must have been difficult to persuade the majority of the people,
 who felt themselves at their ease and in perfect health ; for this
 was not pretended to be necessary with a view to remove any
 present evil, but to prevent  a danger which  might  never occur.
 As no general method of proceeding  could possibly secure the
 well-doing of every patient, the failure of this strict regimen in
 any individual case was brought forward  as an argument of its
 general impropriety.  In fact, though this plan might be always
 rigorously enjoined, it appears to  have  been seldom exactly
 followed.
  The proposal of  allowing a diet more plentiful  in quantity,
 and more cordial in quality,  was founded on the presumed ne-
 cessity of guarding against the consequences of that weakness,
 which  was thought to be occasioned  by the circumstances at-
 tending childbirth.   Then  was  recommended the  custom of
 supplying to the constitution those deficiencies, which might be
 occasioned by the uterine discharges, with plentiful living ; and
 caudle was dispensed with an unsparing hand, to remedy every
 temporary inconvenience.   Consent  is seldom refused to that
 medical advice, which is agreeable to the will of patients, or
 the partiality of friends; and this regimen was of course readi-
 ly adopted, and long maintained its influence.
  When I was first elected to the care of the lying-in  depart-
 ment of the Middlesex Hospital, it was a regular custom to give,
right and day, to  each patient, a basin of caudle.
  A consideration of these  two different  methods of proceed- 
MANAGEMENT OF WOMEN IN CHILDBED.     559
ing will explain all that has been said by different writers, on
the doctrine and practice of low and generous living in childbed.
  There have been also recommended in a few instances, other
methods of treatment instituted according to the fancies or opi-
nions of physicians who have applied themselves to this subject,
but of these I shall only mention two.
  1.  It had been observed, that fevers of any kind were seldom
terminated without  an increased perspiration  or a profuse
sweating. A fallacious inference was then drawn, that the  same
process by which the constitution was  freed from  a disease,
would, before the formation of such disease, be the most likely
method of preventing it.   On this ground the custom of keep-
ing women in a state of constant perspiration for a certain  num-
ber of days, after their delivery by warm drinks, hot  rooms,
close beds,  and diaphoretic medicines, was  established; and
the greater the degree to which it was carried, and  the longer
it was continued, the greater security was presumed to be given
to the patients from  the apprehended diseases.   Many incon-
veniences followed this method of proceeding, especially by
checking the natural discharges, by interrupting the  secretion
of the milk, by reducing the strength, and  increasing the irrita-
bility of the patient.  But the practice was long pursued,  neither
common sense nor experience having power to extirpate deep-
rooted prejudice.
  2.  It was by some  believed, that a woman lately  delivered
ought to be treated as if she had been injured by  a concussion
or violent bruise of some internal part; and that the means to
be advised for the relief of present inconveniences, as well as
the prevention of future mischief,  were such as might be pro-
per under similar circumstances from any other  cause.  There
is no occasion to recapitulate all the means recommended  upon
this principle ; but it may be  observed, that spermaceti,* the
most popular medicine given to women in childbed at the pre-
sent time, was originally  advised, because it was esteemed of
sovereign efficacy in the case of an internal bruise.
  It is remarkable,  that different  and opposite  modes of
treatment have been enjoined to women in childbed universal-
ly,  without any discrimination of peculiarity of constitution,
former habits of living, disposition to certain diseases, or  the
kind  of labour  which the patient might have endured; and
without due  regard to heat or coldness of the climate, or the
season of the year when the patient might be confined.   Ge-
neral as the regulations were, all that was supposed necessary
* [This is not, and never has been, American practice.  KJ 
560
INTRODUCTION TO MIDWIFERY.
 to be done, was, to follow one or other of these injunctions, im-
 plicitly ; and whenever a disease arose, it was attributed, often
 erroneously, and sometimes very unjustly, or some irregularity
 or deviation from these, or to the want of due care and  intelli-
 gence in the attendants.
    It has been  often observed, that the state of pregnancy  was an
 altered, but not a morbid state.  The same observation may be
 made with equal propriety and  truth of a woman in actual la-
 bour; and it may be extended  to women in the state of childbed,
 which, though sometimes accompanied with diseases, cannot se-
 riously be suspected to be of necessity the cause of them.  One
 moment's consideration and the slightest  view of  the perfectly
 safe termination of  labours in general, and of the happy recovery
 of the mass of women from childbed, under infinitely various cir-
 cumstances, must convince us of the contrary.  Before we there-
 fore fix upon this or that method of treatment,  it is worth our
 trouble to inquire,  whether it be necessary to establish any pecu-
 liar method.
   When a woman is recently delivered, the attending circumstan-
 ces, as the discharge of the waters, the exclusion of  the child and
 of the placenta, together with  the lochial discharge,  commonly
 reduce her to the state of a person, who has had a profuse  evacu-
 ation of any other kind. The great efforts she may probably have
 made, in the course  of even a natural labour, must also for  a time
 considerably increase this change in her constitution. From what
 causes does  this change arise ?  from emptiness  and the  fatigue
 consequent to  vehemently increased  action.   Is it possible to fix
 upon any better method of treatment, than what would be esteemed
 right and proper under the same circumstances  from any other
 cause ; that is, to give her suitable refreshment, and leave her to
 repose?   Judging from events we certainly cannot; and after
 seeing and considering much practice and trying various me-
 thods, not only immediately  after delivery,  but through the
 course of childbed,  1 am fully persuaded, that laying aside all
 refined speculation,  those patients will fare the best, and recover
 most certainly and speedily, by whom the least change from their
 former habits is made.   Some  difference of treatment must ne-
 cessarily be required for  the delicate and the robust,  for the
 nervous and the plethoric, when there has been a long and diffi-
 cult, or a short and easy labour, in  a hot or a cold climate, in
 summer or in winter, and in  the same climate, under particular
 situations and circumstances.  These must of course  be  left to
 the judgment of the medical attendant;  but when no particular
 reason, which  demands a contrary treatment, exists, I am con-
 vinced, that the general principle of making as little change as
possible from their former habits and customs, either in diet, or
in any other respect, will best answer his expectations.   In the 
MANAGEMENT OF WOMEN IN CHILDBED.
661
colder climates, some extraordinary  care seems necessary  to
guard against the evils and inconveniences to be dreaded  from
cold ;  bat in Africa the woman immediately walks into the ad-
joining river for the purpose of purifying herself and her infant
from the consequences of her delivery ;  and to these opposite
methods regard is  to be paid in different seasons in the same
climate.
   Some years ago, it was a general custom tobind the abdomen
very tight immediately after delivery, wi'h fhe view of aiding
the contraction of the integuments, and ot preserving the shape
of the patient.   In some countries, India in particular, this was
practised to a  degree,  that one cannot think of without shud-
dering at the mischief which must of necessity  have been very
often occasioned.   In this country the practice has been very
much discountenanced  as useless and pernicious, and it  is now
wholly,  or  nearly laid  aside, except in particular cases,  which
have been already specified, till five or six days after delivery;
when a broad band, daily but very gradually drawn a little tighter,
maybe applied not only without injury, but with some advantage.
   One of the first, and not an uncommon consequence of deli-
very is faintness.   This may proceed from any of these causes,
loss of blood, fatigue of the labour, sudden emptying of the abdo-
men, and its consequent changes, or from great agitation of mind.
The  method to be pursued, when it arises from the first cause,
has been fully  considered when  we spoke of  uterine hemor-
rhages : and when it proceeds from other causes, wine or sometem-
perlte cordial  is to be given, and the patient is to be kept per-
 fectly undisturbed till she recovers.   From the dread of any ac-
 cident happening through misconduct,  and not choosing to put
 confidence in those who may not be well acquainted with what
 is necessary to be done on extraordinary occasions, should they
 arise, 1 have long made it a general rule, to wait  with every
 patient for an  hour after her delivery.
   Sometimes, but very rarely indeed, one of the labia becomes
 suddenly and enormously enlarged, either toward the conclusion
 of labour, or immediately after delivery,  from an effusion  ot
 blood in the cellular membrane oi tiiat part, and in a short space
 of time  after  the appearance of the accident, the skin bursts
 from the violence of the distention.  This complaint was first
 described by Dr. Macbride,* of Dublin, in the year 1766, and
 since that time, 1 have been called to three distances.    It oc-
 casions very great pain, yet one most important part of it is the
  * Medical Observations, London, Vol. V.  See also Medical Com-
mentaries, Edinburgh, No. xxi. 
562
INTRODUCTION TO MIDWIFERY.
surprise it occasions, and the alarm  it gives, when it is not well
understood.  But I believe it is void of danger, not having seen
or heard of any dangerous consequences from it, or ever found
any thing  necessary to be done, but to wrap the tumefied part
in a flannel wrung out of warm water and vinegar, and  on the
discharge of the coagula, which  should  not be hastened  to
dress the little sore with some soft liniment.  It is remarkable,
that the labium always bursts on the inside, as if it were  merely
from mechanical distention;  and as the pain is sometimes vio-
lent, and the patient full of apprehension, it  will  be expedient
to give a proper dose of the tinctura opii  in  some cordial.   I
have also seen one case of a similar kind produced by external
injury, in  a  person who had never been  pregnant, and this
yielded to the like treatment.
   Few women  pass through  the state of childbed without suf-
fering  more or less pain in the abdomen, denominated afterpain,
and this may arise from various causes.
   1. From coagula of blood formed and retained in the  cavity
of the uterus ;* or according  to the  opinion of some,  by the
shrinking of  the uterus to its  proper  size.  In the uterine dis-
charges consequent to  delivery,  there is a general  order, but
with an endless variety, depending upon the  constitution of the
patient,  the  circumstances which attended  the delivery, and
the local  state  of  the parts.!  A proper  and all  necessary
knowledge of these may be readily acquired ; and when coagula
are formed, as above stated, the pains thereby occasioned, which
are called afterpains, are usually according  to the size of the
coagula, and  the difficulty with which they are excluded. These
pains come on soon after delivery, and  they  return,  though
with longer intervals and less  in degree, in the manner of those
of labour, excluding in due time  whatever  coagula might re-
main in the cavity of the uterus.  Women have not often pains
from  this cause with first children, and they are supposed to
have  them in proportion to the number of children they have
had, which is generally true.  Very  much  of  this  pain  may,
however, depend on the manner  in  which  the  placenta and
membranes were brought away, for if that were done with vio-
  * Cum uteri cervix post partum sese modice contrahit, et propte-
rea sanguinis grumi cum difficultate  aliqua prodeunt, doloresque fa-
ciunt, quos obstetrices nostrse enixus posteros (after-throes) vocant,
&c.  See Harvey, page 567.
  t Per lochia emanat primo sanguis purus postea saniosus, recen-
tis carnis loturae similis, deinde ichorosus—ideoque per excreta de
puerperae sanitate aut discrimine statuimus.  Harvey, Exercitatio de
Partu. 
          MANAGEMENT OF WOMEN IN CHILDBED.     563

lence, or in a hurry, the uterus will be left in a very irritable
state, and being much distended, there will generally be  form-
ed a succession of large  coagula; whereas, if we  had waited
for their exclusion by the natural action of the uterus, or given
only very gentle assistance, the cavity of this might have been
gradually diminished as the placenta descended, and of course
have prevented either the effusion of so much blood, or the for-
mation of such large coagula ;  which  might also,  if formed,
have come away, involved in the membranes.
   The  sufferings of women from these pains,  are  sometimes
very great, though they prove eventually  salutary ; and if we
had it in our power, should not be suppressed, till the end for
which they are excited is answered.   They may, however, be
safely moderated  by  warm  applications  to  the abdomen, and
when extremely  violent,  by small doses  of the tinctura opii,
though much unjustifia ble clamour hath  been raised  against
the use  of this medicine for  women in  childbed.   It will  also
be of service, as soon as it can with propriety be done after deli-
very, to procure one  or more stools, by an injection or some leni-
ent medicine.   The freedom from danger prevents all solicitude
on this account, and we know, when the uterus is cleared, pains
from this cause will  usually cease within twenty-four hours af-
ter delivery.
  2. When the abdomen has been greatly distended, the integu*
ments, even before  delivery, will be tender and often slightly
inflamed, and the tenderness may be increased by the labour,
and continue after delivery.  A warm flannel,  well  sprinkled
with any kind of  spirit, applied over the  whole abdomen, and
occasionally renewed, is the only thing I have found it necessary
to employ, after delivery, for this complaint, and this application
is very useful on many other occasions.
  3. From wind in the bowels.
  On the exclusion of the contents of the uterus, a considerable
change immediately takes place  in the position of many parts
contained in the abdomen, and from many  others the accustom-
ed pressure  or support which they received during pregnancy,
is wholly taken away.  A greater freedom  being given to every
part,  the change for  the  present often gives the same uneasy
sensation, as wind pent up or rolling in the  bowels,  though in
a short time it is generally removedby  the accommodation of
the parts to their new state.   Should there afterward be reason
to attribute the pain  in the abdomen, with which a woman  may
be troubled, to this cause, instead of giving strong aromatic or
heating  medicines, it will  be proper  to procure one or more
stools by an injection, or some lenient  purgative, the most effi-
cacious and excellent of which is that in common use, prepared
in the following manner : 
5v?Jf          INTRODUCTION TO  MIDWIFERY.
   IjL.  Kali tartarisat.  vel natri tartarisat. vel magnesia? vitriolat.
         Svrup rosas, aa unciam dimidiam,
         lnfus. sennae tartarisat. uncias quatuor,
         Tinct. ejusd. drachm, sex. M.
   Capit cochlearia iij. vel iv.-ampla primum, et post tres horas coch-
         learia duo secundis horis, donee alvus soluta erit.

   After the operation of the  medicine,  an opiate in any proper
 vehicle may be given, and the patient will  be freed  from the
 complaint.
   4. From spasm.
   After delivery, the uterus itself, or its appendages, or any
 of the contents of the  abdomen, may be affected from this cause,
 with pain varying in  degree, but sometimes extremely severe.
 This may often be relieved by lightly rubbing the abdomen with
 a  warm hand, or with some anodyne embrocation, or the appli-
 cation of wrarm flannels wrrung out of some spirituous  fomenta-
 tion.  If  these fail, recourse  must be had to tinctura opii, at
 least to opium in some way  or form, given in  suitable doses,
 according to the  degree of pain, and repeated as may be neces-
 sary, and these may be joined with the spir. aetheris  vitriolic.
 comp. castor, camphor, or other medicines of that class.  Spas-
 modic pains of the abdomen  very often resemble those arising
 from inflammation, and in  some cases 1  consider it as one of the
 most difficult things in the practice of medicine,  to discriminate
 them.   In very irritable habits the difficulty is much increased,
 as such are extremely liable to painful spasms, to  have their
 pulse quickened, heat excited, and the whole frame disturbed
 in a manner very like to what happens in true fever or inflam-
 mation, yet all the disturbance may often be speedily quieted
 by a proper opiate.
   5. From  inflammation.
   This leads us to the consideration of that disease  now gene-
 rally called the puerperal fever; not because it is peculiar to the
 state of childbed,  but because  it is the most common species of
 fever, to which puerperal women are subject, and certainly occa-
 sions the death of much the  greater part of those  women,  who
 die in childbed, whether considered as original fever, or local in-
 flammation producing  fever.    This has been described by the
 ancient as well as  modern writers, with perspicuity sufficient to
 distinguish it, but the methods  proposed for the cure have been
 less satisfactory.  Evident disadvantage hath arisen from its hav-
ing been attributed to  a variety of causes, and from the different
 opinions which have been admitted of the nature and qualities of
the disease,  from the  suspicions  entertained, that the peculiar
state of the patient required peculiar management, and from its
having been described under  such various appellations.   It has 
          MANAGEMENT OF WOMEN IN CHILDBED.      565

been represented by  some  writers,  as entirely  owing its  exist-
ence to the undue secretion or subsequent deposition of the milk,
and therefore denominated the milk fever; by others, to a sup-
pression of the  lochia, and  called by that name; while others
have described  it as the miliary fever.  Some again have consi-
dered this disease not  as  fever,  but as an  inflammation or  ul-
ceration of the  uterus ;* while others  have contended,  that the
inflammation was wholly confined to  the  omentum, the perito-
naeum,  or the  intestines, and  that the uterus  was not any wise
concerned.  A  contrariety of opinion of more importance was
produced by the interpretation of the word  erysipelas, which was
probably given by the ancients to this disease, without any  inten-
tion to denote a specific kind of inflammation ; yet the early  use
of this term was of sufficient  consequence to bind those, who  at-
tended  to the nicer distinctions in nosology, to a particular mode
of practice, according  to the  nomenclature.f  With such differ-
ent notions regarding the  causes and nature of this disease,  we
might expect, that the treatment  would  be different;  and as it
was contradictory, we  may presume, that it must often have
been hurtful.   There is  undoubtedly much  difficulty in forming
a just idea of a very complicated disease,  and in proportion to
the difficulty, every attempt to make accurate distinctions  is  de-
serving  of commendation.   But  however  symptoms  may vary
from affections  of particular parts, or in particular constitutions,
there is but one essential nature of the disease; and  if we have a
true notion of this, we have less reason to be solicitous about the
cause, or the determination of the part originally or principally
affected.  For a similar treatment may be  enjoined with  equal
propriety for an inflammation of the uterus, omentum, perito-
naeum,  or intestines, or perhaps any of the contents of the  abdo-
men ; whether the disease remain  local,  or a fever be produced
by its influence being  extended  to the constitution in general.
It is however observable, that inflammation of the  uterus is far
less dangerous  than an equal degree of inflammation  of any of
the viscera of the abdomen,  especially in the state  of childbed ;
because the uterus readily admits of a return of the lochia! dis-
charge, which always  affords relief, and sometimes cures the dis-
ease.  But in inflammations of any of the contents of the  cavity
which have no  vent or outlet, the effects of the inflammation be-
  * Uterus a placentae separatione, praecipue violenta, excoriatur,
tanquam ulcus ingens internum lochiorum  liberiore emanatione de-
tergitur et  mundificatur.   Ideoque per excreta  de puerperas sani-
tate aut discrimine statuimus.—Harv. p. 556.
  t Si mulieri pregnanti fiat in utero  erysipelas, lethale est.  Hip-
pocrates. 
566          INTRODUCTION  TO MIDWIFERY,
 come an addition to the existing disease, or a cause of new dis-
 ease.
   The knowledge  of the causes of this disease,  whether occa-
 sional or immediate, will be of service rather in enabling  us to
 prevent it, than in  leading us to the cure when  it is formed ; for
 if a patient be brought into a certain state, the  peculiar cause of
 that state will not demand any material difference  in the treat-
 ment directed for her relief.   There  is but  too much reason to
 lament, that inconsiderate proceeding, and the  want of common
 care, frequently give rise  to the puerperal fever.   But indepen-
 dently of the changes  occasioned in  the constitution by particu-
 lar modes  of  living, women, with a view to  parturition, will not
 bear a comparison  with other creatures.*  The erect position of
 the body, the different structure of the uterus and placenta, and
 the passions,  though  necessary,  and perfectly adapted to the
 rank in which Providence hath placed mankind, become perma-
 nent causes of much pain, and eventually produce inconvenien-
 ces, and  sometimes danger; and for these  reasons women are
 also subject to so great  a number of complaints during  preg-
 nancy, from  which all  other creatures are exempt.  Some of
 these complaints, the retroversion of the  uterus  for example, are
 dangerous  in their own nature, while others indicate or produce a
 disposition to diseases, not formed in the  constitution  till  after
 delivery ; and the inflammatory appearance,  so  often observed in
 the blood of pregnant women, may perhaps be justly esteemed a
 mark of a state particularly disposed to fever.   Some habits are
 naturally liable to diseases of the bowels, proceeding from an ex-
 cess in the quantity, or an alteration in  the  quality of the bile,
 and such may derive a new and  temporary  cause of them from
 irritation, and from the disturbed  secretions  of  the viscera, from
 the pressure of the enlarging uterus,  or by the labour.  Nor is it
 improbable, but that, by the sudden removal of this pressure at
 the time of delivery, a  greater proportion of fluids, than circu-
 lates even in a natural  state, may rush upon some particular part
 and from a very light  obstruction cause a local plethora.   Im-
 prudent management at the time of labour, especially rude  treat-
 ment of the os uteri, and a violent or hasty separation of the
 placenta, will often give rise to  this  disease.   In short, every
 cause capable  of producing either local  inflammation,  or fever
 under any circumstances, will at this time be  followed by greater
effects; and any disturbance raised in the constitution will, after
    MuheribuspracaBterisanimalibushaBCcontingunt, et prjesertim
dehcatis, vitamque umbratilem et mollem degere  assuetis ;  ut et iis
qu<e tenerae valetudinis sunt,  et facile in  morbos labuntur.~Harv.
Exercicat de Partu. 
          MANAGEMENT OF WOMEN  IN CHILDBED.      567

delivery, be invited as it were to parts already in a very irritable
state, from  the violence which they have already undergone.
   It is natural for women,  especially  with their first  children,
to have slow and painful labours, which they will generally bear
with resolution, and, if not mismanaged, commonly without dan-
ger. Instead, therefore, of hurrying and deranging the order of
a labour, which is always improper,  and sometimes  injurious,
under the  false  and ill-judged notion of more speedily  freeing
the woman from her misery, we should consider,  that the busi-
ness was intended to proceed slowly, and should be left entirely
to the action of the uterus,  and the efforts of the constitution.*
When there  are deviations  from the regular course of labours,
the usefulness of midwifery  as an art, and the judgment and skill
of the practitioner will  be shown, in deciding which of these re-
quire the assistance of art, and in choosing the safest and the best
means of giving relief.
   There is not throughout nature an operation more wonderful
than the act of parturition  ; and there is little reason  to be sur-
prised at the bad consequences which sometimes follow an alter-
ation so  important, though  this alteration  be natural.   Judging
from speculative principles, they might be expected to  occur
more frequently ; and, though they are often occasioned by bad
management, they cannot always be avoided under  the  most
promising circumstances, and with the greatest care.
  When a woman  is delivered,  it seems  necessary to make a
moderate and uniform compression upon the abdomen,  but bind-
ing it tight is  certainly improper ; and the general abuse of band-
ages, as was  before observed, has induced me to forbid it alto-
gether till the seventh  or eighth day after delivery.   Women
are certainly not so often attacked  with this fever, after diffi-
cult labours,  because of  the particular care with which  they
are then managed,  whereas after easy  ones they are more un-
guarded.
  *  Increpandae sunt obstetrices,  praesertim juniores temeraris;
quae,  cum parturientes prae dolore ejulare opemque efflagitare audi-
unt, ne imperitae vel parum satagentes videantur,  manus oleis obli-
nendo, locaque muliebria distendendo, mire tumultuantur ;  porrec-
tisque potionibus medicatis, facultatem expultricem irritant; atque
morae debitae impatientes, dum accelerare ac  facilitare  partum cu
piunt,  eundem retardant potius et pervertunt, efficiuntque non natu-
ralem et difficilem.—Melius profecto cum pauperculis res agitur, iisque
quae furtim gravidae facta? clanculum pariunt, nullius obstetricis advo-
cata opera : quanto enim diutius partum retinent et morantur, tanto
facilius et felicius rem expediunt.—Harv. Exercitatio de  Partu. 
568
INTRODUCTION TO MIDWIFERY.
   The time when women are chiefly subject to this fever, is un-
 certain.   There are not wanting instances  in  which it  has been
 evidently forming before delivery,  or during  labour, or at any
 intermediate time  for  several weeks afterward ; and the sooner
 from the time of delivery the patient is attacked,  if in  an equal
 degree, far greater is  the attendant danger.   But the most fre-
 quent time of its appearing is on the third or fourth day  after de-
 livery, when the patient is seized with a shivering fit,  from the
 violence  and duration of which  we  may generally estimate the
 danger of the succeeding disease.  In some cases, however, there
 has been no cold or shivering fit, or none which was observable;
 and in others,  the shivering  fit  in  the state of childbed has not
 been  followed with those symptoms which were to be apprehended.
 Before the shivering fit,  the patients have  been much debilitated,
 and complained of wandering pains in the  abdomen, which very
 soon  became fixed in the hypogastric region, where a swelling or
 fulness with exquisite tenderness soon ensued.   As the disease ad-
 vances, the whole abdomen becomes affected and tumefied, some-
 times nearly to  its size before delivery, the  woman herself being
 sensible of and  describing its  progress.  She also feels great pain
 in the back, hips, and  sometimes in one or both legs, and other
 parts affected in uterine complaints.   She can scarcely lie in any
 other position than on her back,  or on  one side,  with her body
 incurvated, and if the disease be confined to the uterus, the seat
 of the pain seems  to  be changed  when she alters her position.
 There is  usually either a vom iting of green or yellow bitter mat-
 ter, or a  nausea and loathing of the stomach,  with an offensive
 taste in the mouth.   An instantaneous change both in the quan-
 tity and  appearance of the lochia  takes place, and sometimes,
 though rarely, they are wholly suppressed.   The milk,  if secre-
 ted, recedes or is diminished, and the taste with the appearance
 is much altered.  The urine  is  voided often, with pain, and in
 small quantities, and is remarkably  turbid.   A tenesmus or fre-
 quent stools come on, and from  the general  disturbance it is often
manifest,  that all the contents of the pelvis are at once  affected
by the disease.   The tongue  becomes dry,  though sometimes it
remains moist and is covered  with a thick brown fur; but as the
disease advances its appearance varies, and in some dan gerous
cases  it has been little  changed.   The patient  immediately  en-
tertaius the strongest apprehensions   of her danger, and usually
labours under vast anxiety, her countenance bearing indubitable
marks of great  suffering both in body and mind.
  The progress of this disease is sometimes extremely rapid, es-
pecially in unfavourable  seasons and hot climates.  Instances
 have occurred,  in  which  women have died within twenty-four
hours of the first attack; and  I have seen a  few, who never grew
warm after the rigor, which  then resembled a  convulsion.   In 
MANAGEMENT OF WOMEN IN CHILDBED.
569
  some, death has followed quite unexpectedly, either from inatten-
  tion or  from the  scarcely perceptible but insidious progress of
  the disease, the indications not having been at ail proportionate
  to the danger.   In other cases  the shivering  fit is succeed by
  heat, thirst and other symptoms, according to the course observ-
 ed in other fevers;  but the pain which originated  in  he undo
  men, joined with these, is to be  esteemed the pathognomonic or
  chief sign of this disease.   It seems necessary  to enunieraie all
  the symptoms,  which commonly, though not exclusively, attend
  this fever, and not in any individual patient,  yet cases will occur
  in practice, in which there will be much variation, depending on
  the degree of  disease,  the part affected,  the constitution of die
 patient,  and the period after delivery when the fever makes its
 appearance.
   The pulse has almost jnvariably  in  this  disease an unusual
 quickness from the beginning.   It  has often that  strength  and
 vibration observed in disorders of the most inflammatory kind,
 in robust constitutions; and yet is sometimes exceedingly feeble
 and quick, beyond what might be expected from the concurring
 circumstances.   The latter  is to be  reckoned among the most
 dangerous signs,  proving, perhaps, increased  irritability with
 great violence of disease, and that the powers  of the constitution
 are unable to struggle with it, or scarcely to bear the operation
 of the medicines which  might be necessary for its relief.    There
 is much variation in the subsequent stages, but there is scarcely a
 worse omen than a very weak and accelerated pulse,  even though
 the other symptoms may seem to be abated.  But the mere quick-
 ness of the pulse,  if not attended with other perilous signs of in-
 flammation or fever, is not to be considered as indicating danger;
 experience having shown that very irritable patients have  some-
 times an unusually quick pulse,  unaccompanied with any other
 alarming symptom.
   The signs of inflammation, joined with those of extreme  irrita-
 bility, continue for a few days,  when those of putridity appear,
 sooner perhaps  in this than in most other diseases, which are
 originally of the truly inflammatory kind.  The teeth very early
 collect a brown adhesive sordes,  and all 'rinds of food and drink
 are nauseated,  except such as are agreeable from their coldness
 or sharpness.   A singultus attends, every return of which affects
 the abdomen in the most painful manner.   Petechias or vibices
 are often found in the unwholesome situations, and in some con-
 stitutions of the air,  at a very early period of the disease, and
 there are  frequently miliary  eruptions;  but the  latter seem
 rather a  consequence of the method  of treatment than of the
disease, for they do not afford that relief  which sometimes fol-
 lows their appearance in true eruptive fevers.
  The bowels are in general very much disturbed,  and'»»  -~v~~
                              72 
570
INTRODUCTION  TO MIDWIFERY.
cases a looseness take9 place  immediately upon the  accession,
in others three or four days after, or not till the last stage of the
disease ; but it very seldom fails to attend, nor can it be removed
without the greatest  difficulty as well as danger, before  the
disease is terminated.  The stools toward  the close often come
away  involuntarily,  being always preceded by  an increase of
pain, and every evacuation gives momentary relief.  They are
uncommonly fetid, of a green  or dark brown colour,  and work-
ing like yest.  It is also remarkable that after the long  continu-
ance of the looseness, when the patient has. taken little or no
solid nourishment, large and  hard lumps of excrement will be
sometimes  discharged, which one might  suspect to have  been
confined in the bowels  for a  long time before delivery.   With
regard however to this symptom, it is very necessary to  observe,
that in delicate constitutions  great disturbances of the bowels
are frequently occasioned by  mere irritation, which are soon re-
moved by the well-timed exhibition and repetition of some cor-
dial opiate.
   There is a peculiarity in this  fever, which 1 believe has  not
hitherto been observed or mentioned.  It is  an erysipelatose
tumour of a dusky red colour, on the knuckles, wrists, elbows,
knees, or ancles, about the size of a shilling, and sometimes lar-
ger.   This is almost universally a mortal sign,  and on the in-
spection of those whohave died with this appearance, the disease
has been found to have  affected principally the uterus  or its ap-
pendages.
   When this  fever  commences soon after delivery,  and con-
 tinues its progress with violence for a few days,  our hopes of a
 favourable event will often be disappointed, and the impending
 danger may usually  be foretold by the uninterrupted progress of
 the symptoms, or by returns  of the rigor.  An  early derange-
 ment of the faculties of the mind is always a very  threatening
 symptom.  A looseness immediately succeeding  the attack,
 though in one sense it may indicate   the degree of  disease, al-
 ways contributes to its abatement, and sometimes proves critical;
 as does  likewise a  spontaneous vomiting, sometimes even to-
 ward  the last stage,  when all  hopes of recovery were abandoned.
 The profuse sweat, which follows the shivering fit, has very often
 been completely critical.  In some there has been a translation
 of the disease to the extremities, where the part has inflamed,
 and a large abscess  has been formed  ; a similar abscess has also
 in some cases been formed on one  side of  the  abdomen
 which has been  healed by the most simple treatment.  Fresh
 eruptions of the lochia are always a  favourable  symptom,
  and are to be reckoned among the most certain signs  of amend-
  ment.  A subsidence of the  abdomen after copious stools,  and
 with a moist skin, is a fortunate alteration for the patient; but
  that circumstance without evacuations, and a dry skin, threaten 
MANAGEMENT  OF WOMEN IN CHILDBED.      571
the utmost danger.   In the most severe degrees of this disease,
which have resisted all the means of relief in the early  stage,
those who have escaped  seemed to  have owed their safety to
the vomiting before mentioned, to an increase of fresh lochial
discharge,  or to a constitution happily strong enough to  bear
the long continuance of the looseness, by which the effects of the
disease were gradually drained away.
   Of an uncommon case of an abscess  of  the kind above men-
tioned, it will not be useless or superfluous  to add the following
account.
   On June the 10th, 1798, a lady had been delivered of a dead
child, between the seventh and  eighth month of her pregnancy,
when she suffered very acute pain in the extraction of the pla-
centa,  which was, I presume, thought to be necessary.  For se-
veral days  previous to her delivery she had a considerable de-
gree of fever, and much general uneasiness over the abdomen, for
which  she was bled, and took  some cooling and quieting medi-
cines.   On the 12th (the second day after her delivery), she had
a strong and violent rigor, succeeded by very severe pain  in her
left side, near the spine of the ilium, and fever, which continued
for several days,  when her milk (before secreted) entirely disap-
peared.
   Though the pain  and fever were  abated, they never entirely
left her;  and after another rigor on the  19th, with an increase of
fever and pain in  the part first affected, her friends were alarmed,
and  a physician of eminence was  desired to see her.   He pre-
scribed what the situation and circumstances of the  patient seem-
ed to require, and she was much relieved.  There were, however,
frequent exacerbations of fever;  the  pain  of  which  she  origi-
nally complained never entirely left  her, and was sometimes vio-
lent.   It was now perceived she had  no  power of moving her left
leg or thigh, and  she herself was sensible of a deep-seated swell-
ing on the left side of the abdomen, though it could not be disco-
vered by her attendants.   A blister was applied to the whole of
the pained side, and after some  farther days  attendance, the phy-
sician withdrew, recommending her to go into  the country, and
encouraging her to hope, that,  as  she  recovered  her strength,
her complaints would leave her.  She was also advised to use as
much exercise as she could, and accordingly  attempted every day
to walk with a crutch, and the  help of her nurse;  but every at-
tempt gave  her  excruciating pain, and she was daily sensible of
losing, instead of gaining strength.
   I first  saw her on the 28th of July.   As there was an evident
fulness on the left side of the abdomen, with  much pain on pres-
sure, loss of appetite, and other symptoms of fever, from some
degree of which she was in  fact never entirely free,  I directed
three or four leeches to be applied to the part affected, and to be 
 572          INTRODUCTION  TO MIDWIFERY.

 repeated every other day, and such  medicines  as were likely to
 abate the fever, to keep the bowels gently open, and to moderate
 the pain.   She was somewhat relieved by these means, and as she
 was very weak, I afterwards tried the bark, and some other tonic
 medicines, from which she did not apparently receive any bene-
 fit.  From  the  contraction and  wasting of the limb, and from
 the other circumstances before recited, thinking it probable that
 an abscess had begun to be formed in some part of the cavity of
 the abdomen,  I requested to have a consultation,  and Dr. Baillie
 was called in.   After a mature deliberation on all the preceding
 circumstances, and  the  present  state of the patient,  it  seemed
 most reasonable to think, that an abscess was forming  in the
 psoas muscle.   Small doses of cicuta in the saline draughts were
 prescribed, and a soft plaster with opium was applied to the side ;
 the case of the  patient seemed to admit of little other  relief than
 some  alleviations of her suffering.  In the middle of August she
 returned to her house in town, not in any respect amended in her
 general health, and she suffered more from her local complaints.
    In a few days after her arrival in town,  the pain being much
 increased,  she went  into the  warm  bath,  and  on the following
 day she was suddenly relieved by discharging a very large quan-
 tity of purulent matter, mixed with her urine.  This was consi-
 dered as a proof that an abscess  had  been formed, and dischar-
 ged into the bladder, probably by means of  an adhesion which
 had taken place,  and  a subsequent communication between this
 and the part first affected.
    She continued  to go into the warm bath for  a few  days, but
 suspecting that she was weakened, and feeling herself very much
 fatigued by  it, she relinquished  it altogether.  At this time her
 medicines were changed  for some of the milder turpentines, in
' small  doses; and, she  still  suffering considerable pain, opiates
 were given, and repeated as the case required.
    When there  was the  greatest quantity  of purulent matter dis-
 charged with the  urine, and  sometimes  I think there could not
 have been less  than four ounces  at a single evacuation, she suf-
 fered the least  pain ;  but when there was a suspension  of the dis-
 charge,  the pain was always most severe.
    In the beginning of September, a swelling of a considerable
 size, with an evident fluctuation in it,  was discovered  on  the in-
 side of the thigh without any appearance of inflammation or red-
 ness of  the skin, as  if the  fluctuating matter had been formed
 there; and,  by a careful examination, the course by which the
 fluid had descended  from the groin to the thigh could be readily
 traced.  The swelling gradually  descended till it came very near
 the ham, varying in size according to  the position of the limb and
 body,  and the  patient thought she could distinctly perceive both
 the descent and rise of  the fluid. 
          MANAGEMENT OF WOMEN IN CHILDBED.      573

   The night sweats,  and other  hectic symptoms,  were now ex-
treme; but, after another trial  of the bark, and other medicines
of that class, which  disagreed,  she for many weeks took no me-
dicine whatever, except small doses of opium,  when the  pain was
violent, and some gentle laxatives, when she was  costive.  She
was allowed to drink porter at her meals, and  at any other time,
without restraint, when  she wished for it, and always considered
herself not only supported, but very much refreshed by its use.
  In October she kept her bed altogether, unable to move, or
help herself in any position, and frequently suffering much pain.
I then proposed a consultation with Mr. Cline, the  surgeon of the
family, to consider of the propriety or expediency of making an
opening in the tumour of the thigh, and by giving it an inferior
vent,  to  prevent the matter from  returning into the abdomen.
Mr. Cline did  not  then think  it justifiable  to  make an opening
in the tumour, and 1 readily acquiesced in his opinion.
   At the latter end of this month, she was reduced to a state  of
extreme weakness, and  exceedingly emaciated, but her appetite,
which had never entirely left her, now began to improve.  The
tumour in the thigh daily lessened, and soon disappeared altoge-
ther ; as did the quantity of purulent matter discharged with the
urine, till that also entirely ceased.   In November  she frequently
voided small quantities of blood with her stools, and at the latter
end of that month her health and strength were considerably im-
proved.  There was also about this time a return of some power
of moving her limb ; she soon became able to walk with  crutches,
the infirm leg being supported in a stirrup;  and she had a re-
turn of the menses, which had not before appeared since the time
of her delivery.
   On the 20th of December she was lifted into the coach for the
benefitof taking the air, and her health might at this lime be said
to be restored, as she had  no complaint, and though weak and
emaciated, was every day sensible of amendment.
   In the beginning of the year she again proved with child, and
went on  to the full  period of  pregnancy, when she was safely
delivered  of a healthy boy ; having recovered before the time  of
her delivery the perfect use of her limb.  She now walks and
performs all the offices of life with her accustomed ease, and has
not the least  remaining token of the complaint from which she
had so severely suffered.  Instances of inflammation with subse-
quent adhesion of a similar kind I have frequently seen ;  and in
one case, from an adhesion of some part of the intestines to the
bladder, faeces were afterward  voided with the urine.
   The swelling and tenderness of some part of the abdomen,
joined  with a fever,  were mentioned as the pathognomonic symp-
toms of this disease.  But as  these parts  are  often affected by
the greatness of the distention  during pregnancy, by after-pains, 
574          INTRODUCTION TO MIDWIFERY.
by flatulence, and by spasms, as well as inflammation, we may
be alarmed without reason, and mistaken in giving  the name of
a disease, which does  not  exist, to complaints of infinitely less
consequence.  On this principle we may acconnt for the slight
manner in which some have mentioned the  puerperal  fever,
while others have recommended methods of treatment foreign to
its nature, and inadequate to  its cure.  But with attention, this
fever may be readily distinguished  from all other complaints, to
which it bears  any resemblance.   Violent spasmodic affections
of the uterus coming on soon after delivery, and extending their
influence to various parts of the  abdomen, if accompanied with
great quickness of the pulse, may  give apprehensions of this fever,
though  they will  be almost  immediately relieved, by a fomenta-
tion to  the abdomen, and the proper use of opiates.   After-pains
approach nearest to  those pains of the abdomen, which  attend
it; but  though these are sometimes accompanied by great tender-
ness of the abdomen, the intervals of perfect freedom from pain,
which are never observed  in  this  fever, notwithstanding  there
may be considerable  exacerbations,  and the  regularity with
which,  in after-pains, the secretions in  general, and  those  of the
uterus in particular, are carried on, will be evident and sufficient
distinctions.
   About the time when this fever most frequently appears, espe-
cially in its worst form, a disturbance is raised in the constitu-
tion  by the  secretion  of the milk.   The  consent  between the
uterus and breasts is of  so intimate a  nature, that it is  scarcely
possible for them to be affected separately, as the transition of the
 humours from one to the other  abundantly demonstrates.  But
though this disease has been very often imputed to  the milk, the
supposition is probably  groundless; for if this secretion  be not
 interrupted  in its natural course, the inconveniences arising from
 it, though they may be  troublesome, will not  be attended with
 any danger.  Those who are unwilling or  unable to give suck,
 or to whom  suckling may on some other account  be improper
 or impossible, are liable to  various complaints, from  which nurses
 are free.  In such cases I  have  found no method of preventing
 so effectually the ill consequences likely to ensue, as  by pro-
 curing stools  before the secretion is  completed, and  for some
 days afterward with regularity, but not violence.  Should inflam-
 mations come on, and abscesses be formed in the  breasts,  they
 are always  much lamented, and  considered as proofs of misman-
 agement; but there is great reason to  conclude, that they some-
 times prevent more grievous and dangerous complaints, and that
 they could  by no  care  have been obviated.   It is remarkable,
 that not one instance has been observed of any woman, who had
 an abscess in the breast, being attacked with this fever; nor of
 any who,  in consequence of  their labour, had such an affection 
          MANAGEMENT OF WOMEN IN CHILDBED.      575

of the bladder, as to occasion a suppression of urine.  At another
period of life, when the disposition to  cancerous  diseases exists
in the constitution, their fixing upon the uterus or breasts seems
to be merely owing to some accidental cause, if both those parts
be not affected.
  A disease in which the symptoms come on with violence, pro-
ceed with rapidity, and of which the event has so often been
fatal, cannot  fail to.alarm every man solicitous for the welfare
of his  patients, or who has a due regard for his own character;
and  under circumstances so peculiarly distressing as  are  those
of women in childbed,  humanity would urge us  to  exert our
abilities for their relief with zeal and tenderness.
   We should in the first place endeavour to  shorten  the rigor,
by hot applications to the extremities, and by giving warm dilu-
ents in small quantities  often repeated.   A  conviction of the
necessity of  speedily removing the rigor, has induced some to
give very active cordials for this purpose; but as the hot  fit
which succeeds will in some measure depend upon the  means
used, it does not seem proper to give spirituous liquors, unless
they are well diluted.
   Bleeding has been advised  in the beginning of violent dis-
eases,  with the intention of suppressing the disease, of  allevia-
ting the symptoms, or of rendering the operation of the medi-
cines,  which were afterwards to be given, more safe  and effec-
tual.   For the cure of the fever now under consideration, some
have placed their whole confidence in the early and free use of
this remedy, while others have expressed  more than ordinary
fears and apprehensions with respect to it.*   Perhaps it may be
impossible to form a rule of practice so general  as to preclude
the necessity of leaving much to discretion ;  for the treatment
of patients differing in constitution,  though labouring under the
same disease, must vary, or the  worst consequences will  inevi-
tably follow.
   In the early partof my own practice, I  had  much doubt of the
propriety of bleeding  indiscriminately for the cure of this dis-
ease, and I was long of opinion,  that it was not the most natural.
safe, or effectual remedy.   I considered, that spontaneous he-
  * Equidem de sanguinis missione multum controvertitur ; nonnulli
enim venam pluries tundendam  esse arbitrantur,  dum  casteri  vel
minimam sanguinis detractionemaversantur.----And afterwards----
Haec (praxis)  enim docet phlebotomiam, haud nisi casu urgentiori et
summa cautela esse celebrandam,  pro rerum conditione.  Caeterum
multa de hac re lepide et dilucide  tradita  prostant  apud scriptores,
quae tamen inter praxim implicatissima  deprehenduntur.  Lieutaud.
Synops. Univ.  Pra. Med. 
b!6         INTRODUCTION TO MIDWIFERY.
morrhages were seldom critical in 'his disease; I suspected,
that women in childbed sustained b'eeding worse, than i:  almost
any other situation; and from  some defect in the reuu dy. or
some error in the application, 1 oft; n found myself disappoin'ed
in my hopes and expectations, when » relied upon it.  It seem-
ed also an  observation of importance,  thai those  women, who
had lost much blood at the time of delivery, were  more  liable
to this disease, and  that it was more c^mmuiily  fa al to them.
   The consequences also of  erring by  the  too free use of the
lancet seemed more to be dreaded, because they were harder
to be repaired, than those which might arise from an opposite
conduct.
   But I am now convinced by  manifold experience, that my
reasoning was fallacious, ant' my fears groundless; and that what
I had considered as proofs of insufficiency  or  impropriety of
bleeding in the true inflammatory puerperal fever, ought in re-
ality to have been attributed  to  the neglect of performing it in
an effectual manner  at the very beginning of the disease.  In
short, if the first stage be suffered to pass  unheeded,  bleeding
will certainly then be injurious,  the opportunity having been
lost; and  the physician afterwards called in, however great his
talents may be, will too often  have the mortification  of being a
speciator of mischief which  he cannot then remedy, and an
event which he can  only deplore.
  It is in general absolutely necessary to bleed in the beginning
of the puerperal fever, and we  may then avail ourselves of the
advantage  which this operation affords, with equal  safety and
propriety as in any other inflammatory disease, under other cir-
cumstances.  With respect to the quantity of blood drawn, we
are to be  guided by  the  constitution- of the patient, and the
violence of the symptoms, being cautious not to err by bleeding
unnecessarily, or in taking away too laige a quantity.  But if
benefit should be derived from  the first operation, and the vio-
lence of the disease should require it, we'shall be justified in
repeating it at  short intervals ;  not with a view of moderating
or retarding the  progress of the  inflammation, but if possible, of
wholly suppressing it.  For when the fever has  remained for a
very few days, the putrid symptoms, which arc usually accord-
ing to the degree of the preceding inl!a:nination, advance very
rapidly, and its continuance depends upon  causes which bleed-
ing cannot remove, and will certainly increase.   When the at-
tack is violent, and the constitution feeble, and under other cir-
cumstances, it is always more  safe and expeditiously serviceable
to draw blood by scarification a-.id cupping, or by the applica-
tion of eight or ten, or eve.i a greater miniL>:r of leeches to  that
part of the abdomen, which appears to  be  principally affected. 
MANAGEMENT OF WOMEN IN CHILDBED.      577
In some countries the application of leeches to the hemorrhoi-
dal veins has been considered as more  effectual in this disease,
than any other mode of bleeding.  I must acknowledge, that
the  advantages  which  1 have  often seen  derived from local
bleeding,  have given me the  greatest satisfaction and plea-
sure.
  But though women,  who have had  profuse uterine  hemor-
rhages at the time of delivery,  are  particularly  liable to  the
puerperal fever from this or some contingent reason; and though
it is seldom removed by spontaneous hemorrhages, yet these are
sometimes critical.  The following case, which was communi-
cated to me by Dr. Joseph Denman, of whom, as he is endear-
ed to me by sentiments of esteem and regard more closely than
by fraternal affection, I might be allowed to speak in terms of
high approbation, is an example  of this kind.
  " I was called in the middle of the night to go ten miles to a
woman, whose placenta had been retained many hours after the
birth of the child.  The want of courage to  withstand solicita-
tion,  and the distance from me, were my reasons for underta-
king to separate  it.   The placenta adhered  strongly,  but the
separation was made  very gently, and without any considerable
hemorrhage.   On the third day, the patient was seized with a
shivering and fever, which continued all night.   From  this  she
was  relieved  by so large a discharge of blood from the  uterus,
that I was again sent  for on that account. There was no swel-
ling of the abdomen, but great  tenderness, much pain in  the
head, constant thirst, a little delirium,  and  she  had no stools.
An increase of fever  every evening,  and the same profuse dis-
charge every forenoon,  continued for ten days.  She took oc-
casionally testaceous powders  with rhubarb, saline mixtures,
tincture of roses,  infusion of bark,  and some doses  of  opium.
She at length recovered."
  The hemorrhage seems in this case to have been absolutely
critical, and  my own practice hath  supplied me with instances
of a similar kind in different stages of this fever, and many more
have proved the great advantage of returning or free sanguine-
ous lochial discharges.   Yet in these cases 1 had sufficient rea-
son to presume,  that the disease had not only originated in the
uterus, but was confined there,  without extending  to the abdo-
minal viscera.
  Having finished these observations on the use and advantages
of bleeding, general  or local, I  beg leave to  repeat, that when
the puerperal fever of a true inflammatory nature exists, J fee]
assured 1  am  right in the opinion I have advanced respecting
bleeding.   But a> it is  sometimes extremely difficult to distin-
guish between this fever and complaints proceeding from mere
irritability, which far more  frequently occur, especially m very 
578          INTRODUCTION TO MIDWIFERY.
delicate habits, and among women of high rank ;  and as all the
complaints arising from irritability would at this time be increased
by bleeding, and rendered dangerous by a repetition of it; I re-
commend in the strongest terms,  that we should be accurate in
our distinctions before we determine on a plan, on our reliance
and pursuit of which the good of our patient may so essentially
depend.*
  When the attack of this fever is violent,  a vomiting of bilious
matter attends ;  there is often a.multiplicity of stools, and the
commencement  is sometimes not unlike a moderate degree of
the cholera morbus.  It has been an  almost universal rule in
practice, in other diseases, to  forward these evident  intentions
of nature, at least  not hastily to obstruct or suppiv-s them ; but
in this, different measures have been pursued,   it has been ob-
jected,  that a woman  lately delivered has suffered  too  much
from  her labour,  to bear with safety a method of proceeding,
found useful in other fevers with the same indications ; or that
the parts affected would be too much agitated by the  operation
of an emetic.  It has also been conjectured,  that the vomiting
and uneasiness of  the stomach ought to be ascribed to uterine
irritation alone,  and are hysteric symptoms in the common ac-
ceptation of the word,  and therefore not likely to be  relieved
by encouragement.  But if in these cases we consider the ap-
pearance of the matter discharged,  the great relief which  the
patient  immediately receives from  the evacuation, and the ad-
vantages which are found to result from it in the course of the
disease,  it seems impossible to fix upon  circumstances, which
more strongly indicate the necessity  of giving an emetic. Assent
has been given to an opinion that the  vomiting of porraceous
matter, when an  hysteric  symptom, does not  require evacua-
tions ; yet even in such cases it may  be suspected, that the por-
raceous matter, by its irritation upon the stomach, is the materia
morbi, which  occasions or increases the spasms, and that the
discharge should not be stopped, while it is preternatural.  It
would be difficult  to imagine a situation,  in which medicines of
any kind were likely to do much service,  when the stomach is
oppressed with vitiated humours.
   But however unsatisfactory these  reasons may be,  experience
 will support me in asserting, that, when such complaints accom-
 pany the beginning of this disease, or occur during its progress,
 we shall lose an opportunity of doing much service, if we be de-
  * [Dr. Hall has lately  attempted  to establish a nosological dif-
ference in these complaints, in a work, entitled, " Cases of a serious
morbid affection, occurring principally after delivery,  miscarriage,
&c."-r-London, 1820.  F.] 
MANAGEMENT OF WOMEN IN CHILDBED.
579
 terred from giving a vomit; and that  the  operation is not only
 perfectly free  from danger, but certainly  answers  many other
 good purposes beside that of cleansing  the  stomach.   It is ne-
 vertheless to be observed, that an emetic was in this case first ad-
 vised, chiefly for the relief of a  symptom,  without any expecta-
 tion of thereby curing the disease.  Yet there are advocates so
 strenuous for the use of emetics  in this disease, as to recommend
 the repetition of them every  day,  and  who  have asserted, that
 they are the most  powerful medicines for the absolute cure of the
 puerperal fever.  To the merit of having first recommended this
 practice  I am not entitled, because my first giving them was acci-
 dental, and  perhaps I am not yet fully competent to judge of it;
 yet experience has in many cases proved  to me, that emetics may
 not only be given, but frequently repeated  in the course of this
 disease, with very great advantage.
   I may in  this place be permitted to make a digression, for the
 purpose  of observing,  that it appears, from the records  of medi-
 cine, that two different  opinions were very early entertained re-
 specting the treatment of fevers  in general.   The  first and most
 prevalent of these  was, that every fever was a process established
 by the powers of the constitution, for the purpose of altering and
 assimilating, or of separating and  rejecting some offending mat-
 ter;  or changing one state of the body into another, better fitted
 for the performance of its functions, and  the process was defined
 by the term generally, though not properly, translated fermenta-
 tion ; by  which the ancients understood  the different states of
 bodies, whilst they  were in  the act of changing into some new
 form or state, or the process by  which they were changed ; and
 not vinous,  acetous, or any other fermentation, according to the
 modern distinctions of this term.  As the process in fevers was
 expected to  be  ultimately  salutary, it  could not,  according to
 this opinion, be disturbed without mischief; unless, on  account
 of violence,  irregularity, or some extraordinary deviation from its
 usual course, it might be judged necessary  to moderate it when
 too violent,  to encourage it when too remiss,  or  to obviate acci-
 dental symptoms.   The second opinion was, that in a fever exci-
 ted by any cause, the body was in a state adverse to its  well-be-
 ing,  and perhaps inconsistent with life ; and that the fever ought
 therefore to  be subdued by the expeditious use of all such means as
 were likely  to remove  the cause, or to appease the action of the
 powers of the constitution ; or, by weakening the powers  them-
 selves, to reduce the body into such a state, that it should be un-
 able to continue or maintain what might be  called the  feverish
 process.
   The marks of these opinions may be readily discovered  to
pervade  every system of fevers, and every  method of treatment,
which have been offered to  our consideration or recommended 
530          INTRODUCTION TO MIDWIFERY.
for our guide, even doWn  to the present time.   There is no
doubt but that the knowledge  of both  these  opinions will oc-
casionally be found of much use in practice, if we be not led
to extremes.   But the knowledge of a disease, or of the  me-
thod of treatment, is of infinitely less value than the faculty of
applying >t,  and constitutes  in fact a small share of the excel-
lence of  a physician.  He, by discovering the p.irt principally
affected,  and by weighing its importance to the constitution, the
nature of the disease,  its present state and probable consequen-
ces ; and by taking into consideration all the collateral (ircum-
stances, will clear his  mind from perplexity and er;or, and form
a rule for his own conduct far  beyond the influence or power
of any doctrine.
  But in the treatment of the puerperal fever, the difficulty has
been much increased, on  account of the very great caution
which, for reasons before assigned, was judged necessary.  It
was also  said, that by regulating  the puerperal discharges, all
the diseases incident to women in childbed were to be prevent-
ed, or most naturally cured;  and all  evacuations, by  which
these were likely to be interrupted or suppressed, were forbid-
den.  In short, in this state there was a suspicion  of something
sacred or mysterious,  with   hich we were not authorized to in-
terfere ;  and neither  common sense nor observation had suffi-
cient effic.icy, to control  these impressions,  which originated
in speculation and prejudice, and which are  now fully proved
to have  been without  foundation.
   Many years ago, after much embarrassment and repeated dis-
appointments in trie treatment of this fever in the customary
way, I gave the powder which was recommended by, and ac-
quired much  reputation  under  the  sanction  of  the  late Dr.
James, and sometimes the following medicine ; and I  was  soon
sensible of their good  effects.

      rjL.  Antimon. tartarisat. gr. ij.
          Chel. cancror. pp 9 ii.  intime misceantur.

   Of a powder thus prepared, after bleeding, and, if thought
necessary, the exhibition of a clyster,  1 have given from three
to ten grains, repeating it as circumstances required.
   Should the first dose produce no sensible evacuations, for on
these only we are to rely, an increased quantity must be given
at the end of two hours, and we must proceed in  this manner,
till the end we wish  be obtained.
   If the first dose should occasion a vomiting, purging, or pro-
fuse sweat, we must wait for the good effect of  these  opera-
tions ; and we s!,all then be able to judge of the propriety of
repeating the powder. 
         MANAGEMENT OF WOMEN IN CHILDBED.     581

  But when the  evacuations are concluded,  if any alarming
symptoms should remain, we  need not hesitate  to give the
powder in the same quantity as was first used, though an equal
quantity is not often  necessary, if the first duse  have operated
properly.   We cannot reasonably expect, that a disease which
exhibits such evident marks of danger  should instantly  cease,
even if the principal part of the cause should be removed,  or if
the effect be abated.  Yet we must be careful not to rely so far
upon  an abatement of the symptoms, as wholly to desist from
pursuing the method which produced the abatement;  for no
disease  is more liable to returns, which are generally more vio-
lent than  the first attack,  and  with accumulated danger.  It
must also be observed, that as  the certainty of the cure often
depends upon the due repetition of the powder, the custom of
giving this or any other medicine at stated hours is never eligi-
ble, and sometimes improper.
  If a sickness,  loathing of the stomach, or offensive taste  in
the mouth, attend the commencement of the disease, this me-
dicine seldom fails to occasion vomiting, and the patient, with
a co Jiitenance strongly expressive  of the benefit  she  has re-
ceived, will  attest the advantage of the method pursued.  Nor
does the medicine often fail to  procure copious stools, which
are uncommonly fetid, and, as was  before  observed, in the
loose  ones  lumps of hardened^ faeces  are  intermixed.  Their
appearance  should in some measure guide  us with respect to
the continuance  of the evacuations, in proportion  to which the
abdomen becomes easy and subsides,  and  the other symptoms
become more favourable.   The urine is soon voided with more
ease, and in larger quantities, a moisture of the  skin or profuse
sweat succeeds,  and the lochia, which were before brown or pale,
fetid, and  in small quantities, increase and become  sanguineous.
But we are to remember, that the small quantity of the lochia
is never to be esteemed indicatory of disease, independently of
other appearances, because with respect to quantity  they evi-
dently vary in every constitution.
   At the same time that we avail ourselves of the  advantage to
be obtained from the use of the antimonial powder,  we  must
not neglect the  use of those means, which contribute to  pro-
cure  immediate ease or relief to the patient.   Emollient clys-
ters in cases attended with violent pain, especially if  preceded
or  accompanied  with  costiveness, are necessary  and proper.
Clysters have  also  been esteemed of more importance than
merely as the readiest means of promoting stools,  or as  a tem-
porary fomentation to the bowels ; for some physicians of great
experience have thought they wrere  able to remove a great part
of the cause, or to prevent the continuance of the disease, by
directing them to be administered so frequently, that they were 
582
INTRODUCTION TO MIDWIFERY.
at length returned without any  mixture of faeces*   Fomenta-
tions, or vapour-bathing, or even  the  warm bath,  may  some-
times be used with advantage ; but I think a folded warm flan-
nel, well sprinkled with brandy, and occasionally renewed,  is
one of the best and most comfortable  applications.  When the
pain is confined to one  part of the  abdomen, or remains after
the abatement of the fever, if not removed by leeches, a blister-
ing plaster, applied directly to the part, may always be recom-
mended with safety, and will sometimes do much service.  Plen-
tiful dilution  being absolutely necessary, the patient should be
carefully supplied with proper drink, in small quantities  often
repeated.  The most palatable, and generally the best, is chicken
water, or very weak beef tea ; or if objections be made to these,
barley water, thin gruel, milk and water, whey,  and tea of al-
most any kind, may be drunk at pleasure.
  In this manner I treated the wife  of a soldier in the guards,
whom  I  attended July  1,  1767,  in a safe but tedious labour.
She was of a  very strong habit of body, and upwards of thirty
years of age.  About thirty-six  hours after the birth of the
child she was  seized with a violent shivering, followed with se-
vere pains in the abdomen and loins,  and within a few hours
from the attack  of the disorder,  became nearly as big as she
had been before delivery.   On the third, I gave her four grains
of the  antimonial powder before mentioned, and finding no
sensible effect, I repeated it in the  same  quantity after two
hours.   She puked  twice, and had  seventeen stools,  like  yest
in appearance, within six hours after the repetition of the pow-
der.  When the  operation of the  medicine  ceased, the abdo-
men had almost wholly subsided, and the tenderness and fever
were much abated.  As  she  was  much fatigued, 1 gave her  a
cordial draught with a few drops  of tincture of opium.   She
had  some  quiet  sleep in the night,  and sweated profusely.
There  did not appear any necessity of repeating the powder,
and she recovered perfectly,  without  taking any other medi-
cine except some saline draughts, and afterward  the decoction
of bark twice every day.
  The event of  this case,  and of some others which  occurred
to me about the same  time, was  very  flattering.   I presumed,
that I had at  length discovered a method of treating this fever,
and a medicine  which  would seldom  fail to answer the most
sanguine expectations.   But further experience  has convinced
me, that without previous  or  even repeated bleeding in  some
cases, when the inflammatory symptoms are violent, this medi-
cine will often fail to subdue the fever, and that it is sometimes
uncertain in its operation.  It is perhaps to be reckoned among
the signs of an unfavourable termination of the  disease, when
the medicine  in proper quantities produces no sensible effects. 
         MANAGEMENT OF WOMEN IN CHILDBED.      583

I am, however, persuaded,  that if we have an opportunity of
giving it soon after the accession of the disease,  even without
previous bleeding, it will often do the most essential service,
and that too much cannot well be said in favour of this method.
And it is above all things to be wished, that physicians had the
early care  of patients  in this  disease; for the dissections of
those who have died, have proved, that very terrible mischief is
produced in various parts with  amazing celerity.  In a very
great number of patients, whom I have had an opportunity of
examining, all or some of the following appearances were ob-
served.   The uterus, or its appendages, were in a state of in-
flammation ; or sometimes one or  both of the ovaria of a livid
colour, and altered in their texture, as if mortified.   The ge-
neral substance of the uterus was  loose and spongy, and it was
less contracted  than it ought to have been since the time of de-
livery.   The os uteri, and that part of the uterus to which the
placenta adhered, were discoloured, and had a sloughy appear-
ance.  Small abscesses were sometimes found in  the substance
of the uterus or in the cellular membrane, which  connects it
to the  neighbouring  parts.  The bladder  was also sometimes
inflamed.   The omentum was  very thin,  irregularly spread,
and in a state of inflammation.   The  intestines were inflamed
chiefly in the peritoneal coat, adhering to each other, and much
inflated.  Inflammatory exsudation, and serum extravasated in
the cavity of the abdomen, have been in various quantities; but
these were in a less degree, when the patient had laboured un-
der a long continued purging.   In the cavity of  the abdomen
were likewise  found large flakes of coagulable lymph, which
have been often  mistaken for  curdled milk, or for  dissolved
portions of the omentum.  It  must indeed be acknowledged,
that the  information acquired in  this search  has not afforded
any  practical advantage, equal  to the care  or assiduity  with
which it has been made.  What  we have been  able to learn
has chiefly proved,  that various parts are affected  in different
subjects; that when the disease  has continued with violence
for a few days, its effects will  generally be beyond the  reach
of medicine, and that if the patient should fortunately recover,
her recovery will depend upon circumstances, which the physi-
cian cannot, without great uncertainty and difficulty, command.
We  have indeed been told, that, in the dissections of some who
are said to have died of this disease, no appearances of inflam-
mation have been discovered ; but I should suspect that in such
cases some important appearances had been overlooked, or that
errors had been committed as to the nature of the disease, and
probably in its  treatment; unless  the patients might be suppos-
ed to have died merely from excessive irritation.
  In the less violent degrees of this disease, and  more delicate 
584
INTRODUCTION TO MIDWIFERY.
constitutions, it will be necessary to pursue the same intentions,
though with  less activity.   In  such cases, after local bleeding
with  leeches  or otherwise, as may be most convenient, and
giving a proper  dose of ipecacuanha,  or washing the stomach
with an infusion of camomile  flowers, more  lenient medicines
must be prescribed.    But they must be such as <.vill produce a
certain and speedy effect, and after the operation  of an emetic,
if stools are not procured, we shall neglect the means, and lose
the opportunity, of doing most effectual service ; for without
them  the relief obtained will not be permanent.   An emollient
clyster may be first  injected, to remove  any hardened  faeces
from the lower part of the rectum ; and then the  antimonial
powder in small doses, or the saline draughts  with a due pro-
portion of the natron or the kali tartarisatum, or with ihubarb,
or the following draught,  may be  given every third or fourth
hour:

           rjL.  Natri tartarisat.
               Mannae opt. aa 3 "•
               Infos, sennae, Aq. menj. sat. aa 3s.
               Tinct. cardamom, fut. xxx. M.

Or two ounces of magnesia vitriolata may be dissolved in a pint
of thin gruel, and one or two large spoonfuls given every hour,
till  due evacuations  are obtained;  and this medicine  has been
found to answer  the  intention, when  apparently more  pleasant
ones could  not be retained in the stomach.
  In every case of disease, which requires speedy  and  repeated
evacuations for its relief, particularly if attended with violent
pain,  it  is necessary  to give a respite to  the constitution, by
which it  may be enabled to exert  its own  powers,  or  recover
from the fatigue of the operations themselves.  For this purpose,
opiates are wisely prescribed, when the operations are concluded.
But opiates, being given for the  purpose of easing pain,  or  of
quieting some agitation, if they be not given in a sufficient quan-
tity to produce the intended effects, are useless; for it is by their
effects we are to judge of the propriety or advantage of their use.
In some cases also, which were accompanied with violent pain at
the commencement, it has been found  necessary, to give a large
dose of tinctura opii,  immediately after the first bleeding,  without
waiting for any other evacuations,  by which the progress of the
disease will be retarded, and sometimes  subdued.   Nor  is there
ever occasion to hesitate upon the use or repetition of an opiate
at any period of this disease, when  the  violence of the pain re-
quires it;  for though the pain may originally  be a consequence
of the disease, it becomes after a certain  time a powerful cause of
its continuance and increase. 
          MANAGEMENT OF WOMEN IN CHILDBED.      585

   In the inferior degrees of this  disease,  after bleeding  once,
 either with  the  lancet,  or, which  is generally preferable, by the
 application  of leeches to the part,  if thought necessary, and the
 exhibition of an emetic, which can seldom be dispensed with, we
 shall find the  simple method  of exhibiting an opening draught
 for the purpose  of procuring four or five stools every day, and
 an opiate every  evening, produce the most happy effects.   But it
 is not possible for me to express my sentiments of the advantage
 which may  be sometimes procured by daily purging, and by the
 subsequent exhibition of opiates, so clearly as by the relation of
 the following case,'which was lately under my care.
  The wife  of an eminent tradesman was brought to bed of a
living child, after a very tedious and  difficult labour.  She was
 of a corpulent but relaxed habit, and this  was  her  first child.
 About four hours after her delivery she was seized with a purging,
 and  the stools, which were of a dark colour and exceedingly of-
fensive, soon  afterwards came  away involuntarily.  I  saw her
early the following morning, November  22d.  She bad constant
but not exquisite pain in the abdomen which was tumefied;  her
skin  was hot, her  pulse  quick, and she was thirsty   Having
voided no urine, I introduced the catheter, applied  a flannel well
sprinkled with brandy  to  the lower part of the abdomen, and
ordered an opening draught of the kind  before mentioned.  #She
had  proper  evacuations by stools all day,  and in the  evening
took an opiate.  On the 23d,  I found that the purging continued,
and  there  was  little alteration in the  other symptoms.  The
 opening  draught was repeated in the morning, and the opiate at
bed-time.  On the 24th I  was  informed she had  got some re-
freshing sleep in the night.   The pain in the bowels and feverish
symptoms were abated, but the  stools, which were yet very fetid,
came away  involuntarily.  Both the draughts were  repeated as
on the preceding day.  On the  25th, though the stools continued
to come  away without her consent, the  abdomen  had subsided,
and the tenderness was  almost gone.   On  the 27th, the purging
ceased, and  she recovered without  the repetition  of the~medi-
cines.  I was under  the necessity of drawing off her urine twice
every day, till the eleventh after her delivery, when she was able
to void it without any assistance.  But  it is not to a single case
that I should have occasion to appeal in  a matter of so much con-
sequence.  A long  and successful practice hath convinced me,
that the purging, which often attends this disease, is not only salu-^
tary, but frequently critical, and instead  of being suppressed,  that
it ought to a certain degree to be encouraged.  Nor would it be
difficult  for me  to recollect  many cases, in which  fatal conse-
 quences have speedily followed imprudent  attempts  to  stop the
 evacuations.
                             74 
586
INTRODUCTION  TO MIDWIFERY.
  These remarks on the necessity of procuring stools so freely,
are to be  considered as applicable only before the patient is re-
duced to a state of great debility, or perhaps in fevers occasioned
by  local inflammation  of  some of the contents of the abdomen.
Experience has  proved, that,  in  the  advanced state of fevers of
the typhus class, costiveness is  the most  favourable  symptom.
Sydenham takes particular  notice of this in his most  excellent
treatise on the fever of 1661  ; and in a principal hospital of this
city,  it is an established rule,  never to promote stools,  or any
weakening evacuation, in fevers of this class, after the fourth day.
But in the advanced state of these fevers, costiveness, for a great
number of days, not  only prevents an increase of  the debility,
but is  the most promising  symptom of a happy termination of
the disease.  It deserves to be particularly noticed,  whether pa-
tients in the advanced state of the typhus fever ever die while the
bowels are constipated.
  As the disease passes into its more advanced stages, it becomes
more complicated and  dangerous, and there is a necessity of be-
ing very circumspect in our endeavours to give relief.   Bleeding,
unless by scarification, or the application of leeches  to the abdo-
men or  hemorrhoidal vessels,  will very seldom be  proper at this
lime; and if directed, or repeated, from the encouragement which
the inflammatory appearance of the blood may afford, will gene-
rally hasten the fate of the patient, by reducing  the strength in a
much greater degree,  than  it can  abate the disease ; as  I have
seen in many instances of this and other kinds of fever.   It must
therefore  be  omitted,  or  prescribed  with  the greatest caution.
But if the stomach  or bowels be much disturbed, and an emetic
were not given in the beginning, one may be given at almost any
period of the disease with safety and advantage.  Or if there be
no  looseness,  and stools  have been procured sparingly through
the course of the disease, the general method of cure may be pur-
sued, if the state of the parts first affected should  require it,  al-
lowing for the  reduced strength of  the patient.  The frequent
injection of gently purgative  or emollient clysters will be extreme-
ly proper,  and laxative medicines of the kind before mentioned ;
not omitting to give and repeat  the opiates at  proper intervals,
to procure temporary ease at least; or neglecting the use of such
diet and general regimen,  as will support the strength of the pa-
tient, without increasing the fever.
  But when the stools  are very frequent or involuntary, and all
appearances threaten imminent danger, we  must be cautious that
our attempts to cure the disease  are consistent  with the state of
the  patient, though something must  be hazarded for her relief.
Clysters of chicken  water, or flour and water, boiled to a proper
consistence, or of a decoction of linseed, often repeated, then con-
stitute a very important part of  the cure, by washing off some 
        MANAGEMENT OF WOMEN IN CHILDBED.        587

part of the offending matter, which stimulates the bowels to fre-
quent evacuations,  and by acting perhaps as a fomentation, and
to these may be occasionally added a proper quantity of fhe tinc-
tura opii.  But if great care be not taken in their administration,
the patient will suffer intolerable pain on account of the tender-
ness of the uterus,  which  I  suppose to be the part principally
affected, at least in  which the disease most commonly originates,
and of the influence of which this part never fails to partake.
   At this time it will also  be useful to  give very small doses of
ipecacuanha mixed with the opiate as a diaphoretic, or the pulv.
ipecacuanhae compositus, either  in  some cooling vehicle, as the
saline draughts, or  with cordials, as the situation of the patient
may require.  But  if the stomach or bowels should be much dis-
turbed in the advanced stage, or if any new cause of disturbance
should occur,  the ipecacuanha  may even then be given some-
times in such a quantity, that it may act as a gentle emetic.  The
white decoction with  a  large proportion of gum arabic,  or the
common emulsion with  spiritus  aetheris  nitrosi, makes at this
time a proper and agreeable drink.   If the strength of the pa-
tient should sink and great faintness come on,  a necessary quan-
tity of some cordial and wine must be giveu in the  interval be-
tween the draughts.   I have also often in this stage given cam-
phor in substance, in julep, or in the form of emulsion, but have
generally been obliged to discontinue its use, because it soon be-
came disgusting to the palate, and offensive to  the stomach ; nor
have I ever found  that  advantage from the  more liberal use of
camphor,  which some have taught us to expect in this disease,
though in many instances the camphor mixture has appeared to
be an agreeable cordial, and to moderate pain.
   Under the most deplorable circumstances, we ought never to
desist  from using our endeavours with assiduity, to  relieve and
extricate the  sick from  the  imminent danger they are in,  both
from principles of humanity and  prudence; for they will some-
times  recover very  unexpectedly, when every  prognostic  is
against them.   Something always remains to be done, which may
be of use,  or contribute  to their comfort; either with the view of
obviating  troublesome or painful  symptoms;  or of  supporting
their strength  by means adapted to  their  state; or of promoting
some obstructed  secretion, especially  by regulating  the stale of
the bowels.  On such occasions I have among other things been
induced to try clysters of various kinds, emollient, anodyne, and
antiputrescent, particularly of strong decoctions of Peruvian
bark;  but the event obliges me to acknowledge, that I have not
observed much advantage from them, beyond  what may be de-
rived from the domestic ones, which are in common use, with the
addition of a proper quantity of the tinct. opii.
   Nor has the bark, though given in different stages of the dis- 
588          INTRODUCTION TO MIDWIFERY.
 ease, with remissions tolerably distinct, answered the intention as
 a febrifuge;  though in a few cases, in  which the  intermissions
 were complete, it has succeeded.   As a supporter of the general
 strength of the constitution, the bark has been likewise found of
 less service than might have been  expected;  because of the  dis-
 turbed and very irritable state of the bowels, which it tends to
 increase.   Instead of this medicine, the columba root, in powder
 or infusion, has been given every fourth or  sixth hour; or the
 common  bitter  infusion prepared with cold  water, and joined
 with some aromatic ; or a strong infusion of chamomile flowers,
 with the  addition of a few  cloves; and sometimes  the following
 medicine, especially when the hiccup has been troublesome :
       R  Spir. aetheris vitriolici 3ii.
          Aqu. purae, vel inenth. sativ. 3viij.
          Sacchar. pur. q. s. fiat rnistura, cujus sumat aegra
            uncias duas, tertia vel  quarta quaque hora.
  In other cases, aether, or Hoffman's  mineral anodyne liquor,
 has  been given ; but they have often proved less agreeable to the
 stomach,  and I  believe not  more efficacious  than  the spiritus
 aetheris nitrosi, which 1 have substituted for them, and given with
 great freedom and advantage.   It was before observed, that  the
 hiccup was frequently an indication of a collection  of  offensive
 humours in the stomach,  and has generally preceded the sponta-
 neous vomiting, which in the worst state has  sometimes proved
 critical; though the same symptom is also not seldom a proof  of
 the progress of the disease, and a sign of the utmost danger.
  In the course of the disease, when the abdomen had been much
 distended, notwithstanding the evacuations, I have recommended
 the application of the cataplasmacumini moistened with  brandy;
 and  sometimes directed clysters composed of electarium e baccis
 lauri, or a solution of asafoetida in simple peppermint water ; and
 wish I was justified  in speaking  more highly in  their  praise :
 but they are among the things which have occurred to me, when
 I have scarcely known  what  to  propose.   But in general the
 abdomen has been wholly  covered  with a blister in the early
 stages, or one may be applied with safety, and probably with
advantage, at any period  of the disease.
  I have rarely attempted to inject medicines of any kind into
 the  vagina or uterus, though from a consideration of the probable
 state of the parts, and of the fetid humours discharged, it is rea-
 sonable to think,  that emollient  or  gently detergent injections
 might sometimes be useful.   But the  helpless state of the patient
is such, as to render the operation  itself very troublesome ; and if
they be advised, great caution will  be necessary both  in their
composition and administration ; but fomentations to the external
parts have, I think,  sometimes afforded comfort, aud  been  of
service. 
         MANAGEMENT OF WOMEN IN CHILDBED.      589

  These are all the observations I have made, and the opinions I
have entertained on the puerperal fever in its  simple state; that
is, considering  it as a disease, originally, of the truly inflamma-
tory kind, affecting one or more of the  parts  contained in the
abdomen, extending its influence over the whole constitution, and
speedily  assuming a putrid form with more or less virulence, ac-
cording to its  degree and  treatment during the inflammatory
state.  But when putrid diseases are epidemic,* the puerperal
fever may, at the commencement, partake  of the reigning disease,
(varying only  in the affection of the parts concerned in  parturi-
tion,) as the histories of the  plague,  in this and other countries,
have  sufficiently proved.  This disease may also be combined
with a phrensy or peripneumony, with symptoms multiplied and
varying  according to the combinations.  Then our principal at-
tention  must of course  be paid  to  the most  urgent disease  or
symptom ;  but the event of such cases must be more  dangerous,
on account of  the number and  importance  of the  parts con-
cerned.
   There is another consequence of- an epidemic, or even a spo-
radic puerperal fever, on which it would be criminal to be silent.
This is  the  contagious nature of these fevers; it having been
long suspected, and being now fully proved,  that they  may be,
and  often have been conveyed by midwives or nurses, from one
patient to  another.  This fact explains the  reason why  persons,
practising  for many years with the  most  enviable success, have
at one or more periods of their  lives,  without any change in the
principles or manner of their practice met with a number of un-
fortunate cases; when  perhaps an adjoining neighbourhood  has
been entirely  free frum  such diseases.  Of this I  have known
many instances which could be exactly traced,  and have repeat-
edly seen it  the cause of the most  painful distress, and  severest
reflections,  in  my  own practice.   Nor  should this  subject  re-
main a barren speculation,  but according to  the value set upon
 reputation, teach  those who are engaged in the practice of mid-
 wifery,  the impropriety of their  attending patients in fevers and
 other dangerous diseases, if it can possibly  be avoided; or if
 they should  be compelled to this by necessity, that they use every
  * The first account I have met with of a puerperal epidemic is in
Peu.  It appeared in the year 1664,  in ti»e Hotel-Dieu, at Paris.
In this account there are some very curious observations.  In this
country we have very reprehensibly neglected to preserve any re-
gister of the times  when such fevers have  prevailed.  But ia  the
year j 788, an account of a puerperal epidemic was published by my
ingenious friend, Dr. John Clarke, according to its appearance in one
of the hospitals in  this city,  andrin some instances, in private  prac-
tice. - 
590           INTRODUCTION  TO MIDWIFERY.
precaution not to  carry contagion from one patient to another.
The nature -and the power of contagion  in  general seem not to
be perfectly  understood, and it may exist in  many diseases, in
which it has not yet been suspected.   This  subject is  therefore
deserving of the most serious investigation and inquiry.*
   * [There are few parts of this work more satisfactory than that
portion of it which  relates  to puerperal fever.  Our author's ideas
of it are those of an acute  clinical observer.  Let the practitioner
ever keep in mind the opposite characters which this disease assumes
under different circumstances, and thereby avoid the errors so fre-
quently  committed by  those heedless  of such  distinction.   The
puerperal fever, in its simple state, is one of the most formidable of
inflammatory disorders ; dissections strikingly illustrate this fact, and
as such the disease requires prompt recourse to the antiphlogistic
treatment.  Among the efficient means for this purpose, venesection
stands foremost;  and the detraction of thirty or forty ounces'of blood
will frequently be demanded. It is difficult, however, to prescribe the
limits of bloodletting.  An excess of this evacuation is not so hazard-
ous to the security of the patient as a temporising practice with re-
gard to the  mode of depletion.  " I have employed  bloodletting in
this disease  (says Mr. Hay)  to a greater extent than any other prac-
titioner with whose writings I am acquainted, and have hazarded the
opinion that the quantity of blood  is scarcely to be limited but by the
removal or considerable diminution of the pain ;  but let it be  recol-
lected, as a  necessary appendage to this opinion, that the period for
bleeding is confined to an early, though not a very definite stage of
the disease."
   Purging and blisters are  also among our best auxiliary remedies.
Dr. Channing has remarked that  during puerperal epidemics those
women have been most frequently observed to do well  who have
suffered least  from costiveness during  pregnancy,  and more espe-
cially if the  bowels have been freely opened during labour.   Much
credit is due to American physicians in enforcing the  proper method
of cure in puerperal fevers.   Subsequently European writers have
profited by  their suggestions.  Yet it must be  remembered that the
typhoid form of this complaint is rarely to be seen in this country ;
while its inflammatory type is still more aggravated than we generally
find it to be  abroad.
   In the typhoid form of the puerperal fever,  our indications vary
with the particular causes upon which it depends.  The  discharges
by the skin,  urinary organs,  intestinal canal, &c. are to be regulated
as in idiopathic typhus;  repeated and  extensive experience has
shown, even in this complex character of the disease, the value of
purgatives.  In the very  fatal puerperal epidemic of Aberdeen, Dr.
Gordon assures us,  that of those  who  were freely purged the day
after delivery, only one died of puerperal fever.  The direct pros-
tration of the energies of the system by the lancet is also  to be stu-
diously avoided in this form of puerperal fever, nor ought  the appli- 
MANAGEMENT  OF  WOMEN IN  CHILDBED.     591
                           SECTION II.
                            Mania.
   Amidst the great variety of complaints to  which  women in
 childbed are liable, there is none so distressing as that aberration


 cation of  blisters to be made with the same freedom  as in the pure
 inflammatory type of the disease.  Fomentations of tepid vinegar and
 water are useful, both in the typhoid and inflammatory forms, and de-
 cidedly preferable to those of brandy or other spirituous applications.
 The sanative powers of camphor  in this complaint have been too
 highly extolled ; and the  analogy by which Peruvian bark is prescri-
 bed is in this instance fallacious.
   Very  recently  several distinguished physicians of Dublin  have
 earnestly  recommended the  internal and external use of the spirits
 of turpentine in puerperal fevers, ascribing to it almost the efficacy
 of a specific.  However respectable this authority, I  should deem it
 hazardous practice in the inffammatory form of the disease : if at all
 admissible, it seems most applicable to the typhoid state of the disorder.
   The  contagious character of the puerperal fever has been denied
 by some writers,  while others have  represented it to be so in an emi-
 nent degree. The records of the Lying-in Hospitals of Great Britain
 confirm this latter opinion.   While  I visited  the  Royal Infirmary of
 Edinburgh, in 1816, Dr. Duncan, jun. informed me that six cases had
 at that time  occurred, in three of which the disease was satisfactorily
 ascribed to attendance on the puerperal women.  The contagion was
 communicated by the nurses.
   " Puerperal fever," says Dr. Hosack, " ought to be divided into
 the idiopathic and symptomatic kinds :  in the former we may observe
 the characteristics of an acute and pure inflammatory disorder, while
 in the latter are to be seen those of a typhoid affection. This typhoid
 state is to be considered as depending upon  a peculiar condition of
 the system, and previous exposure to the sources of typhus.  In this
 case, puerperal fever is not unfrequently highly contagious. The poi-
 son of typhus attacking the lying-in woman,  an inflammation of the
 womb has been its accompaniment.   A similar combination  I have
 met with of scarlatina and hysteritis, in which the same typhoid state
 of body was induced. Facts of this nature have led me to  distinguish
 hysteritis into that which is exclusively inflammatory, and that which
 is complicated by  its union  with typhus fever, scarlatina, or other
forms of a malignant or typhoid character.  In the hospitals of Europe,
the latter  type of this disease is of frequent  occurrence,  but in this
 country it is scarcely known. In this city I have never met with this
 union of typhus and puerperal fever.  Three years ago, I am in-
formed, upon very  respectable authority, that it prevailed in Eliza-
beth  Town and its neighbourhood,  in the state of New Jersey, and
proved  fatal to several lying-in women.  In some of those cases it
was supposed to be conveyed by the accoucheurs themselves.—These
two forms of the disease evidently call for different modes of treat-
 ment."  F.] 
592
INTRODUCTION TO MIDWIFERY.
of the mental faculties, which  sometimes, though happily very
rarely, we have an opportunity of observing.  This disorder has
sometimes shown itself immediately  on women becoming preg-
nant, in others when the time of labour approached, in others du-
ring the state  of  childbed, apparently  occasioned  by some,ex-
traordinary disturbance or  peculiar irritation of the uterus.  In
some cases it has, however, been evidently caused by irritation of
another part; as when the breasts have been inflamed, or an ab-
scess had been formed ; and at the time of first suckling or wean-
ing the child, seven or eight months after delivery ; but in every
case, the disorder has been occasioned by an uncommon irrita-
tion of one of these parts, spreading its influence to  the brain,
though without any reference to former dispositions or habits, ac-
quired or hereditary.  Speaking of convulsions,  it was said, that
pregnant  women labouring  under any distress of mind  from the
peculiar circumstances of their situation, were liable to them; and
the same  observation may  be made of this disorder; for if the
nervous system be once disturbed to a certain degree, or in any-
particular manner, the  kind of disorder  thereby produced  may
be  accidental; and  the same cause, which  shall in  one person
produce convulsions or paralytic affections, shall in another pro-
duce the disorder of which we are speaking, either of the melan-
cholic, or  violent kind.  In the same manner, patients who have
long suffered from intermitting fevers, have in some seasons been
disposed to maniacal disorders.*
  Almost  all the diseases  of women in childbed were formerly
attributed to two causes,  the interruption of the lochial dischar-
ges, and the milk ; the latter of which when imperfectly secreted
was supposed to have a pernicious  influence upon the constitu-
tion in general, or on some  part in  particular.  Hence the name
of the milk fever,  the oedema lacteum;  or the edematose swelling
of  the leg, and in general of all swellings or abscesses formed in
any part of the body soon after delivery, which the French have
therefore classed under the general  name of depots du lait; and
this aberration  of the mind  is, for  the  same reason, called by
some nosologists,  the mania lactea.  But with  respect to treat-
ment, I do not know  whether there be any  real difference in
this disorder when it happens to  women in childbed, or under
other circumstances,  or in  the symptoms  attending it;  saving,
as that state is constantly  undergoing some change, as women
depart from the time of delivery,  there is  always  a chance of
amendment from every degree of change.   Perhaps for this rea-
son, this disorder, in some instances, ceases in twenty-four hours,
and in others,  it  continues only for a few days, in some a few
* See Sydenham. 
MANAGEMENT OF WOMEN IN CHILDBED.
593
 weeks, and in others for several months.  But the instances of its
 continuing  more  than  six  months are very rare ; and there is
 scarcely one to be found, who did not ultimately recover, if there
 was no previous or constitutional disposition;  yet the longer the
 disease is protracted, the more  uncertain is the recovery.   It has
 been asserted, in very unqualified terms, that women who become
 maniacal in childbed, always recover.  This opinion, 1 presume,
 extends only thus  far, that if they live, they always recover their
 faculties, the distemper proceeding from disordered functions and
 not from an  organic disease; but I have seen several women die
 during their  maniacal state, and not long after  the accession of
 the disorder.  Their death has  sometimes  appeared to be owing
 merely to the vehemence and continuance of their exertions, which
 it seemed impossible to moderate.
   The time when  this disorder appears is different; in some cases
 a few  days after delivery, in others abotfra fortnight or  longer,
 or in the manner before mentioned.  All women, soon after deli-
 very, are either more irritated, or more subject to irritation, than
 they perhaps are at any other time; and hence chiefly arose the
 necessary custom of keeping them quiet, and secluding them for
 a certain time from the chance of meeting with such occurrences
 as might disturb  them.   I have known more  than one instance
 of a lying-in woman in a very irritable state, but with perfect
 composure of mind, becoming at once deranged  by some fright
 or mischief apprehended to herself or child, or from some dismal
 story related  to her; who might have escaped,  had she been ma-
 naged  with  circumspection.  It is impossible to describe how
 much of the prevention and  cure of these  and other complaints
 depends on the judicious conduct and proper manners of their
 attendants.
   As to the delineation  or history of maniacal disorders, under
 any circumstance,  this does not seem necessary, if it were practi-
cable ; because the name does  not depend on  a  symptom, or a
 single  act, unless  it  were an outrageous one indeed ;  but often
upon the construction put upon general,  or frequently repeated
unusual conduct, varying in degree and  outward form in every
individual patient.   For these  reasons  it is not surprising, that
in some  cases there should be  a difference of opinion as to the
actual existence of  the disorder,  even among men of experience :
or that, on the first interview, it  is often impossible to give an opi-
nion which could  be supported.  The difficulty  of deciding is
also  very much increased, by the difference in  the conduct of the
 patient at particular times; for even in very bad cases there are
generally lucid intervals, or a  reasonableness  except on  certain
subjects, when the disorder would not be suspected.  Yet if we
once conclude a patient to be maniacal, which we were unwilling
to suspect, and still less willing  to announce, a  review of the pre- 
594          INTRODUCTION TO MIDWIFERY.
eeding circumstances commonly exhibits  pretty clear proofs of
the gradual progression of the disorder.
   On the attack of every complaint of this kind, from the exer-
tions of the patient, and the tumultuous derangement of her mindj
the pulse  becomes extremely quick, the cheeks flushed, the eyes
inflamed or glistering,  the general heat of the body is increased,
and there are in most cases the common symptoms of fever, though
mania has been defined a delirium without fever.   Nor when cases
become chronic, is there ever a time,  when they are  to be seen
without more or less of what  might be called fever, especially in
and after fits of outrage.  In some instances, the pulse has been
wonderfully quick, the tongue white, and every other symptom
of extreme irritation, but without any marked aberration of the
mind.
   Though there is sufficient difference in the general appearance
of the patient in these ftsorders,'to make it evident on  the attack,
that it  is not properly  speaking fever,  something like the same
method of treatment has been judged necessary.  It was former-
ly the  custom  to enjoin the use of very powerful medicines, and
very severe treatment,  for  maniacal patients, and among other
things  copious bleedings. But for women reduced in their strength
by the circumstances of  childbed,  more  gentle proceedings are
requisite.   Bleeding, if advised in  any  degree, must be perform-
ed with a sparing  hand; and if there be a fact of which I am as-
sured,  it is, that copious bleedings  are extremely prejudicial,  but
little abating the disorder even for  the present, and if the patient
survive, increasing and rendering it more deeply rooted  and per-
manent afterwards.  Generally speaking, bleeding, unless in very
small quantities, by the application of leeches  to the temples, or
by cupping, should  therefore be altogether omitted.   It is also
because they increase the present irritation, and have been  found
ultimately to do little service, that blisters are seldom recommend-
ed in these cases.  The resistance  which is often unwisely  made
to the harmless wishes  and inclinations of the patient, frequently
becomes a cause of violent outrage, as  has also been observed in
fevers  attended with delirium; it should  therefore  be carefully
avoided.
   The intentions in the use of medicines are, to remove all  fever-
ish disposition, whether  original or symptomatic, and  to lessen
at the  same time the excessive  irritation.  For these purposes it
is usual to give the saline draughts, with  a suitable quantity of
syrup of white poppies, or a few drops of Tinct. Opii.  repeated
as the case may require, and sometimes the antimonial powder.
The secretions being generally much interrupted, especially those
by the bowels, these must be promoted by the occasional  use of
clysters, if they can be administered, or of the common purging
mixture, and sometimes by small doses of calomel, so as to pro- 
MANAGEMENT OF WOMEN IN CHILDBED.
595
cure two motions regularly every day ; and in this state of the
disorder no other medicines seem to be required.
  Immediately on the attack, with many other alterations of the
countenance, especially of the eyes, which acquire a fierce look
easily observed, but which cannot be described, the skin has of-
ten a yellow tinge, and sometimes there is a complete jaundice.
It is then thought requisite to give an emetic, not with the view
of curing the disorder, but of relieving the symptom, and of re-
gulating the constitution, and this must be our guide  in all me-
dicinal treatment; for I believe the idea of any medicine having
the power of influencing the  mind, except by producing certain
effects upon the body, is wholly abandoned.
   In the more  advanced and settled state of the disorder,  the
chief view has been to abate irritability,  though very different
means have been used for this purpose, and to regulate the ge-
neral functions of the body; but it is remarkable that much dif-
ference, whether that function,  which we might  conclude to be
of principal consequence, that is, regular or defective menstrua-
tion, has not been perceived.  In cases of great depression of
the spirits, or what has gone under the general name of  melan-
choly, gentle emetics have been much advised, and I think with
much advantage, every  other or every  third day  ;  and at the
intermediate times, nervous medicines, such as the spirit, aether.
vitriol, comp. confect. Damocrat., or the fetid gums, especially
the gum ammoniac and camphor, the last of  which Dr. Kinneir
recommended many years ago in full doses, (though in less doses,
and regularly given, it sometimes apparently relieves,) in strong-
er terms than experience will justify.   On  occasional  returns
of great pertubation and violence, we must recur to the method
used on the first attack.
   Opiates have been given with two intentions.  Some  have
merely proposed to soothe and moderate the violence of the dis-
turbance by the frequent repetition of small or moderate doses,
but these do not often answer our expectations.   Others  have
aimed by the more liberal use of opium, often repeated, to sup-
press the irritability altogether.  As far  as I  can judge,  the for-
mer method is far preferable to the latter ; and 1  think there can
be no doubt, but that opiates in large doses,  instead of diminish-
 ing, add in no small degree to the irritability which before exist-
 ed.  A physician of very great eminence observed to me, that
 opium almost universally excited disturbance, before it  exerted
 its quieting powers, but thatother narcotics, cicuta orhyoscyamus
 for instance, immediately acted by their peculiar quality,  w ith-
 out raising any previous disturbance.  The Tinct. Digitalis has
 of late been commonly given in these  cases,  perhaps  in some
 with advantage, but more frequently without procuring any evi-
 dent benefit.   Nor has any evident advantage be^n  obtained 
596          INTRODUCTION TO MIDWIFERY.
by the occasional or continued use of the warm  bath,  farther
than as a present indulgence.
   Among many other medicines, which have been recommend-
ed in the advanced stages of this disorder,  it would have been
extraordinary, if some of the preparations of quicksilver had not
been tried ;  and of these calomel  has had the preference.  It
was the favourite medicine in maniacal cases,  as  long as  I re-
member any thing of the profession.  By some, all preparations
of quicksilver have been thought to increase,  and by  others to
lessen irritability, but the explanation of the operations o/medi-
cines has very little forwarded the improvement of the art; and
I am not clear, whether the practice of medicine may not, even
at this time, be justly considered as empirical, jthe excellence of
the art chiefly depending on the sagacity and judgment of each
person who practises it, and not on any fixed or unquestionable
principles.
   Calomel has usually in these cases been given as  an alterative,
in doses too small to produce any immediately evident effect, but
repeated so  often as to make very material alterations in the con-
stitution.  Sometimes it has also been given as an active  purge,
the operation of it being supposed more efficacious than that  of
any other medicine of this class.  The causes  of mania,  or the
effects produced by it, speaking of the  disorder at  large,  as has
been proved by the dissection of dead bodies, may be widely dif-
ferent,  and for these different  medicines may be necessary and
proper ; but whatever may be the remote causes,  the  different
functions of the body, especially those  of the abdominal viscera,
are usually disturbed or  not regulated without much  difficulty. In
that species  of which we are now speaking, it is not supposed,
that any organic disease exists in any of the constituent  parts  of
the body,  but that it wholly proceeds from disturbed  action  of
the nervous  system ; and that we shall probably succeed the best,
not by aiming to cure a  disease which does not exist, or which is
beyond the power of physic, with very active medicines ; but by
obviating symptoms,  which may, in  this case at least, be said  to
constitute the disease.
   Throughout the course of the complaint the strictest regularity of
the non-naturals is to be established ; such as the times of going
to, and rising from bed, the kinds and degrees of exercise, em-
ployments, and  amusements, if possible;  the  times  of taking
food,  kinds and quantities of food, and the like; and above all,
care is ever to be taken,  that the patients, in their fits of despon-
dency  or rage, be prevented from doing mischief to  themselves or
others, and they are always extremely artful.  From a strict re-
gulation of these matters, by soothing them when  violent,  and
comforting them when dejected, by changes of scene, by separa-
ting them altogether from the society of their relations and par- 
MANAGEMENT OF WOMEN IN CHILDBED.
597
         licular friends, and by the establishment of a mild, but firm and
         vigilant authority, it is probable that more advantage will be de-
         rived than from  any medicine; for the  prudent and intelligent
         conduct of the attendants has undoubtedly, in  many cases, con-
         tributed more to the recovery of the patient than the most power-
         ful medicines.
           The first signs  of recovery are to be observed in the abatement
         of the fits of  afgitation in their violence, or the return of the right
         understanding though of short intervals.  It seems that particular
         address is required to foster every tendency  to  their natural ha-
         bits, and by a sensible  and nice management of these tendencies,
         the recovery  may be much promoted.

                                 SECTION III.

                             On the Swelled Leg.

          Of every   complaint  to which  women in childbed are liable,
         and which may require medical assistance, it is  not  necessary or
         possible here  to take notice.  I have, therefore, confined myself
         to those which seem of the greatest  consideration either  from
        their frequency or importance, and of this kind  is the puerperal
        swelling of the inferior extremities, as it may not improperly be
        called.  This disease has been long ago and often mentioned by
        the French writers, most  commonly under the name of l'enflure
€nw*  des jambes et des ^niisses de la femme accouchee ;  or that of de-
        pot du lait, from its supposed cause ;  but often with so little accu-
        racy, as to make it difficult to distinguish what kind of swelling
        they  meant to describe.   By the Germans  it  is usually called
        the oedema lacteum. Though the disease has frequently occurred
        in this country, and has been long understood in practice, I do
        not  recollect  that any  treatise was written  upon it before  that
        published by  Mr. Charles White of Manchester, which was fol-
        lowed by another by Mr.  Trye of Gloucester.  As might be ex-
        pected from men of their abilities and  eminence, in each of their
        works there are many things deserving attention  ; but as the sub-
       ject yet requires farther investigation, with regard to its cause, its
        history, and method of  treatment, I shall  offer the result of such
        observations  and  opinions as have occurred to me on this dis-
        ease.
          The puerperal swelling of the inferior extremities does not seem
        to depend upon the kind of labour the patient may have had,  as it
        indiscriminately happens after those which were easy, and those
        which were difficult; or on any evident peculiarity of the consti-
        tution, the corpulent and the  thin,  the feeble and  the  strong,
        being equally  liable to it; or on rank in life, as the rich aud poor
        are alike subject to it; or on any mode of treatment in the state
        of childbed.   Nor does any appearance during pregnancy usual- 
598          INTRODUCTION TO MIDWIFERY.
ly denote a disposition to it,  the swelling of the inferior extremi-
ties at  that  time being  a  totally different complaint; yet the
whole  disease seems to  arise from  some  circumstance,  subse-
quent  to  the delivery of the patient.  It is  also  remarkable,
which is a  satisfactory reply to  those who have attributed  this
swelling to the deposition of the milk, that it has  happened to
those who had an abundance, and those  who  had  a scarcity of
milk;  to those who did,  or  those who did not give suck ;  and
sometimes, though rarely, in abortions,  when no  milk was se-
creted.
  Before the appearance of any swelling or any sense of pain
in the limb about to be  affected, women  become very irritable,
with a sense of great weakness, and grievously depressed in their
spirits,  without  any  apparently  sufficient reason,  complaining
only of transient pains in the  region of the  uterus, and  from
these the  approach of the disease has frequently been foretold.
After a short time they are  seized, often very suddenly, with an
extremely acute pain  in  the calf of the leg, extending to the in-
side of the heel,  and  then, observing the course of the lympha-
tics, stretching up to the ham, along the internal part of the thigh
to the  groin, occasioning a slight soreness over the lower part of
the abdomen.  Then also the inguinal glands  are affected, some-
times  the external, which are  perceptibly enlarged,  indurated,
and painful; and sometimes  the  internal, or both ; and probably
also, judging from the symptoms,  those which lie at the bifurca-
tion of the vessels at  the loins; except that 1  have not observed
the limb  to  be discoloured,  or the  lymphatics inflamed, and
marking their course by a  redness of the skin, (which we  pro-
vincially call the anguish vein,) the  first effects of this  disease
very much resemble those;  which would attend the absorption of
some poisonous matter  from the  lower part  of the limb.   The
whole surface of the swelled  limb  becomes insufferably tender to
the slightest touch or pressure, especially in  those parts where
the glands are seated ; yet without any other apparent change,
except that  the skin  is glossy and of a  deadly paleness; and  a
certain degree of paleness, not unlike that of a chlorotic or drop-
sical person, is spread over the countenance  and whole body,
every  vein  seeming to be scantily supplied with blood.  When
 the pain has continued about twenty-four hours, the limb begins
to  swell, and the pain  is usually abated in  proportion  to the
increase of the swelling; but from the moment of the attack, all
power of acting with the limb is  lost, every  attempt to move  it
 giving great torture, and  a disposition to  faint.   There are,
 however, many  varieties in the manner in  which the disease
 commenceth, as well as in its degree and progress; but the glands
 and lymphatics of the limb are evidently the parts first and prin-
 cipally affected.  In  some  cases the access of  the disease   is 
         MANAGEMENT OF WOMEN IN CHILDBED.      599

slower, and  the  symptoms less violent, hesitating,  as  it were,
whether it should be  formed or not.  In these the pain  is not
only less severe,  but diffused over the limb, instead of being fixed
on  particular parts,  and the  swelling scarce  sufficient to draw
attention.
   This disease happens at no precise time after delivery, as it has
come on at any  period, from the fifth or sixth day, to the third or
even  fourth  week, but  most  commonly, I  think,  between  the
fifth and twelfth day.  Whenever it does appear, the whole con-
stitution  is  speedily  and greatly  affected by it.   The pulse is
extremely quick and  generally feeble, the  heat  of the body is
much increased, the tongue is white and clammy, and the coun-
tenance  pale and dejected ; the urine, which is voided in small
quantities, is thick  and  of a muddy colour,  unlike  what  I have
observed in any other disease, the muddiness gradually lessen-
ing as the disease abates ; the patient  is costive, the faeces being
of a pale colour and clayey consistence ; and the uterine dischar-
ges, whatever their quantity  may be,  have an offensive smell,
and unnatural appearance.   It is  however  to be observed, that
this smell and appearance do not  always continue  through the
course of the disease, but on inquiry will be  found to have exist-
ed at, or some days before, its commencement.
   Either or both the legs maybe affected together or successively.
When the latter is the case,  the disease having remained for a
certain time in one leg, and the symptoms being abated, the other
has been suddenly and unexpectedly seized.   Then the symp-
toms have recurred with equal violence, and gone through a simi-
lar course.  But the patient,  having escaped the danger before
apprehended, though disconcerted, bears the second attack,  even
if it be more severe, better than she did the  first.   Should  the
second leg become affected, it is not by a translation of  the dis-
ease from one limb to the other, the leg first affected remaining
 in the same stale,  and observing the same progress as before the
affection of the second.   When only one leg  is affected,  there are,
 in some cases,  occasional exacerbations of the disease,  after ap-
 parently considerable  amendment ;  and these may render it ne-
 cessary  to change the order of treatment, or even to return to that
 which was proper at the commencement.
   After eight or ten days continuance, according to its lenity or
 violence, the more  urgent  symptoms of  this disease begin  to
 abate, but in many cases very slowly ;  the debility and oppression
 sometimes remaining for several weeks, as the constitution is natu-
 rally more  inert or vigorous.  Though all the  other symptoms
 be removed, the swelling may,  and generally does remain for
 many weeks, or even months,  and in some very bad cases,  the
 limb has never  been reduced to its primitive  size,  or recovered its
 wonted  powers of agility and  firmness, during the patient's life. 
600
INTRODUCTION TO MIDWIFERY.
  The constitution seems to be very much disturbed and enfeebled
at the beginning of the disease, and  unequal to the due perform-
ance of its common functions ; yet after a certain time it seems to
become local,  for the patients recover their health, and often men-
struate regularly ; but even  this change has seldom  afforded the
expected relief to  the affected limb.
  Though  this disease often creates  much and great alarm to the
patient  and her friends,  and always  occasions much pain and
suffering, yet on  the whole it may be said,  that it is not danger-
ous.  1 do  not mean,  nor should I be justified in saying, that it
was never attended with danger; having been informed of several
cases,  and  seen one,  which proved fatal, where no other cause of
the patient's death could be assigned  or suspected.  But on the
retrospect it appeared, that this might possibly have been avoided,
if more regard had been paid to the representations of the feelings
of  the patients ;  for they were  urged, at least encouraged,  to
exert themselves beyond their abilities and inclinations,  and sunk
immediately after, or while they were making some great effort.
   From this description of the disease, the inguinal and neigh-
bouring glands seem to be the parts  first affected, and the subse-
quent  swelling of the limb  to  be evidently occasioned  by the
blocking up of all passage for the  lymph through those glands. '
The pain  and extreme soreness of the limb, which are always
somewhat abated when the swelling comes on, appear to be inci-
dental, and to be produced by the distention of the lymphatic ves-
sels ; so that the  swelling seems to prove that those, which were
before over distended, are relieved, either by the bursting of some,
allowing the effusion of lymph into  the cellular membrane ; or a
series of vessels of small dimensions  are enlarged, by which those
lymphatics, which before suffered  from extreme distention, to-
gether with the parts on which they  made compression, are eased.
   But it remains to be proved how it comes to pass,  that these
glands are originally  affected ;  and this I should endeavour  to
v explain by presuming, that,  as the lymphatic vessels of the uterus
and vagina are very  much increased in size during pregnancy,
they are more capable of absorbing any fluid,   which may come
into contact with their orifices ; and if any fluid, not consonant in
its qualities with that which  they were by nature intended to con-
vey,  were  to be admitted and conducted to the gland,  to which
any particular lymphatic may  lead,  a morbid  affection of the
gland might be produced, which would occasion all the succeed-
ing mischief.  Whether the internal cr external inguinal glands,
or those at the head of the triceps, or any other, were chiefly af-
fected,  will depend on the course of the lymphatic which had taken
up the offending matter.
   It was before  observed,  that the uterine discharges  have an
offensive smell, and unusual appearance.  Now it has been prov- 
MANAGEMENT OF WOMEN  IN  CHILDBED.
601
 ed, that the most healthy fluids of the body,  perfectly innocent
 and unoffending to the part where they were secreted,  may act
 as means of great  and morbid irritation, if transferred to a part
 not originally destined  to receive them ; that is, they may act in
 some degree as poisons.  But in the present case, the secretion
 being of a morbid kind, as far as can be  judged by smell and
 appearance," the malignity of its effects may be aggravated.  I
 therefore feel satisfied, that the absorption of vitiated matter from
 the uterus is the cause of the swelling of  the  inguinal  glands.
 Farther,  if this absorbed matter had not been interrupted by the
 gland,  and thus prevented from  spreading  over the whole body,
 a disease infinitely more dangerous would have been caused;
 and this opinion  is  strengthened, not only  by the common con-
 sequences of acknowledged poisons when absorbed, but by ma-
 ny similar complaints frequently  met with  in practice : as in the
 swelling  of  the  inferior extremities  in men, when the  prostate
 gland is affected; in one or both legs, when the uterus is diseased,
 as has  sometimes happened after the extirpation of a polypus,
 which can then bear  only the most lenient applications  and me-
 dicines ; in the arm, when the axillary glands are enlarged; and
 in many other cases.   But the changes in the uterine discharges,
 which precede  this  disease, are not, it is apprehended,  like the
 changes produced by the retention  of coagula, or of small por-
 tions of the placenta or membranes becoming putrid, but they
 are consequent to  an unhealthy state  or  morbid action of the
 uterus.
   Having formed this opinion of the cause of this disease, and
 reasoning by analogy of its effects, in the  method of treatment,
 without aiming to cure the disease in the first instance, 1  take the
 symptoms for my guide, and endeavour to relieve these by all
 the  means in my power. ' As the  sense of extreme weakness,
 and excessive irritability, are the most prominent and distress-
 ing,  the patient is  to be well supported by cordial medicines,
 and by a liberal use of wine; not restraining her to any precise
 quantity, but leaving her at liberty  to judge what that shall be,
 by the degree of depression which she feels.   Opiates are also
 to be given, to abate and soothe the general irritability of the
habit, and together with these, such medicines  as promote the
secretion by the skin and kidneys.  For these purposes I usual-
ly give the following draught:

         r> Aq. ammon. acetat. 3ss.
           Syrup, papaver. alb.
           Spir. nuc. mos. a 3ii.
           Aq. ment. sat.
           — purae a gss M. f. haustus quarta vel sexta
              quaque hora sumendus.
                             76 
602
INTRODUCTION TO MIDWIFERY.
  Should this fail  to moderate the sufferings of the patient, a
few  drops  of tinct.  opii. may be occasionally  added  to the
draughts, especially to that taken at bed-time, and the quantity
of ammonia acetata may be increased, or pure ammonia may be
given in some cases of great depression.
  Perhaps the best application to the swelled limb is a liniment
composed of one drachm of camphor dissolved in an ounce of oil
of olives; or some of the expressed oil  of mace softened down
to a proper consistence with a sufficient quantity of oil of al-
monds ; and  to either of these  may  be added from five to ten
grains  of powdered  opium.  The most painful parts, or the
whole  limb,  may  be gently anointed with a small quantity of
these every night  and morning, and afterwards covered with a
loose flannel.  By such  means some  relief is usually obtained,
though not much permanent benefit; and  they are preferable,
I think, either to spirituous or to hot fomentations, which, with-
out producing more advantage, are apt to bring on profuse sweat-
ing, and great faintness.
  In this stage of the disease,  local bleedings with  leeches,  and
blisters applied to the enlarged glands, have been recommended,
as effectual means  of speedily curing the  disease  by removing the
glandular obstruction.  But if my opinion of the cause of the dis-
ease be just,  the hasty dispersion of the swelling of the glands, if
it could be effected, though it might lessen or wholly remove the
swelling of the limb,  would ultimately  prove a very great disad-
vantage, by allowing the absorbed virus  to escape;  and this per-
vading the whole body, a disease primarily local would become a
general one of the most dangerous kind.   In the case of poisonous
matter of any kind absorbed by a slight  wound or abrasion of the
skin of the hand or fingers, (an  accident to which  surgeons are
particularly liable in their dissections 'and operations,) the swell-
ing of the  nearest or some gland, which cuts off the communica-
 tion between the limb and the body,  leads  to the security of the
 patient.  But if active and effectual means be used to remove the
 swelling of the gland, the absorbed virus passes iuto the  consti-
 tution, and the patient will probably be  destroyed.   It was by an
 error  of this kind we lost Mr. Hewson, the  celebrated anatomist,
 when  he was rising into eminence, and many other deserving men,
 whom I recollect, and with whose cases  I was well acquainted.
   With regard to the state of the bowels,  though  we are to  be
 circumspect  in preventing the inconveniences of constipation, it
 is never advisable to purge in this slate of the disease.  Their
 regular course maybe obtained  by the occasional use of magne-
 sia vitriolata, or any other medicine of  the kind which will an-
 swer  the  purpose,  and is  least likely  to disturb the stomach.
 Clysters are not eligible, because the change of position, which
 they require, is often extremely difficult and painful. 
MANAGEMENT OF WOMEN IN CHILDBED.
603
  The great tumult raised on the first attack of the disease being
appeased, the quantity of wine and opiates may be lessened, or
they may be less frequently given; but in this we are to be guided
by the degree of debility and irritation that  remain.  As a pre-
ventive also, when the disease is threatened,  a generous  diet and
wine are to be allowed, if the appetite of the patient will permit
her to take nourishment.
  When the constitution is, according to the old mode of expres-
sion, fortified, and the health somewhat restored, the swelling of
the leg is to be considered rather as of a chronic, than of an acute
kind,  and all reasonable endeavours may be used to disperse it.
I have then given  the decoctum cinchonae or cascarillae, with a
saline draught, or the kali vitriolatum, or magnesia vitriolata, or
a strong infusion of burnt sponge, two or three times a day,; and
every night at bed time, half a grain, or a grain of calomel, with
or without an opiate.  In some  cases I have thought it  more eli-
gible to give from three to five grains of calomel twice a week,
with  a purging draught on the following morning,  and some of
the draughts before mentioned on the intermediate days.  In other
cases, the crystals of tartar have  been liberally given in  any con-
venient form; or the  cicuta with the decoction of sarsa, and va-
rious  other  things usually advised on  similar occasions  : and
whenever there was much remaining weakness, some preparation
of iron, as the ferrum vitriolatum or ammoniacale, in suitable doses,
 has been of much service.
  Then also, but not sooner, it is necessary and proper to sup-
 port the swelled limb by a slight flannel bandage drawn  gradually
 tighter, and to use different applications, such as the volatile lini-
 ment, or one composed of three parts of linimentum saponis, and
 one part of tinctur. cantharidum, and sometimes small  quantities
 of the unguentum hydrargyri.   The frequent application of small
 blisters to different parts of the limb has been also  then strongly
 advised, and in many cases with evident advantage.  Electricity
 has been tried, but of its real benefits I am not competent to judge.
 Certainly many patients have been much relieved by persevering
 in the use of warm sea-bathing ; and they are to be encouraged,
 but with some caution,  to use exercise, otherwise the  desuetude
 will endanger  their being crippled.   It may lastly be  observed,
 though some women have been afflicted with this swelling of one
 or  other of  the inferior extremities in several successive labours,
 in  general they who have had it in one labour,  are not more lia-
 ble to it  in subsequent ones,  and are sometimes relieved during
 their confinement from ^some of the consequences of a former
 attack.*
* [This disease, already known by many names, has recently been 
604          INTRODUCTION TO MIDWIFERY.
  Before I conclude, I must express my satisfaction at the favoura-
ble reception of the former editions of this work, and my thank-
fulness that my life has been sufficiently prolonged to allow  me
to revise the present,  which I have used  my utmost endeavours to
correct and improve.
denominated Cruritis,  from the symptoms of an inflammatory nature
which it exhibits,  the causes by which  it is  most frequently  pro-
duced, and the treatment by which it is most advantageously removed.
(Hosack,  System of Practical Nosology.)   The  phlegmasia  dolens
is of rare occurrence, and seldom of a formidable  character.  A
late case is recorded,  in which  extensive ulceration  succeeded the
tumefaction.  I have  seen  four cases of this disease :  they  seemed
to have no connection with  the severity or tediousness of the la-
bour, or  the condition of the lochial discharge.   In  one case, the
swelling took place on the 4th day after delivery ;  and, in two others,
en the 8th or 10th day.  The fourth case occurred in a male subject,
after  an attack of typhus fever.   In  this case  the disease was as
strongly marked as in  any puerperal woman.  This fact of itself goes
to prove that phlegmasia dolens  may arise independent of the lochial
discharge, or the absorption of the vitiated matter of the uterus.  In
two of these cases the patients were exposed to cold and other exciting
causes of inflammation*  In one  case blood-letting was employed to
the amount of 14 ounces.  In all, the usual means, such as the saline
catharthics, small doses of calomel and James' powder, and tepid
fomentations of vinegar and water, were  had recourse to in the  first
stage ; in the second stage, the  patient's strength was cherished by
the moderate use of nutritious diet, and the application of the vola
tile liniment and flannel roller.  F.] 
APPENDIX.
   I cannot dismiss these Notes,  without observing,  that the stu-
 dent, who shall have attentively perused our author's  pages, will
 have such firm confidence in the ample resources of nature, that he
 will  be  little disposed to have recourse  to instruments,  plainly and
 explicitly as Dr.  Denman has pointed out their application.  It is
 indeed painful to consider how many lives must have been sacrificed
 before  the obstetrical powers of nature were understood ; and for
 this salutary improvement in  practice, mankind are in a  great mea-
 sure indebted  to  Dr. Denman.  Immense has been the change ef-
 fected in this respect in Great Britain within the last fifty years ; and
 in our own country,  where  the science  of  obstetrics  universally
 forms a  part of a medical education,  the enlightened practitioner
justly considers instrumental delivery as a final resort.   But it  is to
be regretted that instances occasionally occur within our  notice,
 where obstinacy and ignorance, usurping the place of knowledge,
 have recourse to artificial aid, when neither  the contracted dimen-
 sions nor the deformity  of the pelvis, the presentation of the child,
 nor any  other untoward circumstance,  warrants their interference.
 The following case came under my care in 1815 : fortunately for the
medical character of our country,  such instances are comparatively
 very rare.
  IVJrs. H-----, of New-York, was married when within two months
of fourteen years  of age, and had never menstruated : a short period
 after, her menses came  on for the first time, she became pregnant in
about two months, and when she had been married eleven, was de-
 livered  of her first child, after a tedious labour, by the natural pains.
 The child was a female, born alive, and weighed about seven pounds.
 About a year after she again became pregnant, and  went her full
time : she was delivered by the crotchet,  and the child  necessarily
 destroyed.  Fourteen months after this she miscarried ; and twelve
months after was delivered by the forceps of a living child.   Twelve
months  after, again by  the forceps, of a dead child; and after the
expiration of another year, was again delivered by the forceps ; the
child alive.  Again, after twelve months, she was delivered by the
forceps  of a dead child.   Somewhat more than a year after this, she
was again delivered by the forceps of a living child.  She complained
that some injury was done her in the delivery ; yet,  notwithstand-
ing,  within little more than two years, she bore a healthy child by
the natural pains ; and on the 28th  of June, 1815, she was again
delivered of a  healthy well-formed child, of the ordinary size, by
the natural  pains.  As  to this last occasion,  to which \  was called,
{he membranes had broken, and the waters were discharged above n 
606
APPENDIX.
month before the access of the labour ; during which interval  she
snffere'd so much pain as repeatedly to suppose herself in labour ; but
by patience and careful management,  and by inspiring her with con-
fidence in the resources of her constitution, she went on to her full
period,  and  at  last was safely delivered, after a labour,  in all re-
spects natural, save its duration, which was not above thirty-six  hours
in continuance.
  This woman, ther in her first and last two labours, bore healthy
well formed children, of  the common size,  by the  natural pains ; a
manifest proof of a well formed pelvis, and  affording the  strongest
presumption, that the same management might have  conducted her
with equal success  through the labours  of the intermediate period,
during which, from causes not necessary to be assigned, instruments
were unnecessarily made use of in six successive  births,  and three
human beings destroyed.

   Tabular Views present facts and inferences so distinctly  to the
mind, that I am induced to insert the following.
                          TABLE  I.

Statement of Presentations  at  the Maison  d'Accouchemens, furnished
                   by the late M. Baudelocque.
  '* There have been admitted  into the Lying-in Hospital  at  Paris
(Maison d'Accouchemens,) between the  9th of Dec. 1799, and the
31st of May 1809, 17,308 women, who  gave birth to  17,499 chil-
dren :  189 of them have been delivered of twins, and two only of
three children.   The proportion of twin cases to single births is 1 to
91.
  ** Two thousand of these women were affected afterwards with ill-
ness, or some serious accident; 700 died  out of the 2000.
  " Of the 17,499 births, 16,286 were presentations of the vertex to
the os  uteri.
 No.
215 were presentations of the feet
296 the breach     ....
 59 the face   -
 52 one of the shoulders
  4 the side of the thorax   -
  4 the hip    -
  4 the left side of the head
  4 the knees      ....
  4 the head, an arm, and the cord
  3 the belly      ....
  3 the back      ....
  3 the loins      ....
   1 the occipital region
   1 the side, with the right hand
   1 the right hand and left foot
Proportions.
 to   8 If
 -   59*
 —  296i
 —  3361
 — 43742
 — 4374£
 — 4374?
 — 4374|
 -- 4374f
 — 5833
 — 5833
 — 5833
 —17499
 -—17499
 —17499 
APPENDIX.
607
       I  the head and the feet     -    -   -   1 —17499
       2  the head, the hand, and forearm     -   1 —  8749|
     37  the head and umbilical cord     -   -   1 —   473

  " Of this great number of women 230 were delivered by art;  the
rest were natural births : being in proportion of 1  to 76i. 161 were
delivered by the hand alone, the children being brought by the feet;
49 were delivered by the forceps, either on account of iMIl small di-
mensions of the pelvis, the falling down of the umbilical cord, or the
wrong position of the head, when the woman was exhausted, or her
life was in danger by convulsions, &c. ; 13 were  extracted  by the
crotchet after perforation of the head, on account of mal-conforma-
tion of the pelvis : in these instances, the death of the child was first
ascertained.
  " The Cesarean operation was performed in two cases, the dia-
meter of the  pelvis being only one inch six lines from sacrum to
pubes.
  " In one, the section of the symphysis pubis was performed, the
diameter of the  pelvis from sacrum to pubis being only two  inches
and a quarter.
  " Gastrotomy was performed once, the foetus being extra-uterine:
the child weighed 81bs. 2 oz."
                         TABLE II.

Exhibiting the Result of Practice at the Hospice  de  la  Materniie, at
  Paris, among 20,357  Patients, from 1797 to 1811 ; taken from
  Madame Boivins " Memorial de VArt des Accoucliemens," Ed. 2d.
  (1817.)
  N. B. The preceding table, exhibiting the cases of 17,308 women
is included in this.

  20,357 women produced  20,517 children—20,200  being single.
           154 twin, and 3 triplet births.
  20,183 children were born without artificial assistance.
     218-------------delivered by turning.
      96-------------by the forceps.
      16-------------by the perforator.
       2-------------by the division of the  symphysis pubis.
       2-------------by gastrotomy.

  No mention is made of the number of deaths among  the  children
born without artificial assistance : but amongthe 334 where artificial
aid was required, 91 were dead born ; of which 68 appear to have
lost their Jives during  the labour, and 23 were dead  before the la-
bour began.  Of the deaths of the mothers we learn  nothing from
Madame Boivin.—See Merriman's Synopsis. 
608                      APPENDIX.
                          TABLE III.

Calculations of the  Number of Accidents or Deaths  which happen in-
  consequence  of Parturition ;  taken from the Midwifery Reports of the
  Westminster General Dispensary.   By Robert Bland, M. D. (1781.)

  Of 1897 women delivered under the care of the Dispensary,
63       4pr 1 in 30) had unnatural labours :  in
     18  of these  (or  1  in 105) the children  presented by their
            feet;  jn
     36  (or  1 in  52) the breech presented ;  in
      8  the arms presented ; and in  )   ,g* or j m 210.)
      1  the funis.                    $   ^               "'

     63

17       women (or 1  in 111) had laborious  labours ; in
      8|  of these (or 1 in 236) the heads of the children were les-
            sened ; in
      4  a single blade of a forceps was used  ;  and  in the remaining
      5  in which the faces of the children were turned to the pu-
            bes,  the delivery  was  at length  accomplished by the
            pains.

     17

   1        woman had convulsions about the seventh month of her
              pregnancy, and was delivered a month after of a dead
              child and recovered.
   1        woman had convulsions during labour,  brought forth a
              live child, and recovered.

  82
   9|       women (or 1 in 210) had uterine hemorrhage before and
              during labour.
      Of these 1 died undelivered ;
               1 died in a few hours, and
               1 ten days after delivery ; and
               6 recovered.
91
  * In all these nine cases the children were turned.
  t Two of these women have since been delivered of full-sized healthy children.
A third bore a very small and weakly child, who died in two or three days.  A
fourth was delivered of a seven months' child, without mutilating it, which died in
its passage.  The number of women, therefore, who from error in their conforma-
tion were incapable of bearing live children, appears to be very inconsiderable
Of the remaining four I have not been able to get any intelligence.
  t In these nine cases, only one child was saved. 
APPENDIX.
609
91
  5        women had the puerperal fever, of whom four died.
             In one of these the placenta  was undelivered,  and
             continued so to her death.
  2        women were seized with mania, but recovered in about
             three months.   In
  1        woman a suppuration took place, soon after her labour,
             from  the vagina into the bladder  and  rectum.   This
             patient recovered, but the  urine and stools continue to
             pass through the wounds.  Of
  1        woman the perinaeum was  lacerated to  the  sphincter
             ani.   A suture was  attempted, but without effect; she
             recovered but is troubled with prolapsus uteri.
  5        had large and painful  swellings  of the legs and  thighs,
             but recovered.

 105       therefore of these  (or 1 in 18) had preternatural or la-
             borious births, or suffered in consequence of  labour.
             Of this number of cases, 43 (or 1 in 44) were attended
             with particular difficulty or danger ; and 7 only (or 1 in
             270) died.   The remaining 62  were delivered, and
             recovered with  little more than the common assist-
             ance ; and
1792       had natural labours, not  attended  with any  particular
             accidents.

1897
                          TABLE IV.

Statement of the Presentations of the Child in  2947 Cases of Parturi-
  tion, in private Practice;  with  the  Accidents,  Deaths, Sec. which
  happened in the whole Number.—See Merriman's Synopsis.

  2947 labours produced 2988 children—1518 boys, 1470 girls.

  In 2810 cases, the head presented, viz.
2735  times in the most natural and convenient posture.
  44  or  1 in 67 with the forehead turned toward the pubes.
  10  or  1 in 294 with the face foremost.
  13  or  1 in £27 with the hand by the side of the head.
   8  or  1 in 368 with the funis.

   In 19 instances, or 1 in  155, the superior extremities presented,
viz.
              14 times, one hand or arm.
               2 ---- both hands.
               3 -..— . one hand, and one or both feet.
                              77 
610                      APPENDIX.
   In 78 instances, or 1 in 38, the nates or one hip presented, viz.
         72 times not complicated with any other part.
          5 ----together with one foot.
          1------------------the navel string.

   In 40 instances, (or 1  in  76) the lower extremities presented,
             37 times one or both feet.
               1---- the knee.
               2---- the feet and funis.

   In 128 cases, or  1 in 22,  of  natural  presentations, the labour
lasted more than 24 hours.
     21  or 1 in  140 there was accidental hemorrhage.
      7  or 1 in 421 there was unavoidable hemorrhage.
      4  or 1 in 210 there was hemorrhage after delivery.
      5  or 1 in 588 there were convulsions.
     39  women, or 1 in 76, were delivered of twins.
      1  woman had triplets.
      1----------the hymen unruptured.
      1----------extreme  constriction of the vagina, in conse-
                    quence  of inflammation subsequent to a former
                    labour.
      1  ----------excessive  induration of the os uteri, which in a
few months terminated in carcinoma, and proved fatal.

   In 9 cases, or 1 in 328, the perforator was employed.
     *7 times on account of distortion of the pelvis.
      2----in very lingering labour, when the want of pulsation
in the presenting funis had fully proved the death of the children.

   In 21 cases, or 1 in 140, the forceps or vectis were  found neces-
sary, viz.
         twice in consequence of convulsions.
         twice from wrong position of the head.
         twice from repeated syncope.
         15 times from want  of expulsive power in  the uterus.
           In 16 cases it was the patient's first child.

   Of the children brought into the world by the forceps,
           15 were born alive.
            6---------- dead.
   viz.  in 1 case of wrong position of the head, the child was putrid.
          2 cases the mothers were convulsed.
          3---- no other cause could be  assigned than the length
or difficulty of the labour.
  * In four cases, where, on account of deformity of the pelvis, it had been found
necessary to  ute the perforator, premature labour was  afterwards induced) by
which means two children were preserved. 
APPENDIX.
611
Of all the children born, 149, including the above 6, were dead.
Of these 83 were premature births, and most were dead betore tne
                occurrence of the labour.
         66 appeared to die from the severity of the labour.
      viz. 9 in nates case.
          6 — feet ditto.
          2 — arm ditto.
          4 — funis ditto.
          9 — accidental hemorrhage ditto.
          5 — unavoidable ditto      ditto.
          5 — convulsion ditto.
           1 — rupture of the uterus.
           1 when the mother died undelivered.
         24 from the  long duration of the labour—this includes the
 6 forceps and 9 perforator cases.

     14 of the mothers, or  1 in 210, died during the month of childbed,
 VIZ*
      3 of peritonitis, or puerperal fever.

      1 bnroCkeD7largeSblood-vessel, and suddenly died undelivered.
      1 of runture of the uterus—(this was a narrow pelvis.;
      1 suddeCy  on the fifth day  after delivery, without any known
cause.
1 who had vaginal stricture.
1 of hemorrhage in a placenta presentation.
1 of peripneumonia notha, which brought on premature labour.
4 of phthisis pulmonalis.
\ 
612
APPENDIX.
                           TABLE V.

Table of the average number of Deaths in Childbed in Philadelphia,
  taken from the Bills of Mortality.—See Dr. James' Edition ofMer-
  riman.

  The population of the city of Philadelphia and its suburbs, within
the bills of Mortality,  may be estimated at  100,000.   The  average
number of deaths in childbed solely, and also in  childbed and puer-
peral fever jointly, taken from the said bills for nine years, is as fol-
lows :
Childbed solely.
For 1 year ending Jan. 2,  1808— 1 in
  Childbed and
Puerperal Fever.
1809—1  in
1810—1  in
1811 — 1  in
1812—1  in
1813—1  in
1814—1  in
1815—1  in
1816—1  in
 170
 567
2004
2036
 447
 600
 408
 296
 291
n 107
n378
a 400*
n 15bt
n 265
n257
n 272
n 254J
n 204
   The average number of deaths in childbed, exclusive  of puerpe-
ral fever, for 9 years, is  1 in 418.
   The  average number  of deaths in childbed, and. puerperal fever
jointly,  for 9 years, is  1 in 219.
  * In this year, but 1 woman is stated to have died in parturition, and 4 of puer-
peral fever—the total number of deaths being 2004.
  t In this year, but 1 woman is stated to have died in childbed, and 12 of puer-
peral fever—the total number of deaths being 2036.
  t In this year, but 1 woman is stated to have died of puerperal fever, and 6 in
childbed. 
APPENDIX.
613
                          TABLE VI.

Number of Deaths in  Childbed, and  by  Puerperal  Fever, in  the
  City of New-York, from 1814 to 1820, inclusive—extracted from
  the Reports of the City Inspector.
                                      d »> _  i  Total No. of
                                      By JTjie_*?eral  deaths of Males
                                                   and Females.
                                                          1974
                                                          2507
                                                          2739
                                                          2527
                                                          3265
                                                          3176
                                                          3515
  Dr. David R. Arnell, Physician at Goshen, State of New-York,
has favoured me with the following results of twelve hundred cases,
in his private practice, in a communication dated, February, 1821.
Years.	Deaths in		Childbed. D	y ruerp Fever
In 1814	.	12	.	1
1815	-	17	.	3
1816	-	22	-	6
1817	-	17	.	1
1818	.	8	.	3
1819	-	15	-	4
1820		20 TA	-	7
			BLE VII.	
In 1200 cases of Labour, there were,	
Difficult and tedious .	40
Feet presentation . Breech cases .	4 2
Face presentations . Instrumental, (the forceps) Presentations requiring turning Still-born.....	4 5 12 23
Diminishing the head Adhesion of the placenta Mothers died after delivery	4 2 8
Mother died in labour	1
Twins .....	16
Triplets..... Born with teeth ....	1 1
 
614
APPENDIX.
    I shall conclude with giving place to the ensuing interesting letter
  from William Moore, M. D. of the City of New-York,  a gentleman
  long distinguished   for  his  extensive  experience  in  obstetrical
  practice.
                                     New-York, June 26, 1821.
  Dear Sir,
    In compliance with your request, and my promise made som^ days
  ago, I have examined my register of Midwifery cases, from uhir.h I
  find that 2866 labours have produced 14bl sons, 1435 daughters, 1
  hermaphrodite, and 2 masses of hydatids.
    There are 33 cases in which twins were born.
  2,516 Natural Labours, in which both mother and child did well.
    106      do.        in which trie child was dead or died.
      8      do.        in which the mother died.
      2      do.        in which both died.
     65 Preternatural cases, in  which both did well.
     41      do.        in which the child died.
      5      do.        in which both died.
     29 Flooding cases, in which both did well.
     26      do.        in which the child died.
      5      do.        in which the mother died.
      9      do.        in which both died.
      8 Convulsion cases, in which both did well.
                       in which the child died.
                       in which both died.
                      in which both did well.
                       in which the child died.
                       in which the mother died.
                       in which both died.
                      11 mothers recovered,  3 died.
                      in which the woman died undelivered.
   Upon inspecting  this list, we perceive  that in 2632 Natural La-
 bours,  10 mothers died, which is about equal to one in every 263
 cases ;  and that 108 children died,  which is about one in every 24
 cases ;  hence it is evident that, at all times, the child is in much
 greater danger  than the mother.
   In 111 Preternatural cases, 5 mothers and 46 children died, which
 is about  one mother in every 22  cases, and  nearly one-half the
 children.
   In 69 Flooding cases, 14 mothers and 35 children died, which is
 about one-fifth of the mothers, and one-half of the children.
   In 20 Convulsion cases, 3 mothers and 12 children died, which is
 about one in 7 of the  mothers, and three-fifths of the children.
   In 19 Forceps cases, 5 mothers and 11 children  died, or about
 one-fourth of the mothers, and above one-half the children.
   In the Crotchet cases about one in  5 of the women died.
   From taking a general view of the whole number of cases, we find
that in 2866 labours,  41 mothers and 227 children have died, which
is about equal to one  mother in every 70 cases, and one child in
every 12i ; but, in estimating the proportion of deaths to recoveries,
it is  proper to observe here, that the above list contains a greater
9	do.
3	do.
7	Forceps cases,
7	do.
1	do.
4	do.
14 Crotchet cases,	
1 Laborious case,	
 
APPENDIX.                     615
proportion of unfortunate cases than will be found to occur in ordi-
nary practice.   For, as I have made it a rule to register every case
to which I have been called, I have not only recorded my own share
of bad cases,  but many of those,  also,  which have occurred in  the
practice of my friends, with whom 1 have been  called in consulta-
tion.  The only way to obtain  a true result,   in  this particular,
would be, to register every case of labour that should occur in some
city, or district of country,  and then to compare the whole.
  As to the poor woman who died  undelivered, I have ever regret-
ted, that I did not recommend the Caesarian operation as soon as she
died ; for I am persuaded, that, had it been promptly performed, the
child might have been saved ; for, after reflecting upon her symp-
toms, and all  the circumstances of her case, I was fully convinced
that there must have been a sudden rupture of the  uterus, and that
the child had escaped into the cavity of the abdomen.
  I have but little to say upon the use  of ergot,  in addition to what
was published in Doctor Bard's book, having seen  it  administered
only in one case since, in which the mother was very soon relieved ;
but the child,  as is too often the case, was born dead.
  From having observed, in our bills of mortality,  such an increase
in the  number of still-born children, I am induced to believe  that
some of our  practitioners  of Midwifery are too fond of the use of
ergot,  and that they give it prematurely.  It is my opinion, that it
ought to  be administered in such cases only, as  those in which  we
would recommend the forceps, if that should not succeed.
              I  am, very sincerely, yours, &c.
                                               Wm. MOORE.
Dr. John W. Francis. 
 
              APHORISMS

                    ON

          THE APPLICATION AND USE

                    OF

    THE FORCEPS AND VECTIS;

ON PRETERNATURAL LABOURS ; ON LABOURS ATTENDED WITH
       HEMORRHAGE, AND WITH CONVULSIONS.

      BY THOMAS DENMAN, M. D. &c. he. 
t 
&**aufieiiuttt of Hafcowfl*
      FOUR CLASSES.

  I. Natural.
 II. Difficult.
III. Preternatural.
IV. Anomalous, or complex.
                         CLASS I.

                   NATURAL LABOURS.

  Character.  Every labour  in which the process is completed
within twenty-four hours, the head of the child presenting, and no
adventitious assistance being required.

                        varieties.
  1. The face inclined toward the sacrum.
  2. The face inclined toward the ossa pubis.
  3. The head presenting with one or both arms.
  4. The face presenting.
  That part of a child which descends lowest into the pelvis is to be
esteemed the presenting part.

              Circumstances attending Labours.
  1. Anxiety.
  2. Rigours.
  3. Stranguary.
  4. Diarrhoea.
  5. Mucous  discharge, with or without a mixture of blood.
  6. Pain.

                       Causes of Pain.
  1. Expulsatory action of the uterus.
  2. Resistance made to the  effect of that action.

                    Distinctions of Pain.
  1. True.
  2. False.
  Causes and  signs of false pain.
  Means >jf removing them.
  Means by which true pains are supposed to be regulated, and their
effect promoted. 
620
DENMAN's  APHORISMS.
   Note.  The pains attending labour are subsequent to the action of
 the uterus, though in common language the word pain, and the action
 of the uterus, are used synonimously.

                 Progress of Natural Labours.
   Three periods or stages.
     1st period.
        Dilatation of the os uteri.
        Rupture of the membranes.
        Discharge of the waters.
     2d period.
        Descent of the  child.
        Dilatation of the external parts.
        Expulsion of the child.
     3d period.
        Separation of the placenta.
        Expulsion or extraction of the placenta.
   Note.  It very often  happens that the membranes do not break till
the head of the child is on the point of being expelled.  This is the
natural and most desirable progress of a labour, and it is a negative
proof that the labour has been well conducted ; that is, not interrupted.
But the description given above will answer the purpose of impres-
sing a clear, general idea of labours.
   The two circumstances which principally require attention in natu-
ral labours are, to guard  the perinaeum  and  to extract the placenta
with discretion.
                           CLASS II.
                    DIFFICULT LABOURS.
   Character.   Every labour in which the process is prolonged be-
yond twenty-four hours, the head of the child presenting.
   Note. Some objections may be made to this definition taken from
time, but it will be found to apply to  practical uses better than if it
was taken from circumstances.
   It would often be extremely difficult to say with precision when a
labour actually begins, because of the number of concurrent changes;
but in general some progress must be made before we can allow a
labour to be commenced.

                        four orders.
                           ORDER I.
Labours rendered difficult from the inert or irregular action of the
                            Uterus.
                            CAUSES.
   1. Too great distention of the uterus.
  2. Partial action of the uterus. 
denman's  aphorisms.
621
  3.  Rigidity of the membranes.
  4.  Imperfect discharge or dribbling of the waters.
  5.  Shortness of the funis umbilicalis.
  6.  Weakness of the constitution.
  7.  Fever.                   .
  8.  Want of a due degree of irritability.
  9.  Passions of the mind.
 10.  General deformity.
                           ORDER  II.
Labours rendered difficult by the Rigidity of the Parts to be dilated.

  1.  First child.
  2. Advancement in age.
  3. Too early rupture of the membranes.
  4. Oblique position of the os uteri.
  5. Fever or local inflammation.
  6. Extreme rigidity of the os uteri.
  7. Uncommon rigidity of the external parts.

                           ORDER III.
Labours rendered difficult from Dispropordonbetween theDimen-
   sions of the Cavity of the Pelvis and the Head of the Child.

   1. Original smallness of the pelvis.
   2  Distortion of the pelvis.                        ..  ,
   3  Head of the child unusually large, or too much ossified.
   4* Head of the child  enlarged by  disease.
   5. Face inclined toward the ossa pubis.
   6. Presentation of the face.
   7. Head presenting with one or both arms.

                           ORDER  IV.
     Labours rendered difficult by  Diseases of the soft Parts.

   1. Suppression  of urine.
   2. Stone in the bladder.
   3. Excrescences of theos uteri.
   4. Cicatrices in the vagina.
   5. Adhesion of the vagina.
   6. Steatomatose tumours.
   7. Enlargement of the ovaria.
   8. Rupture of the uterus.
   WnTP   The disturbance of the natural progress of labours more
 especially th^premature rupture of the membranes, ,s the most gene-
 ral cause of difficulties  in parturition.
   Women are to be relieved  in difficult labours,
   1  Bv time and patience.
   2 By encouragement to hope for a happy event.
   3." By regulating their general conduct. 
622              denman's aphorisms.
  4.  By lessening or removing the obstacles to the effects which
       should be produced by the pains.
  5.  By the assistance of instruments.

              Intentions in the Use of Instruments.
  1.  To preserve the lives both of the mother and child.
  2.  To preserve the life  of the mother.
  3.  To preserve the life  of the child.

       Instruments contrived to answer the first Intention.
       1. Fillets.          2. Forceps.         3. Vectis.
  Three things are  to be considered with respect to the Forceps or
Vectis. and to the use of instruments in general.
  1.  To make an accurate distinction of those cases which require
        their use.
  2.  Of those cases which allow their use.
  3.  Of the manner in which they ought to be used.
  We are in the first place to speak of the application and use of the
forceps.

Directions for, and Admonitions  in, the Application and Use of the
                           Forceps.
                           SECTION I.
   1. It has long been established  as  a general rule, that instruments
are never to be used in the practice of midwifery; the cases in which
they are used are therefore to  be considered merely as exceptions
to this rule.
   2. But such cases can very seldom occur in the practice of any one
person ; and when they do  happen, neither the forceps nor any other
instrument is ever to be used in a clandestine mannert
   3.  The first stage of a  labour must be completed, that is, the os
uteri must be dilated, and  the membranes broken, before we think of
applying the forceps.
   4.  The intention in the  use of the forceps is, to preserve the lives
both of the mother  and  child, but the necessity  for using them must
be decided by the circumstances of the mother only.
   5.  It is meant, when the forceps are  used,  to supply with them
the insufficiency or want of labour pains ; but so long  as the pains
continue, we have reason  to hope they will produce their effect, and
shall be justified in waiting.
   6. Nor doth the  cessation of the pains always prove the necessity
of using the forceps, as there may be a total or a temporary cessation
 of the pains.
   7. In  the former, the pulse,  the  countenance, and  the general
 appearances of the patient indicate extreme debility, and resemble
 those of a person worn out with  disease or fatigue.
   8. But in the latter there are no alarming symptoms, and the patient
 often  enjoys short intervals of refreshing sleep.
   9. A  rule for the time  of applying  the forceps has been formed
 from the following circumstance,  that, after the cessation of the pains, 
denman's  aphorisms.              623
the head of the child should have rested for six hours in such a situ-
ation as to allow the use of the forceps before they are  used.
   10. But this and every other rule intended to prevent the rash and
unnecessary use of  the forceps, must be subject to the judgment of
the person who may have the management of any individual case.
   11. Care is also to be taken that we do not, through an aversion
to the use of instruments, too long delay that assistance we have the
power of affording with them.
   12.  The difficulties which attend the application and the use of the
forceps are far less than those of deciding upon the proper time when,
and the cases in which, they ought to be applied.
   13. The lower the head of the child has descended, and the longer
the use of the  forceps is deferred, the easier will in  general their
application be, the  success of the  operation more certain, and the
hazard of doing mischief less.
   14.  The forceps  should  always  be applied  over the  ears of the
child ; it must therefore be improper to apply them when we cannot
feel an ear.
   15.  But when an ear can be felt by a common examination, the
case is alway9 manageable with the forceps, if the circumstances of
the mother require their use.
   16.  The ear of the child which can be felt will be  found toward
the 03sa pubis, or under one of the rami of the  ischia.
   17.  The ears are not turned to  the sides of the pelvis till part of
the hind head has emerged under the  arch of  the ossa pubis, when
the use of the forceps can very seldom be required.
   18.  When you have determined  on using the forceps, and explain-
ed the  necessity of using them to the patient and her friends, she
is to be  placed in the usual position on her left side, near to the edge
of the bed ; and the instruments warmed in water, and smeared with
some unctuous application, are to be laid conveniently  by you.
   Note.  Women, impelled by their fears and their sufferings in
difficult labours, will very frequently implore you to  deliver them
with instruments, long before you  will be convinced of the necessity
of using them.   In  many cases 1  have found it expedient and encou-
raging to them to fix upon some distant time  when they should  be
delivered, if the child were  not before born ; six, or eight, or twelve
hours, for instance. In some cases  of great apprehension I have also
shown them, upon one of my knees, all that 1 intended  to do with the
force p9.
   The following rules are given on the presumption  that the  head
of the child presents with the face inclined,  or verging toward the
hollow of the sacrum, and that the common short forceps are intend-
ed to be used ; but if any other kind of forceps should  be preferred,
the rules must be adapted to the instrument.

                           section ii.
   1. Carry the fore finger of the right hand to the ear of the child.
   2. Then take the blade of the forceps to be first introduced by the
handle in the left hand, and conduct it between the head of the child
and the finger already introduced,  till the point reaches the ear. 
624
denman's  aphorisms.
    3. The farther introduction  must be made with a motion resem-
  bling a slight degree of semi-rotation, and the point of the blade must
  be kept close to the head of the child, by gently raising the handle
  as the instrument is advanced.
    4. The blade  of  the forceps  must be  carried  up,  till the lock
  reaches the external parts near the inferior edge of the ossa pubis.
    5. Should any difficulty occur in the introduction of  either of the
  blades, we must withdraw them a little to discover the  obstacle, and
  never strive to overcome it with violence.
    6. When the first blade is introduced, it must be held steadily in
  its situation, as it will be a guide in the introduction and application
  of the second blade.
    7. The second  blade of the forceps must be conducted upon the
  fore finger of the left hand, passed between the head of  the child and
  the perinapum, in the same cautious manner as the  first, till the lock
  reaches the perinaeum, or even presses it a little backward.
    8. When the  second  blade is  properly introduced,  its situation
  should be opposite to the first.
   9. In order to lock the forceps, the handles of which  are at a con-
  siderable distance from each other,  the blade first  introduced must
  be brought down, and carried so far back that it will lock with the
  second blade held in its first position.
   10. Care should be taken that nothing be entangled in the lock of
  the forceps, by carrying the finger round it.
   11. It is convenient to tie  the handles of the forceps  together,
 when locked, with force sufficient to keep them from sliding or shift-
 ing their position.
   12. If the blades of the forceps were introduced so  as not to be
 opposite to each other, they could not be locked.
   13. Should the handles of the forceps when applied  come  close
 together, probably the bulk of the head is not included  between
 them, and, therefore, when we acted with them, they would slip.
   14. If the handles, when locked, are at a great distance from each
 other, they are not well  applied, and will probably slip.
   15. But in these estimations allowance is to be made for the dif-
 ferent dimensions of the  heads of children.
   16. The forceps will never slip if judiciously  applied, if the case
 be proper for their use, and we act circumspectly with them.
   Note.  The difficulties  in  the  application  of the forceps  arise
 from attempting to apply them too soon ; from passing them in a hur-
 ry, or in a wrong direction ; or from entangling the soft  parts of the
 mother between the instrument and the head of the child. Of course
 we are always to be guarded against these circumstances.

                          section hi.
   1.  There is  no occasion, and it would be hurtful to  attempt to
 change the position of the head,  when the forceps are applied,  be-
fore we began to extract.
  2. For if the action with the forceps be slow, the head of the
child will turn in the same manner, and for the same reasons, as in
a natural labour. 
denman's aphorisms.
625
  3. Therefore, the forceps being fixed upon the head must also
change their position  according to its descent,  and the handles be
gradually turned from the ossa pubis and sacrum, where they were
first placed, to the sides of the pelvis.
  4. The handles of the  forceps likewise, though originally  placed
far  back toward the sacrum, that is, in the direction of the cavity ot
the pelvis, will be  gradually turned,  as  the  child advances, more
and more toward the  pubes, that is, in the direction of the vagina.
  5. The first action  with the forceps must be to bring the handles,
firmly grasped in one or  both hands, slowly toward the pubes, till
they come to a full rest.                                       ..
  6. After waiting till the pains return, or an imaginary interval it
there should be a  total want of pain, the handles are to be earned
back  in the same slow aud cautious manner,  till the  lock reaches
the perineum, using, at the same time, a certain degree of extract-
ing force.
  7.  The subsequent actions must be from handle to handle, or oc-
casionally by simple traction.
  8.  By a repetition  of these  actions, always directed according to
the position of the handles, with their force  increased, diminished,
or continued, according  to the exigence of the case,  we shall in a
short time perceive the head of the .child descending.
   9.  When the head begins to descend, the force of the action with
the forceps must be abated, and as that advances, the direction ot the
handles must change by degrees more  and more to each side,  and
toward the pubes.                                            ,
   10. The lower the head of the child descends, the more gently
we must proceed, in order to prevent any injury or laceration of the
perinaeum or external parts, which are likewise to be supported in
the same manner as in a natural labour.
    11.  In some cases, the mere excitement occasioned by the appli-
 cation of the forceps, or the very expectation of their being applied
 will bring on a return or an increase of the pains sufficient to expel
 the child without their assistance.                         •j««,m.
    12.  In other cases we are obliged to  exert very considerable
 force,  and to continue it for a long time ;  so  that one operation may
 be safely and easily finished in twenty minutes,  or ^en a less tim
 and another may require more than an hour for its completion, and
 the repeated exertions of very considerable  force.
    13   In some cases it happens also, that the obstacle to the dehve-
 ry exists at one particular part of the pelvis, and when that is sur-
 mounted, the remainder of the operation is easy ; but in o her cases
 there is some difficulty through the whole course of the pelvis.
    14  Before the exertion of much force,  we are always to be con-
 vinced that a small or moderate degree offeree is not equal to our

 PUl5°Sfn every case in  which the  forceps have been applied, they
 are not to be moved before the head is extracted, even though we
 might  have little or no occasion for them.
    16.  When the head of the child is born, the forceps are to be  re-
79 
626
denman's aphorisms.
moved, and the remaining circumstances are to be managed as if the
labocr had been natural.
  Note.  The  general  arguments against the  use of instruments
have been drawn from their abuse :  It appears, however, that ne-
cessity will, in some instances, justify the  use of the forceps ;  that
when such necessity exists, their  use is not only justifiable, but of-
ten highly advantageous ;  that delay to apply them,  and slowness in
their application and use, will  secure,  as  far  as is possible, both
the mother and child from untoward accidents ; but  that  mischief
cannot be prevented if they are applied too soon, or the operation
with them be performed in a hurry.
  It would be a very desirable thing that every student should have
an opportunity of seeing the operation with the forceps performed
before he goes into practice ;  but that is not always possible.   Yet
if he has been  properly instructed  in the principles of the applica-
tion and use of the forceps, reflects seriously before he determines
on performing the operation, and proceeds slowly but not timidly in
it, he can hardly fail to succeed.  Hurry in any operation, is a very
common  sign both of want of information and of fear; and attention
is  to be  paid  to the  order of the  rule in Celsus  1. tuto,  2. cite,
3. jucunde.

                          section  iv.
              On the application and use of the Vectis.
   1. We shall have a just idea of the vectis by considering it as one
blade of the forceps, a little lengthened and enlarged, with the han-
dle placed in a direct line with the blade, that is, without any lateral
curvature.
  2. The general condition and circumstances of labours before sta-
ted, as  requiring and allowing the use of the forceps,  will hold equal-
ly good when the vectis  is intended to be used.
  3. In the  application of the vectis, two fingers, or the fore-finger
Of the right hand, is to be passed to the ear of the child.
  4. Then taking the vectis by the handle, or with  the blade short-
ened, in the left hand, conduct it slowly till the point of the vectis
reaches the  ear, however that may be situated.
  5. The instrument is then to be advanced, as was  advised with the
forceps, till, according to your judgment, the extremity of the blade
reaches as far, or a little beyond, the chin of the child.
  6. Then grasping the handle of the instrument firmly in the right
hand, wait for the accession of a pain.
   7.  During the continuance of the pain,  raise the  handle of the
instrument gently but firmly toward the pubes, drawing at the same
time with some degree of extracting force.
   8. When the pain ceases let the instrument rest, and on its return
repeat the same kind of action, alternately resting and acting in imi-
tation of the manner of the pains.
   9. By a repetition of this kind  and manner of action, the head of
the child  is usually  advanced,  and the face  turning gradually toward
the hollow of  the  sacrum, the position  of the handle of the vectis 
denman's  aphorisms.
621
will  be altered, and the direction of the  action with it of course
should be changed.
   10.  When the head is perceived  to descend, we must proceed
more slowly and carefully, according to the degree of descent, in
order to  prevent any injury to the external parts, which is to be pre-
vented, as was directed when the forceps are used.
   11.  But if by the continuance of the moderate force before recom-
mended,  the head should not descend, it must be gradually and cau-
tiously increased till it becomes sufficient to bring down the head.
   12.  In the action with the vectis, the back part of the instrument
must rest upon the symphysis of the  ossa pubis, or upon the ramus
of the  ischium, according to  its position, as upon a fulcrum,  for its
support.
   13.  By passing the flat part of the hand to the back of the blade of
the instrument when in action, we shall be occasionably able to lessen
or take off  this pressure,  whieh must otherwise be made upon the
parts of  the mother.
   )4*  Some have recommended  the vectis  to be used when the head
of the child was higher up in the pelvis than is before stated, as jus-
tifying the use either of this instrument or the forceps.
   15.  They have also recommended  the vectis when the head of
the child was  firmly  locked in the pelvis,  and have asserted that by
its use there is often obtained a very good chance of preserving the
life of a child, which must otherwise be inevitably lost.
   16.  Others  have by  frequent use acquired such dexterity, as to be
able to extract the head of a child, in the  situation first stated, with
a single sweep of the instrument.
   17.  Some have also advised the introduction of the vectis between
the  sacrum, or sacrosciatic ligaments, and the head of  the  child,
from a belief that it could be equally or more advantageously used in
this position than in  that first stated.
   18.  But having ever considered the use of all  instruments as a
thing  to  be  lamented, and when  I did use them, esteemed  the safety
of using them as my principal object,  I cannot deviate from these
principles, or enter upon a discussion of points of practice, of which,
as far  as I am  competent to judge, I cannot approve.
   Note.  Before, and immediately  after the publication of my se-
cond  Essay on Difficult Labours, several gentlemen, with whom 1
converse, and to whom 1 ought to pay great respect, reprehended
in very decided terms what I have advanced with regard to the for-
ceps and vectis.   Some maintained that the forceps is an instrument
far superior to the vectis, of which  I was accused of speaking too
favourably.   Others,  of equal respectability, accused me of speak-
ing with timidity or restraint, of those advantages which they assert-
ed the vectis had over the forceps.   This very  strong evidence
could  only be invalidated  by its contradiction, but the very respect
which 1  bear  to the  witnesses compelled  me to pass over their evi-
dence, and  to rely upon my own experience and judgment.
   I did not speak of the  mechanism of the instruments,  or of the
operation performed when we had applied, and acted with them, as
 these  have  hitherto  been  very imperfectly and often erroneously ex- 
628
denman's  aphorisms.
plained.   The  subject came under consideration in the ordinary
course of the work, and having frequently used both the instruments,
I stated the matter  equitably, according to .the best of my abilities,
and in such a way  that, I  thought,  students, who were  principally
concerned  in the discission, beinq; left 'rith 'i.e choice of either in-
strument,  according to the doctrine*  of the  particular professors
whom they might attend, could not be mie'-id.   U is not to be expect-
ed thiit  men versed in  the practice  snouid change their  opinions or
alter their  practice, or, in short, pay mucl, regard to disputes about
instruments, if any were disposed to raise them.
  It then was, and yet  remains my opinion, founded, as I before ob-
served, on  my experience with both instruments, that the  superior
excellence  which has been attributed to each of these instruments,
ought chiefly to be ascribed to the dexterity which may be acquired
by the habit of usinc either of them.   It is also my opinion that we
may, in general, either with the forceps or vectis, effectually and
conveniently  give that  assistance which is required in cases of diffi-
cult parturition, allowing and justifying  their use.   In particular ca-
ses it may perhaps be proved that one instrument is more commodi-
ous than another.
  But if the  vectis be depreciated  by those who have never used
it, and are  not expert in its use,  because they prefer the  forceps ;
or if the known  properties of the forceps be  not allowed  by those
who do not use them, because they prefer the vectis, the proper in-
ference would not be,  that  either of the  instruments ought to be
condemned ;  but that we are in  possession of two instruments well
adapted to answer  the  same purpose, if they are prudently used  ;
or, that neither of them ought to  be used.
                          CLASS III.

                PRETERNATURAL LABOURS.
  Character.—Labours in which any  part of the child presents,
except the head.
                       TWO  ORDERS.
                           ORDER I.

         Presentations of the Breech, or inferior extremities.
                           ORDER II.

       Presentations of the Shoulder, or superior extremities.
                           SECTION I.

   1. The presentation of children at the time of birth  may  be of
three kinds.   1. With the head.  2  With the breech, or inferior ex-
tremities.   3.  With the shoulder, or superior extremities.
   2. Presentations of the  first kind are called natural, those of the
second and third kind, preternatural. 
»enman's aphorisms.
629
  3. Preternatural presentations have been subdivided into a much
greater variety, but without any practical advantage.
  4. The presumptive  signs of the preternatural presentation of
children are very uncertain, nor can it ever be determined what the
presentation is, till we are able to feel the presenting part.
  5. When any part of a child can  be felt, we  may  form our judg-
ment of the presenting part by the following marks.
  6. The head may be  distinguished by its  roundness, its firmness,
and its bulk.
  7. The breech may be known by its bulk, by the cleft between
the buttocks, by the parts  of generation, and  by the discharge of
meconium.
  8. The foot may be  distinguished by its length, by the heel,  by
the shortness of the toes, and the want of a thumb ; and the hand by
its flatness, by the thumb, and the length of the fingers.
                          SECTION !I.
         On the first Order of Preternatural Presentations.
  1. In this kind of presentation, the breech, one  hip,  the knees,
and one or both legs are to be included.
  2  In these presentations it was formerly supposed necessary, as
soon as they were  discovered, to introduce the hand to bring down
the feet, and  to f xtract the  child with expedition.
  3. But, according to  the  present practice, such labours are not to
be interrupted, but allowed to proceed  as if the presentation were
natural ; unless the necessity of giving assistance should  arise from
some circumstance independent of the presentation.
  4. By acting on  this principle, when the breech  of the child is ex-
pelled by the pains,  the parts are  sufficiently distended to allow the
body and head to follow without any danger from delay.
  5. But if the feet of the child were to !>p brought down in the be-
ginning of  labour, the difficulty with wnich it would be expelled or
could  be extracted,  increasing as it advanced, the ,hild would pro-
bably die before the woman was delivered, and she would be in dan-
ger of suffering mischief.
  6. In cases of this kind there is also equal reason, when the breech
is on the point of being excluded,  for our guarding  the perinaeum
from the hazard of laceration, as in presentations of the head.
  7. In  first labours, the  child, unless  it  be small,  will  not unfre-
quently be born dead, when the breech, or inferior extremities pre-
sent ;  but in  subsequent labours they will usually be born living,  if
there be no  other impediment than that  which is  occasioned  by
the presentation.
  8. The  injuries which the presenting part of the child, especially
the penis and scrotum, may sustain, will often  be alarming,  and ap-
pear dangerous, but by  soothing and gentle treatment they are soon
recovered.
  9. Should  there be reason to think the child  dead, or the powers
of the mother insufficient to expel it, we must then give such assist-
ance as may be required.
  10.  This assistance must be given with  the hand, or with a blunt 
630                denman's aphorisms.
hook or crotchet, hitched in the groin of the child ; or, which I pre-
fer, by passing a ligature round the bent part of the child at the groin,
with which we can hardly fail to extract it.
   11.  But every assistance of this kind must be given with discretion,
and we must first be  convinced of the  necessity  before  we inter*
fere.
   12.  Should a child  presenting with the breech advance, though
slowly, it is  better to be satisfied with  this slow progress ; or, we
might break, without much force, the neck  of the thigh bone, or se-
 Sarate the bones of the pelvis of the child, by either of which acci-
 ents future lameness  would be occasioned.

                           SECTION III.
       Of the second order of Preternatural Presentations.
   1. In this kind of presentation are included  the shoulders, the
elbows, and one or both arms.
   2 In all these presentations  we  shall be under the  necessity of
turning the  child,  but as they may be attended with circumstances
widely different, it is  necessary  to make the following distinctions.
   3.—I. When the os uteri is fully dilated, the membranes unbroken,
or the waters lately discharged, a superior extremity being perceived
to present before the  uterus is contracted.
   4.—II. When the membranes break in the  beginning of labour,
the os uteri being little dilated.
   5.—III. When the os  uteri has been fully dilated, the membranes
broken, and the waters long discharged, the uterus being at the same
time strongly contracted, and the body of the child jammed at the
superior aperture of the  pelvis.
   6.—IV. When together with any of these circumstances; there is
a  great disproportion  between the size of the head  of the child, and
the dimensions of the cavity of the pelvis.

                           SECTION IV.
       On the Cases which come under the first Distinction.
   1. Whenever there is a necessity of turning a child,  the patient
is to be placed upon her left side,  near the edge  of the  bed ;  or
sometimes, when we  expect  to find much difficulty, in a prone posi-
tion, resting upon her elbows and knees.
   2.  All the advantage to be gained from any particular position of
the patient is, to allow us the free and dexterous use of our hands;
the situation of the child not being altered by the position of  the
patient.
   3.  The os externum is then to be dilated with the fingers reduced
into a conical form, acting with a semi-rotatory motion of the hand.
   4.  The artificial dilatation  of all parts must be made slowly, in imi-
tation  of the manner of natural dilatation.
   5.  The os externum should be amply  distended before the hand
is carried farther, or its  contraction round  the wrist will be an im-
pediment in the subsequent part of the operation.
   6.  When the hand is passed through the os externum, it must  be 
denman's aphorisms.              631
•lowly conducted to the os uteri? which being wholly or sufficiently
dilated, we must break  the membranes by perforating them with a
finger, or by grasping them firmly in the hand.
  7. The hand must then be passed along the sides, thighs, and legs
of the child,  till we come to the feet.
  8. If both  the feet lie together we must grasp them firmly in our
hand ; but if they are distant from each other, and we cannot conve-
niently lay hold of both feet, we may deliver by one foot without much
additional difficulty.
  9. Before we begin to extract we must be  assured that we do not
mistake a hand for a foot.
  10. The  feet must be brought down, with a slow  waving motion,
into the pelvis;  when we are to rest and wait till the uterus begins
to contract, still retaining them in our hand.
  11. When the action of the uterus comes on, the  feet  are to be
brought lower at each return of pain, till they are extracted through
the external orifice, and the labour may then be finished, partly by
the efforts of the mother, and partly by  art.
  12. If the toes are turned toward the pubes, the back of the child
is toward the back of the mother, which is  an unfavourable position.
  13. But if the toes are toward the sacrum, the back of the child
is toward the abdomen of the mother, which is proper, and all other
positions of the child must be gradually turned to this as the body is
extracting.
  14. Yet this position of the  child is only advantageous  when the
head comes  to be extracted.
  15. When the feet of the child have  passed through the os exter-
num, wrap them in a cloth, and holding  them firm, wait till there is a
contraction of the uterus, or a pain, during the continuance of which
gently draw  down the feet.
  16. When the pain ceases we must rest, and proceed in this man-
ner through the delivery,  assisting the efforts of the  patient, but not
making the delivery wholly artificial.
  17. When the breech comes to the  os externum,  the child must
be extracted very slowly through it, and in the proper direction, or
there will be danger of lacerating the perinaeum.
  18. When the child  is brought so low that the  funis reaches the
os externum, a small portion of it is to be drawn out, to slacken it to
lessen the chance of compression, or to prevent the  separation of it
from the body of the child, or of the placenta from the uterus; and
from this time the operation should be  finished as  speedily as it can
with safety.
  19. But if the circulation in the funis be undisturbed there is ne
occasion for haste, as the child, we are then  assured, is in safety.
  20. The  child may  be extracted without much difficulty if we act
alternately from side to side, by making a lever of its body, and some-
times by pressing it from the ossa pubis with the fingers.
  21. If thexhild should stick at the shoulders, the arms must b«
successively brought down.
  22. This  is to be done  by raising the body the opposite way, and 
632
denman's'aphorisms.
 by successively bending  them at  the  elbow very slowly, lest they
 should be broken, and the hand must be cleared  toward the pubes.
   23.  When both the arms are brought down,  the body  of the child
 must be supported upon our left hand placed under the  breast  the
 fingers on each side of the neck,  and the body supported upon  our
 left arm.                                               r
   24.  Then placing the right hand over the shoulders, and pressing
 with our fingers the head toward the sacrum, we must ease  the
 head along,  gradually turning the body of the  child as it advances
 the abdomen of the mother.
   25.  If the  head should not come easily away, we must introduce
 the fore-hnger of the left hand into the  mouth of the child, by which
 the position of the head will be rendered more convenient.
   26. When the head begins to enter the os externum we must pro-
 ceed very slowly, and support the perinaeum by  spreading the  fin-
 gers of the left hand over it.
   27. In some cases there may be a necessity of speedily extracting
 the  child in  order to  preserve its life,  but we must also recollect,
 that the child is often lost by endeavouring to extract it  too hastily.
   28. When a child has  been  extracted by the feet,  the placenta
 usually separates very soon and very easily ; but in the management
 et this we are to be guided by the general rules.

                           SECTION V.
        On the Cases which come under the second Distinction.
   1   We are first to ascertain the presenting part, and if, together
 with the arm, the head is perceived by a common examination, there
 may be no occasion to turn the child, such case only constituting the
 third variety of natural labour.
   2. But if  the case should be  such as to require the child  to  be
 turned, it might be  doubted whether it were proper to dilate the  os
 uteri by art,  or to wait for its spontaneous dilatation.
  3. Perhaps neither of the methods can be constantly followed, but
 we may generally say, that there is, under these circumstances, nei-
 ther danger nor increase of difficulty, from waiting for the spontaneous
 dilatation,  which is  therefore in general to be preferred.
  4. But if more speedy dilatation should be required, whatever is
 done by art should be done slowly, and in imitation of nature.
  5.  the os uteri is always to  be considered as completely dilated
  cwtJ  gG VVil1  aI1°W 0f the easy introduction of the hand.
  b. When we have  fixed upon the proper time,  and  begin the
 operation,  the os externum must be dilated in the manner before
 advised.
  7. The hand must always be  introduced  into the uterus, on that
 side oi the  pelvis where it will pass most conveniently ; and there is
 usually most room at that part which lead to the feet.
  8. II.is generally most  convenient to  pass the hand between the
body of the child and the ossa pubis, the feet being most  commonly
found lying toward the belly of the mother.                      3
  9. In cases which come  under this distinction the uterus is seldom 
denman's aphorisms.
633
contracted very strongly upon  the body of the child, but always in
some degree.
  10. But the difficulties which may occur in the operation of turning
the child, in these cases, will be fully explained under the following
distinction.

                          SECTION VI.
        On the Cases which come under the third Distinction.
  1. The difficulty in the  management of these cases depends upon
the degree  of contraction of the uterus, and  upon the distance or
awkward position of the feet of the child,  but  chiefly upon  the for-
mer circumstance.
  2. The uterus  is in some cases contracted  in a  globular, and i«
others in a longitudinal form.
  3. It is always  easier, with an equal degree of contraction, to turn
the child when the uterus  is contracted in a globular than in  a longi-
tudinal form.
  4. When we are called to a case of this kind, it is better not to
form or to give a  hasty opinion, nor to attempt to deliver the patient
immediately,  but  to deliberate  upon it, and then to make a second
examination.
  5. If the second examination should confirm  our first  opinion, we
may prepare for the operation.
  6. We shall be able to  judge in what part of the uterus  the feet
of the child lie, if we consider whether it be the right or left hand
which presents, which may be known by the direction of the thumb
and the palm of the hand.
  7. But the contraction of the uterus is the  principal difficulty to
be surmounted, and the danger in turning the  child is in proportion
to the difficulty.
  8. The danger of turning a child  when there is a strong contrac-
tion of the uterus, is  a single danger, that of  rupturing the uterus.
  9. The contraction of the  uterus is of two kinds ; first, the per-
manent contraction, in consequence of the waters having been long
drained off, which may occur when there has been little or no pain.
  10. Second, the extraordinary contraction arising from the action
of the uterus,  returning at intervals,  and always attended with pain.
  11. The hand must be introduced with a degree of force sufficient
gradually to overcome the permanent contraction of the uterus,  or
the operation could never be performed.
  12. But if we were to attempt to overcome the extraordinary con-
traction,  it must follow that we can or cannot overcome it.
  13. In the first instance we should be in danger of rupturing the
uterus, and  in the second, the hand would be cramped,  and we
should be unable  to proceed with the operation.
  14. The deduction is therefore clear, that  we ought not to pro-
ceed  in our attempts  to turn the child, while the  uterus is acting
with violence.
  15. The  action of the uterus is rendered more frequent and strong
by the generally increased irritability of the patient.
                               80 
634
denman's aphorisms.
   16. Before we attempt to deliver, it will be prudent to endeavour
to lessen this irritability, in many cases by bleeding, by clysters, and
by an opiate, which, to answer this purpose, should be given in two
er three times the usual quantity.
   17. When the opiate takes effect, and the patient becomes disposed
to sleep, we must consider this state as  extremely favourable, and
proceed without loss of time to the delivery.
   18. There never  can be occasion to separate the arm which pre-
sents from the body  of the  child ;  and  when this has been done,  in-
stead of facilitating, it has impeded the operation.
   19. Without regarding the arm, the right or left hand,  as may be
most convenient to ourselves, must be introduced in the manner be-
fore directed,  and conducted slowly into the uterus, if there be suf-
ficient room.
   20. But if the  child be jammed at the superior aperture of the
pelvis,  the hand cannot be  introduced.
   21. We must then fix our fore-finger  and thumb in the form of a
crutch in the armpit  of the  child,  and  pushing the shoulders toward
the head, and toward the fundus of the uterus,  we must by degrees
raise the body of the child till there  be room for the introduction
of the hand.
   22. If while we are introducing our hand, we perceive the action
of the uterus come on, we must  not proceed  till that ceases or is
abated.
   £3.  the  hand, when introduced,  is also to be laid flat during the
con.muance of the action of the uterus, lest the uterus be injured by
its own  action on  the knuckles.
   24 When the action ceases or is abated, we must renew our at-
tempts to carry up our hand to the feet of the child.
   25. In this manner we are to proceed,  alternately resting and ex-
erting ourselves, till  we can lay hold of one or both feet.
   26. There is sometimes much difficulty in getting to the feet, and
sometimes  in extracting  them,  especially when the uterus is con-
tracted in a longitudinal form.
   27. In such cases it is often convenient, when we can reach the
knees, to bend them  cautiously, and to bringdown the legs and feet
together.
   28. But before we begin to extract  we should examine the  parts
we hold, and be  assured they are the feet;  and we  must  extract
slowly and steadily.
   29. If we hurry to  bring down the feet they may slip from us, and
return to the place from which they were brought.
   30. We must then carry  up the hand again, and grasping the foot
or feet more firmly, bring them  down in the cautious manner before
advised.
   31. When the feet ire brought down,  if there be any difficulty in
extracting them,  we  must endeavour to  slide a  noose, first formed
upon our wrist, over the hand  to secure the feet,  by which the ha-
zard of  their return  will be prevented, and the succeeding  part of
the operation much facilitated.
  32. When the noose is fixed over the ancles, we must pull by 
denman's aphorisms.
636
both ends of it with one hand,  and grasp the feet with the other, but
we must not  attempt to proceed hastily.
   33.  When  there is  afterwards much  difficulty in extracting the
child,  it is probably owing to the body of the child being jammed
across the superior aperture of the pelvis.
   34.  It will then be proper to pass the finger and thumb as directed
at 21,  to raise the shoulders and body of the child toward the fundus
of the  uterus with one hand,  and with the other extract at the same
time with the noose.
   35.  When the breech of the child has entered the pelvis, we must
proceed with deliberation ; but there will be little further difficulty,
except from the smallness of the pelvis, of which  we shall speak in
the next section.

                          SECTION  VII,
       On those Cases which come under the fourth Distinction.
   1. The disproportion between the head of the child and the di-
mensions  of the pelvis, may be added to any of the circumstances
mentioned under the preceding distinctions'.
   2. But as  the management of these has been already directed,
there is now  occasion to speak only of the peculiar difficulties aris-
ing from that cause.
   3. The degree of difficulty  in  these cases  is greater or less ac-
cording to the degree of disproportion ; but the difficulty  of extract-
ing any part  of the body of the child is little, compared with that
which attends the extracting of the head.
   4. We will, therefore, suppose the body of the child to be brought
down, but that the  head cannot be extracted by any of the  methods
before recommended.
   5. The force with which  we  endeavour  to extract  must then
be increased, till it is sufficient to overcome the difficulty or resist-
ance.
   6. But as the necessity of using great force can only be known by
the failure of a less  degree to produce the desired  effect,  we must
begin  our attempts with moderation, and gradually increase our ef-
forts according to the exigence of the case.
   7. The force exerted should also be uniform, controlled or com-
manded,  and  exerted by intervals,  in the manner  of the natural
pains.
   8. If the head should not descend with the force which we judge
can be safely exerted, we must re9t,  and give it time to collapse.
   9. We may then renew our attempts, extracting from side to side,
•r backwards and forwards, as may best  conduce to ease the head
through the distorted pelvis, alternately resting and endeavouring to
extract
   10.  But if the head should descend in ever so small a degree, the
force is not to be increased with the view of finishing the  delivery
expeditiously, but  we  must be satisfied with our success,  and pro-
ceed circumspectly.
   11.  When the head once begins to descend, there is seldom much 
636               denman's aphorisms.
subsequent difficulty in finishing the  delivery, as the cause  of the
difficulty usually exists atone particular part of the pelvis.
  12. But should the  head rest in  this situation for several hours*
no additional inconvenience would thence arise to  the mother, and
the  longer  it  rested  the  greater advantage we should probably
gain when we renewed our attempts to extract it.
  13. It may be  presumed, when the head of  the child has been
wedged  for a long time in the  position we are supposing, and great
force has been used to extract it, that there is  little reason to expect
the child should be born alive ; yet instances of this are said to have
occurred in practice.
  14. When wecan hook a finger on the lower jaw of the child, the
direction of the head  may be changed to one  more favourable, and
the delivery thereby facilitated.
  15. But we  must not extract with so much  force as to incur the
hazard of breaking or tearing away the jaw.
  16. Pressing the head  of the child from the ossa pubis to the sa-
crum, with the fingers or thumbs carried up as high as h e can reach,
will often be of great use in these cases.
  17. If the difficulty of extracting  the head arises  from its enor-
mous size,  occasioned  by some disease, as the  hydrocephalus, &c,
these methods steadily pursued will  answer our intention ; as by a
prudent use of the force in our power, the integuments will burst,
or even the bones be broken.
  18. Cases of this kind, in which it might be necessary or expedi-
ent to use one or both blades of the forceps, or to lessen  the head,
very seldom occur.
  19. But if such cases should occur, the latter operation is prefera-
ble to the use of the forceps, and the utmost case must be taken that
we  do no injury to the mother.
  20. Under these circumstances, should it be absolutely necessary
to lessen the head of the  child, the perforation may be conveniently
made behind  either of the ears, or  in any part where we can most
conveniently fix the point of the perforator, and the general rules of
the operation must be followed.
  21. By the  force used should the neck  of the child have given
way, we are not to separate the body from the head altogether, but
we must rest longer and act more moderately.
  22. But should the body be separated from  the head by the force
we have used, or should we be called to a case of this  kind, there
will be no occasion, for this  reason alone, to act hastily or rashly, as
the head may  even then be expelled by the pains.
  23. But if this should  be impossible, or if  it be absolutely neces-
sary to  extract the head speedily, on account  of the state of the mo-
ther;   t
   24. Then the general  rules for lessening the head must be accom-
modated to  the exigencies of this particular case, and the head may
be  confined to a proper situation, by compressing the abdomen with
a napkin passed across it, or by the hands of  an assistant. 
denman's  aphorisms.
637
                         SECTION VIII.
                   Miscellaneous Observations.
  1. It sometimes happens that no part of the child can be perceiv-
ed before the membranes  break, though the os uteri be  fully di-
lated.
  2. In such cases we  should not be absent when the membranes
break, lest it should prove a preternatural presentation, requiring the
child to be turned.
  3. In some cases,  even when  the os  uteri is dilated, the mem-
branes broken, and the waters discharged, no part of the child can
be felt.
  4. It will then be  prudent, in the cautious manner before direct-
ed, to introduce the hand far enough into the uterus, to discover the
part which does present.
  5. If the head be  found to present we should withdraw our hand,
and suffer the labour  to proceed in a natural way.
  6. If the inferior extremities should present,  we may bring down
the feet, and then suffer the labour to go on uninterruptedly.
  7. But if the shoulder  or superior extremities should present,
we must proceed to the feet, and turn  the  child as  was  before di-
rected.
  8. By this conduct we shall guard against the danger of turning a
child in a contracted uterus.
  9. If we should be called to  a case in which the arm presented,
and much force had been used to extract the child in that position,
the arm perhaps having been mistaken for a leg, and the pains being
at the same time violent, it may  be impossible, without giving much
pain,  and incurring  some danger  of rupturing the uterus, to turn
the child, or even to  introduce the hand into the  uterus, the shoulder
of the child being pushed low down in the pelvis.
   10. Under such circumstances, it is improper to attempt to intro-
duce the hand into the uterus, or to turn the child, as it will general-
ly be expelled  by the efforts of the mother; or it may be extracted
by methods less painful and hazardous to the mother.
   11. Yet in these cases the body of the child does not come doub-
led, but the breech is the  first part delivered, and the head the last,
the body turning, as it were, upon its own axis.
   12. Nor is this  observation made with regard to a small child
coming prematurely, as it will apply to  a child of common size, and
when a  woman is at her full  time, provided  the pelvis  be  well
formed.
   13. This fact,  of the possibility of a  child being expelled in this
position,  though  originally contradicted with  great  confidence,  is
now confirmed in the most satisfactory manner by many cases which
have  been recorded, in some of which the children have been  born
living.
   14. From  these it might be  inferred, that a  woman in a state  of
nature,  or in  perfect health, would not  die undelivered, though the
arm of the child might present, supposing that she was not assisted
by art. 
638               denman's aphorisms.
  15. Yet it is always requisite and proper to turn children when
the superior extremities present, if the operation can be performed
without the hazard of injuring the mother,  and we have  a  better
chance of lessening the sufferings of the mother, and of preserving
the child.
  16. But when there is no chance of preserving the child, and yet
it cannot  be turned without the greatest danger to the mother, know-
ing the possibility of its being expelled  in  this position,  it  is ne-
cessary to consider the propriety of the operation before we per-
form it.
  17. It  remains, however, to be proved by future experience, how
far, and in what cases, the preceding observations ought to be a guide
in practice.
  18. In cases of presentation of the superior extremities,  in which
the difficulty of turning the child would be very dangerous, and great
or insurmountable, another method has been recommended.
   19.  But of this  method, which has been practised by one gentle-
man to whose knowledge and experience I pay great respect, I am
not a competent judge, having never tried it.
  20. I,  therefore, refer to the annexed note for an explanation and
history of the method to which I allude.
  Note.   Hoorneus, saepe laudatus, adhuc peculiarem, novum eum-
que breviorem modum, foetum mortuum cum  brachio arctissime in
vagina uteri  haeerente extrahendi, invenit atque descripsit, qui  in
eo consistit,  ut  qunndo ad pedes pervenire nequit, colhim utpote
quod in fcetibus valde adhuc tenerum  est, vel  scalpello a reliquo
trunco resecet, vel unco idoneo quam cautissime auferat.  Hoc enim
facto, vel sponte mox prorumpit ex utero fcetus,  vel tamen,  dum
brachium propendens attrahitur, quod medico loco habenae  inservit,
quam facilime excutitur.  Caput vero deinde seorsim mox vel manu,
vel aliis propositis artificiis, si manus parum esset, ejiciendum.
                                  Heister, cap. cliii. sect. ix.
  The latter part of this description is further explained in  the next
section.

                          SECTION  IX.
  I am induced to reprint the following, as they were the very ca-
ses  which first gave me an opportunity of observing the spontaneous
evolution.

                            CASE I.
  In the  year 1772,  I was called to a poor woman  in Oxford Street,
who had been in labour all the preceding night, under the care of a
midwife.   Mr.  Kingston, now living in Charlotte  Street,  and Mr.
Goodwin, surgeon, at Wirksworth in Derbyshire, who were at that
time students in midwifery,  had been sent for some hours  before I
was called.  The  arm of the child  presenting, they  attempted to
turn and extract it by the feet, but the pains  were so  strong  .is to
prevent the introduction of the hand into the uterus.  I found the
arm much swelled, and pushed through  the external parts in such a 
denman's aphorisms.
639
manner that the shoulder nearly reached the perinaeum.   The wo-
man struggled vehemently with her pains, and, during th^ir continu-
ance, 1 perceived the shoulder of the child to descend.  Coucluding
the  child was small, and would pass doubled  through the pelvis, I
desired one of the  gentlemen to  sit down and  receive  it, but the
friends of the woman would  net permit me to move.  I remained
by the bed-side till the child was expelled, and I  was very much sur-
prised to find, that the breech and inferior extremities were expel-
led before the head, as if the case had been originally a presenta-
tion of the  inferior extremities.
  The child was dead, but the mother  recovered as soon and as well
as she could have done after the most  natural labour.

                            CASE II.
  In the  year 1773, I was called to a woman in Castle Street, Ox-
ford Market, who was attended  by a midwife.  Many hours after it
was discovered that the arm of the child presented, Mr. Burosse, sur-
geon, in Poland Street,  was sent for, and 1 was calle.i into consultation.
Wtien 1 examined, I found the shoulder ofthechii-J pressed into the
superior aperture of the pelvis. The pain* were strong, and returned
at short intervals.   Having agreed upon the neceb^it) of turning the
child,  and  extracting  it by the feet,  I sat down and made repeated
attempts to  raise  the shoulder, with all the  force which  I thought
could be safely used ; but the action of the uterus was so powerful
that I was obliged to desist.  I then called to mind the  circumstan-
ces of the case  before  related, mentioaed them to Mr. Burosse, and
proposed  that we should wait for  the effect, which a contiu umce of
the pains  might produce, or  till they  were abated,  when the child
might be turned with less difficulty.  No further attempts were  made
to turn the child.  Then every pain propelled it lower into the pel-
vis, and in a little more than one hour the child was born, the breech
being expelled, as in the first case.
  Thi* child was also dead, but the mother recovered in the most fa-
vourable manner.                                  ?,-■,.
  Having been prepared for  observing the progress of this labour,
I understood it more clearly, and attempted  to explain, both in my
lecture on the subject,  and in the aphorisms which were printed for
the use of the  students, my opinion  of the manner in which the
body of the child turned, as it were,  upon its  own axis.    1 also
pointed out the circumstances in which, 1 supposed, the knowledge
of the fact might be rendered useful in practice ; but with great cir-
cumspection.

                            CASE  III.
  January the 2d, 1774, I was called  to Mrs. Davis, who keeps a
toy-shop  in Crown Court, Windmill Street.  She had been a long
time in labour, and the arm of the child presented.
  The late Mr. Eustace had been called on  the  preceding evening,
and had made attempts  to turn the child, which he had continued for
several hours without success.  I was sent for about one  o clock in 
640
denman's aphorisms.
the morning, and on examination found the arm pushed through the
external parts,  the shoulder pressing firmly  upon the perinaeum.
The exertions of the mother were wonderfully strong.  I sat down
while she had  two  pains ; by  the latter of which the child was
doubled,  and the  breech expelled.  I extracted the shoulders and
head, and left the child in  the bed.  Mr. Eustace expressed great
astonishment at the sudden  change ;  but  I assured him that I could
claim no  other merit on account of this delivery,  except that I had
not impeded an effect which was wholly produced  by the pains.
  This child was also dead, but the mother  recovered in the most
favourable  manner.
  In  all these cases, the women  were at the full  period  of utero-
gestation, and the children were of the usual size.
  Many other cases of the  same kind have  occurred  to me;  and
with the histories of several, varying in the time or manner in which
the evolution of the child was  made, I have  lately been favoured
by gentlemen of eminence in the profession, and many others have
been  published in different countries. But these are  sufficient to
prove the fact, that in cases in which  children present with the arm,
women would  not necessarily  die undelivered, though  they were
not assisted by art.
  With respect to the benefit we can, in practice, derive from the
knowledge  of this fact, I may be permitted to repeat,  that the cus-
tom of turning and delivering  by the feet in presentations of the
arm, will remain necessary and proper,  in all  cases in  which the
operation can be performed with safety to the  mother, or give a
chance of preserving the life of the child.   But when the child is
dead, and when we have no other view  but merely to extract the
child, to remove  the  danger thence arising to the mother,  it is of
great importance  to know the child may be  turned spontaneously,
by the action  of the uterus.   If we  avail ourselves of that know-
ledge, the pain and danger which sometimes attend the operation of
turning a child may be avoided.   Nor would any person, fixing upon
a case of preternatural presentation,  in which he  might expect the
child to be turned spontaneously, be involved in  difficulty, if, from a
defect of the pains, or any other cause,  he should be disappointed
in his  expectations.   Nor would the suffering or chance of danger
to the patient  be increased by  such  proceeding,  as the  usual  me
thods of extracting the child could,  under any such circumstances
be safely and successfully practised. 
denman's aphorisms.
641
                       CLASS IV.
          ANOMALOUS OR COMPLEX LABOURS.
                      FOUR ORDERS.
                         ORDER I.
            Labours attended with Hemorrhage.
                         ORDER II.
             Labours attended with Convulsions.
                         ORDER III.
             Labours with two or more  Children.
                         ORDER IV.
Labours in which the Funis Umbilicalis presents before the Child.
             On Labours attended with Hemorrhage.
  Hemorrhage.  A discharge of blood from the uterus,  inordinate
with respect to time  or quantity.
                         VARIETIES.
  1. In abortions.
  2. At the full period of utero-gestation.
  3. After the birth  of the child.
  4  After the expulsion of the placenta.



prevent the multiplication of classes.


                   ON  ABORTIONS.
                         SECTION  I.
   1 With respect to the time of pregnancy, all  espulsions of the
 nU^n7heb^d:m^Uetdl0aTtreSwhich occor before the
 uteres i ssofflcTently distended to allow of any manual operahon, and
 nS^^tyheb^ePc3e^X"eedc'as°ed0an•thoSe which allow of manual
 Jstle!«red;a„JI which are therefore to be esteemed as


 these distinctions. 
642               denman's  aphorisms.
  5. We may, however,  in general say, that all expulsions of the
foetus,  before the end of the sixth month, are to be considered as
abortions.
  6. But all expulsions of the foetus, after the expiration of the sixth
month, are to be esteemed as labours, and, if attended with the same
circumstances, should be managed upon the same principles.
  7. Yet expulsions of the foetus sometimes happen so critically, as
to make it doubtful to which distinction they should be ascribed, espe-
cially in cases in which there are two or more children.
  8. When manual  assistance is thought needful,  the  longer the
time wanting  to complete the  full period of pregnancy, the more
difficult must be any operation.

                          SECTION II.
                    On the Causes of Abortion.
  1. The predisposing causes of abortion are,  1st, general indispo-
 sition  of the constitution ;  2d, infirmity of the uterus.
  2. The general state of women  who  are disposed to abortion is
very different, some being weak and reduced, and others plethoric.
  3. Weakly  women become more liable to abortion, beause they
are susceptible of violent impressions from slight external causes.
  4. Plethoric women are more liable to abortion,  from the pecu-
liar disposition which the vessels of the uterus have,  from structure
and habit, to discharge their contents.
  5. Every action in common life  has been assigned as a cause of
abortion.
  6. But it is to the access of these actions that we are  to attribute
their effects, for women in health seldom abort, unless from violent
external causes.

                          SECTION III.
                  On the Prevention of Abortion.
  1. As every disease  to which  women  are liable  may dispose to
abortion, the method instituted to prevent it must be accommodated
to the  disease, or to the state of the constitution.
  2. In some constitutions, abortions may be prevented by repeated
bleeding in small  quantities, by  antiphlogistic medicines, and some-
times by warm bathing.
  3. In others, abortion may be  prevented by nourishing and  invi-
gorating diet  and medicines, by bark, by the  liberal use  of wine,
especially claret, and often by cold bathing.
  4. But it will be proper, in every case, to avoid all violent exercise,
to keep the  mind composed, and to rest  frequently in a horizontal
position.
  5. Women seldom abort while they have the vomiting which usu-
ally attends early pregnancy.
  6. In women who have no spontaneous  vomiting, this may be
excited with safety and advantage, by frequently giving  small doses
of Ipecacuanha.
  7. Pregnant women are usually costive, and abortions have been 
denman's  aphorisms.               643
very often occasioned by too great assiduity to remove this costive-
ness, which is a natural and proper state, in the early part of preg
nancy.

                           SECTION IV.
                    On the Signs of Abortion.
   1. The  signs of abortion are, frequent^ micturition, tenesmus,
pains in the back, abdomen, and groins, with a sense of weight in the
region of the uterus.
   2. But the most certain sign is, a discharge of blood, which proves
that some part of the ovum is separated from the uterus.
   3. It has been supposed when this last sign appears, that there is
scarcely a possibility of the  patient proceeding in her pregnancy
   4. But I have met with an infinite number of cases in practice,
in  which,  notwithstanding  this appearance, once  or oftener, to a
considerable degree, the discharge has ceased, and no ill consequences
have followed.
   5. We are therefore to persevere in the use of those means  of
prevention which are thought reasonable and proper, till the abor-
tion has actually happened.
   6. It is not  always prudent to give a decided opinion of the pro-
bable event of those cases in which abortion is threatened, as their
termination is often different  from what might  have been expected
from the symptoms.

                           SECTION V.
         On the Treatment of Women at the time of Abortion.
   1. The  treatment must  vary according to the nature and degree
of the symptoms.
   2. There is  an endless variety in  the manner in which abortion
takes place.  Some  women  abort with sharp and long continued
pains, others with little or no pain ; some with  a profuse and alarm-
ing hemorrhage, others with very little  discharge.  In some the
ovum has been soon and perfectly expelled, in others after a long
time, in small portions, or very much  decayed ; but the only alarm-
ing symptom is  the hemorrhage.
  3. The hemorrhage  in abortion is not always in proportion to the
period of pregnancy, this being in some advanced cases  very small;
and in others, though very early, abundant.
  4. The hemorrhage usually depends upon the difficulty with which
the ovum may be expelled,  and upon  the state of the  constitution
of the patient naturally prone to hemorrhage.
  5. The general principles which should guide us in the treatment
of hemorrhages, from any other part of the body, are applicable to
those of the uterus, regard being had  to the structure of the uterus.
   6. If the patient be plethoric, some blood should be taken  from
the arm at the commencement of the hemorrhage, and the  saline
draughts with nitre, or  acids of any kind, may be given in as large a
quantity, and as often as the stomach will bear.
  7. These'.may also be given during its continuance, and cloths wet
with cold vinegar may  be  applied to the  abdomen and loins, and 
644              denman's aphorisms.
renewed as they become warm.   The patient should be exposed t»,
and suffered to breathe the cold air.
  6. Every application or medicine, actually  or potentially  cold,
may be used.  A large draught of cold  water or  ice may be given
with great propriety ; and it is the custom in Italy to  sprinkle  ice
over the body of the patient if the danger of the ease be imminent.
  9. Every medicine or application which has the power of slacken-
ing  the circulation of  the blood, eventually becomes an astringent;
but astringents, properly so called, can have no power in stopping
hemorrhages from the uterus.
  10.  Hemorrhages are stayed by the contraction  of the coats of the
blood vessels, or by the formation of coagula, plugging up the  orifices
of the open blood vessels.
  11.  Both these effects are produced more favourably during a state
of faintness, which,  though occasioned by the loss of blood, becomes
a remedy in stopping hemorrhages.
  12.  Cordials are  not therefore to be hastily given to those who are
faint from loss of blood ;  unless the faintness should continue  so long
as to make us apprehensive for the immediate safety of the patient.
  13.  The introduction of lint, a  piece of sponge,  or any other soft
substance, into the vagina, has been recommended,  and  sometimes
used with advantage, by favouring the formation  of coagula.
  14.  Cold or astringent injections into the vagina,  or even  a piece
of ice introduced into the vagina, have also been recommended.
  15.  Opiates have been advised in abortions attended  with profuse
discharges, and they may sometimes be proper to ease pain, or to quiet
the  patient, especially where there is a chance of preventing the abor-
tion, or after the accident has  happened.
  16.  But when there is no hope of preventing the abortion,  the de-
gree of pain proving the degree of action of the uterus, and the action
of the uterus producing and favouring the contractile power of the
blood vessels, if by opiates the action of the uterus should be prevented
or checked, they may contribute to the continuance of the hemorrhage.
  17.  Hemorrhages in abortions,  independent of other complaints,
though sometimes very alarming, are not  dangerous.
  18.  But if women abort in consequence of acute diseases,  or if
they are attended with violent spasms, there will be real and  great
danger.
  19.  For they  abort because they are already in great danger, and
the danger is increased and accelerated by the abortion.
  20.  The ovum has been sometimes retained in the uterus for many
months after the symptoms of abortion had appeared, and when it had
lost the principle of increasing.
  21.  But it is not  now thought necessary or proper in abortions,  to
use any means for bringing away the ovum, or any portion of it which
may be retained, with instruments or manual assistance.
                          SECTION VI.
        0» Hemorrhages at the full Period of Utero-gestation.
  1.  Under this section will be included all those hemorrhages which
may happen in the three last months of the pregnancy. 
denman's aphorisms.
645
  2. These are  occasioned first by the attachment of the placenta
over the os uteri ;  secondly,  by the separation  of a part, or of the
whole placenta, which had  been attached to some other part of the
uterus.
  3. Hemorrhages arising from the first cause are more  dangerous
than from the  second ;  but those from  the second have  sometimes
proved fatal.
  4. The danger  attending hemorrhages is to be estimated from a
consideration of the general state of the patient, of their cause, of the
quantity of blood discharged,  and of the effect of the  loss of blood,
which will vary in different constitutions.
  5. Hemorrhages  are infinitely  more dangerous with sudden than
with slow discharges of blood,  even though  the quantity lost may be
equal.
  6. The danger arising from hemorrhages is indicated by the weak-
ness or quickness of the pulse, or by its becoming imperceptible, by
the paleness of the lips, and a ghastly countenance,  by inquietude,
by continued fainting,  by a high and laborious respiration, and by
convulsions.
  7. The two last symptoms are usually mortal, though when women
are extremely reduced, they are liable to hysteric affections of a simi-
lar kind, that are not dangerous.
  8. The vomiting, which generally follows violent hemorrhages, in-
dicates the injury which the constitution has sustained by the loss of
blood, but by  the  action of vomiting the patient  is always relieved,
and it contributes to the suppression of hemorrhages.
  9. Near the full  period of  utero-gestation, women  are always in
greater danger in those hemorrhages which are not accompanied with
pain.
  10. For  the pain proving the contraction of the uterus,  and this
proving that the strength of the constitution is not  exhausted,  the
danger  in hemorrhages may often  be estimated  by the absence or
degree of pain.

On  those Hemorrhages which are occasioned by the Attachment of the
                    Placenta over the Os Uteri.

  1. Though the placenta, which may easily be distinguished from
the membranes, or from coagulated blood, as soon as the os uteri is a
little opened, be attached over the os uteri, the woman usually passes
through the early  part of pregnancy  without  any inconvenience or
symptom which denotes the circumstance.
  2. But before or when the changes previous to labour come on,
there must be an hemorrhage, because aseparation of a part of the
placenta is thereby occasioned, and as the disposition to  labour ad-
vanced, the hemorrhage  is generally, though  not universally, in-
creased.
  3. With this circumstance  very slight external  causes are also
apt to occasion hemorrhage.
  4. When an hermorrhage from this  cause has once come on,  the
patient is never free from danger till she is delivered. 
646
denman's aphorisms.
   5.  The powers of the constitution are undermined by hemorrha-
ges profuse or often returning, so that no efforts, or only very feeble
and insufficient ones,  are commonly made for the expulsion of the
child.
   6.  We are  therefore  often obliged to free the  patient from the
imminent danger she is in by artificial delivery.
   7.  Of the propriety of this delivery, in cases of dangerous hemor-
rhage, there is no doubt, or can be any dispute, except as to the pre-
cise time when the  patient ought to be delivered.
   8.  On the first appearance of the hemorrhage, unless it be pro-
digious in quantity,  or unusually terrifying in its effect, it is seldom
either requisite or proper to attempt to deliver by art.
   9.  Nor does it often happen that a second or a third return of the
discharge compel us to the delivery by art.
   10.  But as a patient with this circumstance cannot be secured till
she is delivered, and as the delivery is seldom completed by the na-
tural  efforts, and as  the artificial delivery, though performed before
it is absolutely necessary, is not  dangerous, if performed with care,
we must be on our guard not to delay the delivery too long.
   11.  In some cases in which it might be thought eligible to deliver
on account of the hemorrhage, the parts are  so unyielding as not to
allow of the operation itself without some hazard.
   12.  Yet when the parts requiring dilatation make no resistance to
the passage of the hand, the event of the operation is always more
precarious, the operation having been deferred too long.
   13i  But though it may be proper insome cases to determine on
immediate delivery, the  operation  must always be performed with
the utmost deliberation.
   14.  The first part of the operation has been described under pre-
ternatural presentations.
   15.  When the hand is carried to the placenta attached over the os
uteri, it is of little consequence  whether we perforate the placenta
with our fingers, or separate it on one side till we come to the edge,
though the latter is  generally preferable.
   16.  If the hand be  passed through the placenta,  we shall come
directly to the part of the child which presents.
   17.  But if we separate the placenta to the edge, the hand will be
on the outside  of the membranes, which must be ruptured before we
lay hold of the feet of the child.
   18.  No regard is  to be  paid to the part of the child which may
present,  as it must always be delivered by the feet.
   19.  The feet of the child being brought slowly into the pelvis, we
must wait till the uterus is contracted to  the body of the child,'which
will be indicated by pain, and known by the  application of our hand
to the abdomen.
  20.  The delivery must then be  finished very slowly, to give the
uterus time to  contract as the  child is  withdrawn from its cavity;
but this  part of the operation  has  likewise been described under
preternatural presentations.
  21,  An assistant should make a moderate pressure upou the abdo-
men during the operation, to aid the contraction of the uterus, and 
denman's aphorisms.
647
to prevent ill consequences  from the sudden emptying of the abdo-
men.
   22. When the child is  born, the hemorrhage will be  generally
stayed, if the operation has been performed slowly.
   23. But if the hemorrhage should continue or return, the placen-
ta is to be managed as will be afterwards directed.
   24. Should no uncommon difficulty attend the delivery, children
will be often born living in cases  of hemorrhage which are attended
with the utmost danger to the mother ; or, as it has sometimes hap-
pened, after the death of the mother.
   25. Before, during, or after delivery, in cases of hemorrhage, the
means and  applications before recommended,  may be occasionally
used with advantage.

                         SECTION VII.
On those Hemorrhages which are occasioned by the separation of a part,
      or of the whole placenta, before or in the time of labour.
   1. Hemorrhages arising from this cause are seldom so alarming or
dangerous as the preceding.
   2. But if the separation of the placenta be sudden and extensive,
the danger may be equal, and the same mode of proceeding requir-
ed.
   3. Our conduct must be guided by  a consideration of the degree
and effect of the hemorrhage, and of the state of the labour when it
occurs.
   4. Should the hemorrhage from this cause occur in the first pe-
riod of labour, the action of the uterus will be weakened,  but it may
be sufficient to dilate the os  uteri.
   5. If the quantity of blood lost in these cases be very considera-
ble when the os uteri is  sufficiently dilated, the greater the degree
the better,  if the case will allow us to wait so long,  tlie membranes
containing the waters may be ruptured.
   6. By the discharge of the waters the distention of the uterus will
be lessened, and by the consequent contraction, the size of the ves-
sels being diminished, the  hemorrhage will  of course be abated or
removed.
   7. After the abatement or suppression  of the  hemorrhage, the
action of the uterus will become  stronger,  so that the delivery will,
in general, be completed without further assistance.
   8. But if the hemorrhage should continue after the discharge of
the waters  in such a  degree as to threaten  danger,  or if it should
commence in the second period of the labour, the interposition on
our part must vary according to  the circumstances, and  chiefly ac-
cording to the situation of the child.
   9. It  may in some cases be necessary to deliver by art, as in the
preceding section,  and in others  to deliver with the forceps or vec-
tis, if the hemorrhage be profuse, and  we despair of the child being
expelled by the natural efforts.
   10. The  proper management of all  such  cases may be collected
from what will be generally said on the subject, being always on our
guard to distinguish between fear and  real danger. 
648
denman's aphorisms.
                          SECTION VIII.
On those Hemorrhages which occur when the Placenta  is retained after
                      the birth of the Child.
   1. The placenta is generally  expelled by the spontaneous action
of the uterus in a short time after the birth of the child.
   2. But sometimes  the placenta is retained, 1st, from the inaction
or  insufficient action of the uterus ;  2d,  by the irregular  action of
the uterus;  3d,  by  the  scirrhous adhesion of the placenta to  the
uterus.
   3. Sometimes there is a profuse discharge of blood, when no ac-
tion is exerted by the uterus to expel the placenta, and this is found
in practice to be far  the  most common cause of hemorrhage at the
time of delivery.
   4. Whenever there is a hemorrhage,  the whole or a portion of
the placenta must have been previously separated, and  the hemor-
rhage usually continues, or  returns  till the placenta is expelled or
extracted out of the cavity of the uterus.

                          SECTION  IX.
On the retention of the Placenta from the inaction or insufficient action
                         of the Uterus.
   1. Though the placenta be retained after the birth of the child, if
there be no hemorrhage,  we are to  wait without any interposition
on our part, in expectation of the action of the uterus.
  2. The time which it may be proper and  expedient to wait, will
depend upon the state of the patient, and  the state of  the patient
generally depends upon the  previous circumstances of the labour ;
so that it may not be proper to wait  in one case for any  length of
time, and in another  we may safely wait four,  six, or even twelve
hours.
  3. But no patient ought to be left before the placenta is brought
away, because though there may be no existing hemorrhage, a dan-
gerous one may at any time come on.
  4. When  the patient complains of  pain, the expulsion of the pla-
centa may be safely forwarded, by aiding the contraction of the ute-
rus by  moderate pressure with the hand upon the abdomen, and by
pulling very gently by the funis.
  5. But if the first pains, with the aid we think it prudent to give,
should  not bring down the placenta,  we are to wait for a return of
the pains, proceeding in the same cautious manner.
  6. When that part of the placenta into which the funis is  inserted
can be felt, little  danger or difficulty is to  be apprehended ; but we
are either to wait longer, or to extract it very slowly.
  7. But if  a hemorrhage were to come on, the placenta being re-
tained, it would be  equally necessary to extract the placenta as it
would  be to extract  the  child,  provided the degree of hemorrhage
was equally profuse or sudden.
  8. After the birth  of the child, the extraction of the placenta  is
therefore to  be considered as the only method  by which an appre- 
denman's aphorisms.
649
 hended or present dangerous  hemorrhage  is  to be  prevented or
 avoided.
   9.  Yet all discharges of blood do  not require a speedy extraction
 of the placenta, but such only  as by  their violence or continuance,
 or frequent returns, threaten danger.
   10.  If much force be used in :>ulling  by the funis, there will be
 danger ; 1st,  of tearing it from the placenta ;  2d,  of inverting the
 uterus ; 3d, of injuring the uterus by the violence ; 4th, of increas-
 ing the hemorrhage.
   11.  The danger of these consequences is greater when  force  is
 used to extract the placenta by the funis, than by the prudent intro-
 duction of the hand into the uterus  for that purpose.
   12.- In cases in which the uterus acts  insufficiently, by attending
 to the  respiration you will sometimes be able to bring down the pla-
 centa, just using so much force, in pulling by the funis, as will pre-
 vent the retrocession of it in the act of inspiration.
   13.  But in whatever manner the placenta may be brought into the
 pelvis,  it  should  be suffered to remain there till the action of the
 uterus comes on, or so long as there is reason to  fear a return of
 the hemorrhage, and it must then  be carefully withdrawn, or until
 it drop away.

                           section x.
   On the retention of the Placenta from the irregular action of the
                             Uterus.
   1. When all the parts of the uterus act with equivalent force, and
 at the same time, the combined power will contribute to the expul-
 sion of whatever is contained in its cavity.
   2. But if  the uterus should act irregularly,  the  contrary  effect
 might be produced.
   3. If the  fundus uteri should not act when the other  parts are in
 action, the longitudinal contraction  of the  uterus would be produced;
 but if the central  parts could only act,  the  uterus  would then be
 contracted in the form of an hour glass.
   4. As the placenta cannot be excluded when  the  uterus acts in
 this irregular manner, it must be extracted by introducing the hand
 into the uterus, provided the state of the hemorrhage should require
 it; and when it cannot be  extracted by using the means before men-
 tioned.
   5. The hand ought never to be introduced into the uterus except
 in cases of real necessity, and then with  the utmost circumspection
 and care ; and the hand when introduced should not be  withdrawn
until the placenta is detached and brought into the pelvis.
  6. If the whole  placenta be loosened, this is easily effected; but
 if a portion of it should be found adhering, this must  be separated by
bending it  back from the uterus, or by passing gently the fingers be-
tween it and the uterus.
   7.  When the uterus is found contracted in the form  of an hour-
glass, and  this is the most common  cause of the retention of the pla-
centa, the  contracted part must be dilated in the manner reco.nmend-
                             82 
650               penman's  aphorisms.
ed for the dilatation of the os uteri, and it must be amply dilated, or
it will immediately contract again round the wrist.
  8.  We must then proceed as before advised.

                          SECTION  XI.
  On the retention of (he  Placenta from the scirrhous adhesion of it
                         to the Uterus.
  i.  Should there be a degree of hemorrhage sufficient to make it
necessary to  introduce the hand to extract the placenta, a part of it
must  be separated, though there may be a scirrhous adhesion of the
remainder to the uterus.
  2.  Then the  method  advised  in  the  last section must be put in
practice, and the firmer we find the adhesion, the slower the separa-
tion ought to be made.
  3.  But if there should be  no hemorrhage  of importance,  and
merely a retention of the placenta beyond its due time,  we may say,
for  example,  more than  four hours, and the means  before recom-
mended are insufficient to bring down the placenta;
  4.  It may then be  necessary  to introduce the hand carefully to
separate  and extract the placenta, and the difficulty will  not be in-
creased by the delay.
  5.  Following the navel string as our guide, we must then pass the
hand to the placenta ; and if it should be found almost wholly adhe-
ring, we  must begin with great caution to separate at the edge, and
gradually proceed as before  directed until the separation is com-
pleted.
  6.  Then grasping the placenta, we  must slowly withdraw our hand,
that the uterus may contract accordingly, and the chance of subse-
quent hemorrhage be prevented.
  7.  The irritation made by the introduction of the hand,  will often
occasion a return of the action of the uterus, before dormant, that will
greatly facilitate the separation.
  8.  Yet it is possible that a portion  of the placenta may  adhere s»
firmly as to make it unsafe to separate it with our fingers.
  9.  Should  this circumstance occur notwithstanding  the most de-
liberate and firm proceeding, it may sometimes be more justifiable to
leave the adhering part remaining, than to use violence in separating it.
  10. But though hemorrhages are stayed when the greater portion
■of the placenta is  brought away, it is always a desirable thing to bring
away the placenta and membranes in a perfect  state ;  and if these
are slowly extracted, any coagula formed in the uterus will usually be
enveloped m  them.
                          SECTION  xn.
On  those Hemorrhages which follow the expulsion or extraction of the
                           Placenta.
   1.  The hemorrhages in these cases may be either a continuation of
that which existed before  the exclusion of the placenta, or it may only
follow ttje exclusion of the placenta.
   2.  Wiwn it is of the former kind,  we may presume that it was not 
denman's aphorisms.              651
 within our power to prevent it;  but the latter kind may often be at-
 tributed to the violence  or hurry with which the placenta has been
 extracted.
   3. This is not so dangerous as either of the varieties of hemorrhage
 of which  we have last spoken, though with imprudent management,
 or under particular circumstances, it has sometimes proved fatal.
   4. All the cautions given with respect to the general  management
 of the placenta, relate to the prevention of this kind of hemorrhage.
   5. When the strength  of women is  much reduced by any cause
 which existed  previous to labour, or when they  have gone through
 much fatigue in the course of it, there is usually great heat and a rapid
 circulation of the blood at the time of delivery.
   6. While they are in  this situation,  if  the placenta  were  to be
 brought away hastily, an extraordinary  quantity of blood must of ne-
 cessity be discharged.
   7. The interval of time which passeth between the birth of tlie
 child and the expulsion of the placenta,  should therefore be employed
 in cooling the patient, and recovering her from her fatigue.
   8. Even when the  placenta is excluded  out of the cavity of the
 uterus,  it  should be suffered to  remain  till all tumult  is quieted,  and
 then, with the membranes, slowly extracted.
   9. The  quantity of blood discharged  in consequence of the separa-
 tion of the placenta will vary in different women, or in the same woman,
 in different labours, independently of the  manner in which the pla-
 centa may come away.
   10. The less the quantity of  blood discharged, the better women
 in general recover, provided there be no morbid cause  of its dimi-
 nution.
   11. Some women are always prone to a great  discharge of  blood
 after the separation of the placenta,  whatever care may be taken in
 extracting  it.
   12. This may often be  prevented by  keeping the patient out of
 bed till the membranes are broken and the  waters discharged, to the
 very moment of the child being born, rather retarding  than forwarding
 its expulsion.
   13. In all cases of dangerous hemorrhage, after the extraction of the
 placenta, it is first necessary that we should be assured, by an exami-
 nation per vaginam, that the uterus is not inverted.
   14. Should there be an alarming  hemorrhage after  the separation
and exclusion of the placenta, notwithstanding all the care which can
be taken according to the methods before mentioned,
   15. The doctrine of hemorrhages  before given, and  the  general
treatment already recommended, will enable you to fix upon  the line
of conduct  it will be expedient to pursue, and to restrain or suppress
them as far as they are under the influence of art.
   16. In cases  of hemorrhage so very profuse as to occasion frightful
faintings, continuing so long as to raise great solicitude for the imme-
diate safety of the patient, it was generally said,  that  cordials ought
not to be given.
   17. But  this requires explanation.  When the patient has continued 
652
denman's  aphorisms.
faint so long as to give time according to our judgment, for the vessels
of the  uterus  to contract, then cordials and nourishment  in  small
quantities, very often repeated, are really needful.
   18. Other means are also to be used for the purpose of recovering
women from this long continued fainting ; and one of the most effectual
is, sprinkling the face freely with cold water.
   19.  After a profuse  hemorrhage, the patient will frequently have a
disposition to  sleep,  which  has generally  been considered as  dan-
gerous.
   20.  But short sleeps are  very refreshing ; though long ones, in a
very weak state, are, under every circumstance, found to be injurious.
   21.  When there  has been a dangerous hemorrhage, the patient
should remain for many hours undisturbed,  and  in an horizontal po-
sition ; and our attention must be continued as long as any danger is
to be apprehended.
                       ON  LABOURS
                ATTENDED WITH CONVULSIONS.
  1. The convulsions which occur in pregnancy very much resem-
ble the epilepsy ; but to the symptoms, which these have in common,
may be  added, the peculiar hisping noise which women almost uni-
versally make with their lips during the convulsions.
  2. When convulsions happen to women with child, they are gene-
rally, but not constantly, accompanied or followed with symptoms of
labour,  but though the  convulsions  may be removed, the child  is
most frequently afterwards born dead.
  3. These convulsions are indicated by a piercing pain in the head,
by giddiness and other vertiginous complaints, by blindness, by va-
cillation of the mind, or a slight delirium, by violent cramp or pain
at the stomach, by a fulness or apparent strangulation of the neck
and fauces, and other affections of the vascular and  nervous system.
  4. The means to be used for the prevention  or cure of convulsions
when threatened or existing, must be regulated according to the con-
stitution of the  patient and the violence of the symptoms.
  5. It  will always be necessary to  take away some blood, and com-
monly  to repeat the bleeding ; and it has been found  particularly
serviceable to open the  jugular vein ; or to take away blood by cup-
ping ; and by applying leeches to the temples.   Emetics, when they
could be given   have been useful, as has sometimes also  the warm
bath   Clysters may be frequently exhibited.   Opiates, joined with
nervous  medicines, may be  given ; and the  patient is, by  all the
means in our power, to be soothed  and restrained from violent ex-
ertions.
  6. During the convulsions,   the means by which contrary  irrita-
tions may be excited are to be used ; and of these the most powerful
is, the dashing of cold water in the face,  which has been known  to
prevent, or even to cure, convulsions.
  7. Some writers  have recommended the speedy delivery  of the
patient,  as the most eligible and only effectual method of  removing 
denman's aphorisms.
653
puerperal convulsions ; but others  have insisted  that the labour
sho'ilti be uninterrupted.
  8. From the histories of  all the cases of puerperal convulsions
which have been hitherto recorded, it appears, that a greater  num-
ber have died of those  who were delivered by  art, than  when the
labours were resigned to nature.
  9. A^j far as my experience enables me to judge, we ought not to
attempt to deliver women with convulsions bof.ne some progress is
made in the labour.
  10. But when the os uteri becomes dilated saffi-ipntly, or to a
certain degree,  the patient safely may, and ought to be delivered by
art, if from the  urgency of the convulsions, and the general danger
of the case, delivery should appear necessary.
  11.  The manner of delivering women in these cases, whether the
operation be performed with  the forceps or vectis,  or by turning
and extracting the child by the feet, has already been iu'lj explained.
   12.  The event of  the operation, both to  the mother  and child,
will also very much depend upon the skill and circumspection with
which it may be performed.
  13. When dangerous convulsions come  on in the early part of
pregnancy, it is often clear  that they  arise from excessive uterine
irritation.
  14.  It will then  be justifiable and proper to  forward the exclu-
sion of the foerus, by puncturing the membranes as soon as it can be
done with safety. 
 
Series of iStiflvatoftifla*
WITH
ILLUSTRATIONS. 
 
 
Pint, I
\
I- 
657
                         PLATE I.

     represents, in a front view, the bones of a well
                        formed pelvis.

         The five vertebrae of the loins,
         The os sacrum.
       A The os coccygis,
       B The os ilium.
     C.C The ossa ischia.
       D The ossa pubis.
       E The foramina magna.
       F The acetabula.
  G.G.G. The brim of the pelvis, or that circumference of its cavity,
           which is described at the sides by the inferior parts of
           the ossa ilium, and at the back and fore parts by the su-
           perior parts of the ossa pubis and sacrum.

   In this Table, besides the general structure and figure of the se-
veral bones, the dimensions of the brim of the pelvis,  and  the dis-
tance between the under part of the ossa ischium, are particularly
to be attended to ; from  which it will appear that the cavity of the
brim is commonly wider from side to side than  from the back to the
fore-part,  but that the sides below  are  in the contrary proportion.
The reader, however, ought not from this to conclude,  that every
pelvis is similar in figure and  dimensions, since  even well formed
ones differ in some degree from each other.  In  general, the  brim
of the  pelvis measures about five inches and  a quarter from side to
side, and four inches and a quarter from the back to the  fore-part;
there being likewise the same  distance  between  the  inferior parts
of the ossa ischium.   All these measures, however, must be under-
stood as tak*en from the skeleton ; for, in the subject, the cavity of
the pelvis is  considerably diminished by its  integuments and con-
tents.  Correspondent also to this  diminution, the usual dimensions
of the head of the full-grown foetus are but three inches and a half
from ear to ear,  and four inches and a quarter from the fore to the
hind head.
83 
658
                        PLATE II.

  REPRESENTS THE UTERUS IN THE EIGHTH OR NINTH MONTH
                         OF PREGNANCY.

       The uterus, as stretched to near its full extent, with the wa-
         ters, and containing the  foetus entangled  in the funis, the
         head presenting at the upper part of the pelvis.
    A.A  The superior part of the ossa ilium.
    B.B  The acetabula.
      C  The remaining posterior  parts of the ossa ischium.
      D  The coccyx.
      E  The inferior part of the rectum.
    F.F  The vagina stretched on  each side.
      G  The es uteri, the neck of the womb being stretched to its
          full extent, or entirely obliterated.
      H  Part of the vesica urinaria.
      I  The placenta at  the superior  and  posterior part of the
          uterus.
    K.K  The membranes.

  This plate  shows in what manner the uterus stretches, and how
its neck grows shorter, in the different periods of pregnancy.
  Notwithstanding  it has been  handed down as an invariable  truth,
from the  earliest accounts of the art to the present times, that when
the head  of the foetus presented, the face was turned to the posterior
part of the pelvis; yet, from  Mr.  Ould's observation, as well as
front some late dissections of the gravid  uterus, and what  I myself
have  observed in practice, I am led  to believe, that the head pre-
sents, for the most  part, as  is here delineated, with one ear to the
pubes, and the other to the os sacrum;  though sometimes this may
vary, according to the form of the  head, as well as that of the pelvis.
  Consult Dr. Hunter's elegant plates of the gravid uterus. 
Plate 2
 
fc 
J 
/*/**■  a
 
6§9
                       PLATE  III.

 GIVES A FRONT VIEW OF TWINS IN UTERO IN THE BEGINNING OF
        LABOUR; THE ANTERIOR PARTS BEING REMOVED.

       The uterus as stretched with the membranes and waters.
  A. A The superior part of the  ossa ilium.
    B The acetabula
  C.C The ossa ischium.
    D The coccyx.
    E The lower part of the rectum.
  F.F The vagina.
    G The os internum stretched open about a finger's  breadth
        with  the membranes  and  waters in the time of labour-
        pains.
    H The inferior part of the uterus  stretched with the waters
        which are below the head of the child that presents.
    I.I The two  placentas  adhering to the posterior  part of the
        uterus, the two foetuses lying before them ;  one with its
        head  in a proper position, at the  inferior part of the ute-
        rus,  and the other situated preternaturally, with the head
        to the fundus : the bodies of each are here entangled in
        their proper funis, which frequently happens in the natu-
        ral as well as preternatural  positions.
  K.K The membranes belonging to  each placenta.

  This representation of twins  I have  placed here, in  order to
show the os uteri grown much thinner than in the former figure, a
little open, and stretched by the waters and membranes which are
pushed down before the  head  of one of the foetuses in  time  of a la-
bour-pain. 
660
                       PLATE  IV.

EXHIBITS ANOTHER FRONT  VIEW OF THE GRAVID  UTERUS IN THE
 BEGINNING OF LABOUR; THE ANTERIOR  PARTS BEING  REMOVED,
 AS IN THE FORMER PLATE; BUT  IN THIS THE MEMBRANES, NOT
 BEING BROKEN, FORM A LARGE BAG, CONTAINING THE WATERS
 AND FCETUS.

           The substance of the uterus.
           The bones of the pelvis.
         A The coccyx.
         B The inferior part of the rectum.
       C.C The vagina.
       D.D The mouth of the womb largely stretched in time of a
             pain ; with E, the membranes and waters.   This cir-
             cumstance makes it usually certain that labour is be-
             gun ; whereas, from the degree of  dilatation repre-
             sented in the  former Plate, there is little to be ascer-
             tained, unless  the pains are regular and strong, the oi
             uteri being  often found more open several days, and
             even weeks, before labour commences.
         F The chorion.
         G The same dissected off at the inferior part of  the uterus,
             in order to show the head of the fcetus through the
             amnios.   N. B. This hint  is  taken  from  one of Dr.
             Albinus's Tables of the gravid uterus.
           The placenta; the  external convex surface of which,
             divided into a number of lobes,  is here represented,
             its concave internal  parts being covered by the cho-
             rion.

  The placenta has been found adhering to all the different parts  of
the internal surface of the uterus,  and sometimes even over the in-
side of the  os uteri; this last manner of adhesion,  however, always
occasions floodings  as soon as the same  begins to dilate.
  See a valuable essay on Uterine Hemorrhage in advanced gesta-
tion, by E.  Rigby, third edition, London, 1784; in which the dis-
tinction between those floodings that  require  immediate delivery,
and thqpe which may be expected  to yield to a more simple  treat-
ment, is properly ascertained.
  Plate  II. 111. show the  internal surface of the  placenta toward
the foetus, with the vessels composing its substance proceeding from
the funis, which is inserted  in different placentas, into all the differ-
ent parts of the same, as well as i n the  middle. 
Plate t
 

i 
1 
*'* 
661
                        PLATE  V.

SHOWS (IN  A LATERAL VIEW .*ND LONGITUDINAL DIVISION OF THE
  PARTS) THE GRAVID UTERUS  WHEN LABOUR IS SOMEWHAT AD-
  VANCED.

         A The lowest vertebra of the back.
         B The scrobiculus cordis ; the distance  from which to
             the last mentioned vertebra is here  shown by dotted
             lines ;  as also part of the region below the'diaphragm.
       C.C The usual thickness and  figure of the  uterus when ex-
             tended  with the  waters at the latter end of preg-
             nancy.
         D The same, contracted and grown thicker after the wa-
             ters are evacuated.
       E.E The  figure of the  uterus when pendulous.   In  this
             case, if the membranes break  when the  patient is in
             an erect position,  the head of the foetus runs a risk of
             sliding over and  above  the  ossa pubis,  whence the
             shoulders will be  pushed info the pelvis.
       F.F The figure of the uterus, when stretched  higher than
             usual,  which generally occasions vomitings, and diffi-
             culty of breathing.  Consult on this subject Mr. Lev-
              ret, sur le Mechanisme de Differentes Grossessos.
         G The os pubis of the left side.
        II.H The os internum.
           I The vagina.
           K The left nympha.
           L The labium pudendi of the  same side.
          M The remaining portion of the bladder.
          N The anus.

   In this period of labour, the os uteri being more and more stretch-
  ed by the membranes pushing down, and beginning to extend to the
  vagina, a great  quantity of waters is forced down  at the same time,
  and (if the membranes break)  is discharged ; whence the  uterus
  contracts itself nearer to the body of the foetus, which is here repre-
  sented in a natural position, with the vertex resting at  the superior
  part of the ossa pubis, and the forehead toward the right os ilium.
  As soon as the  uterus is in contact with the body of the foetus, the
  head of the same is  forced backward toward the  os  sacrum from the
  line  of the abdomen B G into that of the pelvis, viz. from the up-
  permost F. to near the end of  the coccyx, and is gradually pushed
  lower, as in the following plate.
0 
662
                       PLATE VI.

SHOWS THE NATURAL POSITION OF THE HEAD OF THE FCETUS WHEN
  SUNK DOWN INTO THE MIDDLE OF THE PELVIS AFTER THE OS INTER-
  NUM IS FULLY OPENED; A LARGE QUANTITY OF THE WATERS BEING
  PROTRUDED WITH THE MEMBRANES THROUGH THE OS EXTERNUM,
  BUT PREVENTED FROM BEING ALL DISCHARGED, BY THE HEAD'S FIL-
  LING UP THE VAGINA.

    The uterus a little contracted, and thicker, from  some of the
       waters being sunk down before the child, or discharged.
  A The superior parts of the ossa ilium.
  B The inferior part of the rectum.
C.C The vagina largely stretched with the head of the foetus.
D.D The os internum fully opened.
  E A portion of the placenta.
  F The membranes.
G.G The ligamenta lata.
H.H The ligamenta  rotunda.  Both these last stretched upwards
       with the uterus.
  The vertex of the fcetus being now down at the inferior  part of
the right os ischium, and the  wide part of the  head at the narrow
and inferior part  of the pelvis, the forehead,  by  the force of the
pains, is gradually moved backwards ; and, as it advances  lower, the
vertex and occiput turn out below the pubes, as in the next plate.
Hence may be learnt of what consequence  it  is to know, that it is
wider from side to side at the brim of the pelvis, than from the back
to the fore part;  and that it is wider from the fore to the hind head
of the child, than from ear to ear. 
Plate f>
*m 
 
 
/'/„/, 7
 
^9g
                     PLATE VII.

SHOWS THE FOREHEAD OF THE FCETUS TURNED (IN ITS PROGRESSION
 DOWNWARDS, FROM ITS POSITION IN THE FORMER PLATE) BACK-
 WARDS TO THE OS SACRUM, AND THE OCCIPUT BELOW THE PUBES;
 BY WHICH MEANS THE NARROW PART.OF THE HEAD IS TO THE NAR-
  ROW PART OF THE PELVIS, THAT IS, BETWEEN THE INFERIOR PARTS
 OF THE OSSA ISCHIUM. HENCE IT MAYBE OBSERVED,THAT,THOUGH
 THE DISTANCE BETWEEN THE INFERIOR PARTS OF THE LAST MEN-
 TIONED BONES IS MUCH THE SAME AS BETWEEN  THE COCCYX AND
 PUBES; YET, AS THE CAVITY OF THE PELVIS IS MUCH SHALLOWER AT
 THE ANTERIOR THAN LATERAL PART, THE OCCIPUT OF  THE FCETUS,
  WHEN COME DOWN TO THE INFERIOR PART OF EITHER OS ISCHIUM,
 TURNS OUT BELOW THE PUBES.  THIS ANSWERS THE SAME END AS
  IF THE PELVIS ITSELF HAD BEEN WIDER FROM THE POSTERIOR PART
  THAN FROM SIDE TO SIDE; THE HEAD LIKEWISE ENLARGING THE
 CAVITY BF FORCING BACK THE COCCYX, AND PUSHING OUT THE EX,
  TERNAL PARTS IN FORM OF A LARGE TUMOUR.

    The uterus contracted closely to the foetus after the waters are
      evacuated.
    The  vertebrae of the loins, os sacrum, and coccyx.
  A The  anus.
  B The  left hip.
  C The  perinaeum.
  D The  os externum beginning to dilate.
  E The  os pubis of the left side.
  F The  remaining portion of the bladder.
  G The  posterior  part of the os uteri. 
664
                         PLATE  VIII.

   SHOWS IN WHAT MANNER THE HEAD OF THE FCETUS IS HELPED ALONG
    WITH THE FORCEPS, AS ARTIFICIAL HANDS, WHEN IT IS NECESSARY
    TO ASSIST WITH THE SAME FOR THE SAFETY OF EITHER MOTHER
    OR CHILD.

         The vertebrae of the. loins, os sacrum, and coccyx.
       A The os pubis of the left side.
       B The remaining part of the bladder.
       C The intestinum rectum.
     D The mons veneris.
     E The clitoris, with the left nympha.
     F The corpus cavernosum clitoridis.
       X The meatus urinarius.
      . II The left labium pudendi.
       1  The anus.
       K The perinaeum.
     L.M The left hip and thigh.

     The  patient, in this case, may be placed as in this plate, on her
   side, with her breech a little over  the side or foot of the bed, her
   knees being likewise pulled up to her belly, and a pillow placed be-
   tween them, care being taken, at the same time, that  the parts are,
   by a proper covering, defended from the external air.   If the  hairy
   scalp of  the foetus is so swelled, that the situation of the head can-
   not be distinguished  by the sutures, as in plate V. ;  or if, by  intro-
   ducing a finger between the head of the child and  the pubes, or
'   groins, the ear or back part of the  neck cannot be felt, the os ex-
   ternum must be gradually dilated in the time  of the pains, with the
   operator's fingers, (previously lubicrated with  hog's  lard,)  till the
   whole hand can be introduced into  the vagina, and slipped up, in  a
   flattish form, between the posterior  part of the pelvis and child's
   head.  This last is then to  be raised up as high as possible, to allow
   room for the fingers to reach the ear and posterior part of the neck.
   When the position of the head is  known, the operator must  with-
   draw his hand, and wait to see if the  stretching of the parts  will re-
   new or increase the labour-pains, and allow more space for the ad-
   vancement of the head in the pelvis.   1 f this, however, proves of no
   effect, the fingers are again to  be introduced as before, and one of
   the blades of the forceps (lubricated with lard) is then to be applied
   along the inside of the hand or fingers, and left ear of the child, as
   represented in the plate.   But, if the pelvis is distorted, and  projects
   forward  at the superior part of the os sacrum, and the forehead,
   therefore, cannot be moved a little  backwards, in order to turn the
   ear from that part of the pelvis which prevents the end of  the for-
   ceps to pass the same ;  in that case, I say, the blade must be intro-
   duced along the posterior part of the ear at the side of the distorted
   bone.   The hand that was introduced is then to be withdrawn, and 
J> telle 8.
 
 
665
the handle of the introduced blade held with it as far back as the pe«
rinaeum will allow, whilst the  fingers of the  other hand are  intro-
duced to the os  uteri, at  the  pubes  or right groin, and the other
blade placed exactly opposite  to the former.   This  done, the han-
dles being taken hold of  and joined together, the head is to be pul-
led lower and lower every pain, till the vertex, as in this plate, is
brought down to the  inferior part of the left ischium, or below the  •*
same.   The wide part of the head being now advanced to the nar-   4
row part of the pelvis betwixt the tuberosities of the ossa ischium,
it is to be turned from the  left ischium, out  below the  pubes,  and
the forehead backwards to  the concave part of the  os sacrum and
coccyx, and afterwards the head brought along and delivered, as iri
plate IX. and X.  But, if it  is found that the delivery will require a
considerable degree of force, from the head being large, or the pel-
vis  narrow, the handles of the forceps are to be tied together with
a fillet, as represented in this table, to prevent their  position  being
changed, whilst the woman is turned  on her  back, as in plate XV.
which is then more convenient  for delivering the head, than  when
laying on the side.
  N. B.  When the head is wedged in the pelvis, and  the  basis not
yet protruded below the brain, the forceps can neither be employed
with advantage nor safety;  and to attempt the mechanical turns re-
commended here would be difficult and hazardous.
  This plate shows that the handles of the  forceps  ought  to be
held as far back as the os externum will allow, that the  blades may
be in an imaginary line between that and the  middle space between
the umbilicus and the scrobiculus cordis.  When  the  forceps  are
applied along the ears and sides of the head, they are  nearer  to one
another,  have a better hold, and mark less, than when over the oc-
cipital and frontal bones.
St 
666
                       PLATE  IX.

IN THIS, THE OS EXTERNUM IS OPEN, THE OCCIPUT COMES LOW DOWN
  FROM BELOW THE PUBES, AND THE FOREHEAD PAST THE COCCYX,
  BY WHICH BOTH THE ANUS AND PERINEUM ARE STRETCHED OUT
  IN FORM OF A LARGE TUMOUR.

  When the head is so far advanced, the  operator ought to extract
with great caution,  lest the  parts  should  be torn.   If the labour-
pains are sufficient, the forehead may be kept  down, and helped
along, in  a slow manner, by pressing against it with the fingers on
the external parts below the coccyx ;  at the  same time, the  forceps
being taken off, the head may be allowed to stretch the os externum
more and more, in  a gradual manner, from the force of the labour-
pains, as well as  assistance of the fingers.  But, if the former are
weak and insufficient, the assistance of the forceps must be continu-
ed.  (Vide the description of the  parts in plate VIII.)   S.T. in
this, represent the left side of the os uteri.  The dotted lines de-
monstrate the situation of the bones of the pelvis on the right side,
and may serve as an example for all the lateral views of the same.
  A.B.C.H. The outlines of the os ilium.
  D.E. F.  The same of the pubis and ischium.
    M.N. The foramen magnum. 
Plate!)
 
 
 
IHnte /O
 
667
                       PLATE X.

IN THE SAME SECTION OF THE PARTS, BUT WITH A VIEW OF THE
  RIGHT SIDE, SHOWS THE HEAD OF THE FCETUS IN THE CONTRARY
  POSITION TO THE THREE LAST FIGURES, THE VERTEX BEING HERE
  IN THE CONCAVITY OF THE SACRUM, AND THE FOREHEAD TURNED
  TO THE PUBES.

  A The  anus.
  B The  os externum not yet begun to  stretch.
  C The  nympha.
  D The labium pudendi of the right side.

  When the head is small, and the pelvis large, the parietal  bones
and the forehead will, in this case, as they are forced downwards by
the labour-pains, gradually  dilate the os externum, and  stretch the
parts between that and the coccyx, in form of a large tumour, till
the face comes down below the pubes, when  the head will  be safely
delivered. But, if the same be large, and the pelvis narrow, the dif-
ficulty will be greater, and the child in danger ; as in the following
plate. 
668
                       PLATE  XI.

SHOWS, IN A LATERAL VIEW, THE FACE OF THE CHILD PRESENTING,
 AND FORCED DOWN  INTO THE LOWER PART OF THE PELVIS, THE
 CHIN BEING BELOW THF. PUBES, AND THE VERTEX IN THE CONCA-
 VITY OF THE  OS SACRUM : THE WATERS  LIKEWISE BEING ALL
 DISCHARGED, THE UTERUS APPEARS CLOSELY JOINED  TO THE BODY
 OF THE CHILD, ROUND THE NECK OF WHICH IS ONE  CIRCUMVOLU-
 TION OF THE FUNIS.

    A The inferior part of the rectum.
    B The perinasum.
    C The left labium pudendi.

  When the pelvis is large, the head, if small, will  come along in
this position, and the child be saved ;  for,  as the head  advances
lower, the face  and forehead will stretch the parts between the
fraenum labiorum and coccyx, in form  of  a large tumour.  As the
os  externum likewise is dilated,  the face will be forced through it;
the under part of the chin will rise upwards over the anterior part
of the pubes ;  and the forehead, vertex, and occiput,  turn from the
parts below.  If the head,  however, is large, it will  be  detained,
either when higher, or in this position.   In this case, if the position
cannot be altered to the natural,  the child  ought to be turned  and
delivered footling. 
Plate 11
 
 
 
Plate 12.
 
669
                       PLATE XII.

SHOWS, IN A FRONT VIEW OF THE PARTS, THE FOREHEAD OF THE
 FCETUS PRESENTING AT THE BRIM OF THE PELVIS,  THE FACE BE-
 ING TURNED TO ONE SIDE, THE FONTANELLE TO THE OTHER, AND
 THE FEET AND BREECH STRETCHED TOWARD THE FUNDUS UTE-
 i;i.

    A The perinaeum.
    B The os  externum ; the thickness of the posterior part be-
        fore it is stretched with the head of the child.
 C.C.C The vagina.
    D The os uteri not yet fully dilated.

  If the face is not  forced down, the  head  will sometimes come
along  in this  manner ; in which case the vertex will be  flattened,
and the forehead raised  in a conical form ; and  when the head comes
down  to the lower part of the pelvis, the face or occiput will be turn-
ed from the side, and come out below the pubes.   But, if the head
is large, and cannot be delivered by the  pains,  or if the  wrong posi-
tion cannot be altered, the child must be deliveretl with  the forceps.
If they should fail, recourse muist be had to embryulcia. 
670
                      PLATE XIII.

SHOWS, IN A LATERAL VIEW OF  THE RIGHT SIDE, THE FACE OT
 THE  FCETUS PRESENTING, AS IN PLATE XI.  BUT IN A CONTRARY
 POSITION ;  THAT IS, WITH THE CHIN  TO THE OS SACRUM,  AND
 THE BREGMA TO THE PUBES, THE WATERS EVACUATED, AND  THE
 UTERUS CONTRACTED.

  In such cases, as well as in those described in the last Plate, if the
child is small, the  head will be pushed lower with the labour-pains,
and gradually stretch the lower part of the vagina and the external
parts ; by which means the os externum will be more and  more di-
lated, till the vertex comes out below the pubes, and rises up on the
outside ; in which case the delivery is then the same as in natura!
labours.  But, if the  head is large, it will pass  along with great dif-
ficulty, whence the brain, and vessels of the neck, will be so much
compressed  and obstructed, as to destroy  the child.   To prevent
which, if called in time, before the head is far advanced in the pel-
vis, the child ought to  be turned, and brought footling.   If the head,
however, is low down, and cannot be turned, the delivery is then to
be performed with the forceps, either by bringing along the head as
it presents, or as in the following Plate.  See the references in Plate XI.
  N.B. Alarming floodings only excepted, it is bad practice to  turn
the child when the head presents ; and, in cases  of relative dispro-
portion between it and the pelvis, we can never propose to save the
child by turning. 
Plate  I'i
 
A 
 
/'fate II
 
671
                       PLATE  XIV.

REPRESENTS, IN A FRONT VIEW OF THE PELVIS, THE BREECH OF
 THE FOETUS PRESENTING, AND DILATING THE OS INTERNUM; THE
 MEMBRANES BEING TOO SOON BROKEN.   THE  FORE-PARTS OF THE
 CHILD ARE TO THE POSTERIOR PART OF THE UTERUS;  AND THE
 FUNIS, WITH A KNOT UPON IT, SURROUNDS THE NECK, ARM,  AND
 BODY.

  Sometime after this and  the other Plates were engraved, Doctor
Kelly showed me a subject  he had opened,  where the breech pre-
sented, and the child  lay much  in  the same position with its body
as in  the  second  plate, supposing the breech in that figure turned
down to the pelvis, and the head up to the fundus uteri.
   I have sometimes felt, in these cases, (when labour was begun,
and before the breech was advanced into the pelvis,)  one  hip at the
sacrum, the other resting above the os pubis,  and the private parts
to one side ;  but,  before they could advance lower, the nates were
turned to the sides and wide part of the  brim of the pelvis with the
private parts to the sacrum,  as in this plate;  though sometimes to
the pubes.  As soon as the breech advances to the   lower part of
the basin, the hips again return  to their former  position, viz.  one
hip turned out below tlie os pubis, and the other at  the back parts
of the os externum.
   In  this case, the child,  if not very large, or the pelvis narrow,
may be often delivered alive by the  labour pains ; but, if long de-
tained at  the inferior part of the pelvis, the  long pressure of the
funis may obstruct the circulation.  In most cases where the breech
presents, the effect of the labour-pains  ought  to be waited for, till
at least they have fully dilated the os internum and vagina, if the
same have  not been stretched before  with the  waters  and mem-
branes.  In the mean time, whilst the breech advances, the os ex-
ternum may  be dilated gently during every pain, to allow room for
introducing a finger or two of each hand to the  outside of each groin
of the foetus, in order to assist the delivery when the nates are ad-
vanced to the lower  part of the vagina.  But, if the  foetus is larger
than  usual,  or the pelvis narrow, and after a long time,  and many
repeated  pains, the breech is not forced down into the po!- is, the
patient's strength at the same time failing, the operator must,  in  a
gradual manner, open the parts, and, having introduced a hand into
the  vagina,  raise or push  up the breech of  the foetus,  and bring
down the legs and thighs.  If the uterus is so strongly contracted
that the legs cannot be got down, the largest end of  the blunt hook
is to  be introduced.   As soon as the  breech or legs are brought
down, the body and  head  are to be delivered,  as described  else-
where, only there is no necessity here to alter the position  of
 the child's body. 
672
   The  description of the parts in this plate is the same  as  in
that  of  plate  XIII.   only   the  dotted  lines  in  this  describe
the place of the ossa pubis,  and anterior parts of the ossa ischium
which  are  removed,  and may serve in this respect as an example
for all  the other front  views, where, without disfiguring the plate,
they could not be so well put in.
   N. B.  The use of the blunt hook, in  breech cases, is a hazardous
expedient; and manual assistance of every kind should be avoided,
the most urgent cases  only excepted.
   See Dr. Hamilton's Outlines of Midwifery, page 370. et seq. 
ii 
PLATE XV.
Frez-ncis' Cases of Ihmours ofthe Uterus.
H
A^ 
673
                      PLATE  XV.

 EXTRAORDINARY TUMOURS FORMED ON THE EXTERNAL SURFACE
                      OF THE UTERUS.

  [In the Notes on pages  124—6, I have described  two  cases of
remarkable tumours growing from the external surface of the uterus.
The annexed Engravings will convey a better idea  of the  situation
and extent of  these tumours, than any  description.  Tumours of
this nature, I apprehend, are of more frequent occurrence than is
generally supposed.—See the Philadelphia Medical Recorder, vol.
iv.                                                    F.J

      A. The os tincae.
      B. The uterus and its appendages.
      C. The neck of the tumour.
      D.  The tumour.
      E. F. G. H.  I. K. L. Smaller tumours or excrescen-
        ces growing from the great tumour.
85 
674
                    PLATE  XVI.

EXTRAORDINARY TUMOURS FORMED ON THE EXTERNAL SURFACE
                     OF THE UTERUS.

     A. The os tinea?.
     B. The bladder contracted.
     C The uterus.
     D. D.  The parietes of the uterus, thickened, and in several
       parts ossified.
     E. The bony tumour,  growing  internally from its fundus.
     F. The tumour in the fallopian tube.
     G. The enlarged ovarium.
     H. A small tumour from the fundus of the uterus.
     L K. L. M. N. O. Six large tumours attached near the cervix
       uteri.
           P. A portion of the peritonaeum. 
PLATE JCVI.
Fr.ujcJx' leases of Jhmottrs  of the Uterus
11
1)
A 
,v 
INDEX.
Areola,
Anasarca and Ascites,     ,
Abdomen, distention of,
Anxiety previous to labour,
Abdomen, subsidence of,
          coldness of,
          binding the,
          pain in, after delivery?
          integuments of, tender and inflamed,
          abscess in,
Abortion,       ....
         treatment of,    ...
         circumstances attending,
         not often dangerous,
Abscess, case of,     ...
Adhesions of the Vagina,   .
After-pains, causes and treatment of,
Age, advanced, cause of rigidity,
Amulets......
Anomalous labours,
Antimonial powder,
Arm presenting,
Attachment to the placenta over the os uten
227
247
248
269
261
392
561
562
563
570
466
469
471
475
571
352
563
333
365
463
580
440
478
B
Bladder,
Breasts, alteration of,
Bowels, disturbance of,
Bladder, stone in the,
Bleeding, women in labour,
         in convulsions,
Bowels, wind in,
Breasts, flaccidity of,
     106
     227
     241
     349
     329
525—529
     563
     391
c
                          .....    '    .     .     191
Customs, ancient,'respiting placenta and funis,      .    .     .     290
Costiveness,     •     •     •                                  ^  22fi
Conception, signs of,       •                             '          Jlg
Corpora lutea,   .     •     •                             *          ^g
Caruncul* myrtiforraes, 
676
INDEX.
Clitoris,    ..••••
Child's head, structure of,
Comparison of human and brute structure,
Complexion,     .
Catheters,.....
Cesarean operation,   .   '  •
               ,   method of performing,
Chamberlens,.....
Child, first,.....
       head of, uncommonly large,  or too much ossihed
       want of motion of the,
       dead, signs of,      .
       dead, equivocal signs of
      causes of death of
      method of turning
      evolution of         ...
Childbed, management of women in
Cicatrices in the vagina
Clysters, utility  of    ...
Coldness of the abdomen
Complex labours     ....
Consumptive women
Constitution, weakness of       .     ,
            wanting sufficient irritability
Convulsions, puerperal
                      description of
                      causes of
                      signs of
                      method of preventing
                      treatment of
                      manner of delivering in

                                  D
Diarrhoea        .
Discharge, mucous    ....
Disposition, effects of       ...
Disease, venereal     ....
Deformity, general, effects of
Delivery by means of instruments
        management of women after
Difficult labours      ....
Discharge, foetor and ill appearance of
          of meconium    .     .     .
Disease, bead enlarged by
Distortion of the pelvis
Douglas, Dr. his account of a ruptured uterus
      96
      87
     308
     314
     348
417—425
     426
     379
     332
     341
     393
     391
     397
     397
     442
     452
     557
     352
      320
      392
      463
      328
      327
      330
      517
      518
      519
      520
      523
      524
      528
     270
261, 271
     314
     250
     331
     363
     361
     316
     394
     395
     342
340. 455
358
Extraction of the placenta
Examination per vaginam
Egg       ....
Excrescences
EUenborough, Chief Justice
Edematose swelling of the head
Emetics in convulsions
Emphysema of the head
293
263
201
123
213
396
525
296 
INDEX.
677
Enlargement of the ovaria
Erysipelatose tumour on the knuckles, wrists, &c.
Evacuation of the meconium     .    .*
           of the brain    ....
Evolution of the child      ,
Excrescences of the os uteri
Experience, method of improving by
External parts, rigidity of       .
Extraction of the head     ....
Extra-uterine fetus.....
355
570
395
402
452
350
317
338
402
551
Fcetus, human  ,......
             circulation in      ...
Funis umbilicalis      .....
Fever, disposition to.....
Faculties, strong and weak
Fcetus, life, signs of        ....
Fluor albus......
Face inclined toward the pubes
     presentation of       ....
Fainting after hemorrhage  ....
             delivery     ....
Fever, preventing the proper action of the uterus
       puerperal      .....
Fillet, account and description of
Foetor in the apartment of the patient
Fcetus, of the discharges    ....
       extra-uterine       ....
       situation of.....
Forceps, various kinds of   ...
         general observations on
         rules for applying
                 for using when applied
         application of, under various circumstances
         compared with the vectis
Funis, ancient customs respecting
       umbilicalis.....
                 shortness of
                 division of      ...
                 compression of      .    .
                 torn from the placenta
                 descent of before the child
partuntion
210
211
213
232
315
295
243
S44
345
506
561
329
564
367
394
394
551
254
368
370
373
374
377
383
290
213
325
326
437
50!
543
G
Generation, parts of
Grinding pains   •     •     .
Glisson     .
General deformity, effects of
 98
27"
226
331
H
Harvey
Head, presentation ef
195. 202. 257 
&78
INDEX.
 Hemiplegia..........246
 Hemorrhoids     .                   ......240
 Hermaphrodites       .    •    •*......106
 Hernia, particular kind of        .......170
 Hydrocele..........167
 Hydatids......".....146
 Hymen...........109
 Mead of the child, compression of......340
                 uncommonly large, or too much ossified       «    341
                 diseased       ....-•     •    342
                 presenting with the arms       ....    346
                 on lessening the     ...    ...    388
                 edema and emphysema of      .                   396
                 operation of lessening     .....    400
                 extracting of the.....•    402
                 separation of from the body     ....    461
                 left       ........462
 Head-ach after hemorrhage      .....••    507
 Hemorrhage depending on pregnancy and parturition  .    .     .    463
            in abortion........    472
            treatment of........469
            in advanced pregnancy         .....478
            danger of........479
            from attachment of the placenta over the os uteri    •    480
            danger of delay in        ......    481
            manner of delivering in   ......    482
            from separation of the placenta      ....    485
            when the placenta is retained        ....    489
            when the placenta is expelled or extracted     .     •    502
            as connected with puerperal fever     ....    577


                                 I

Incubation..........    202
Impregnation    ..........    204
Indigestion      .     .    .    .     •    .     .    •     .     .     236
Inquietude..........245
Itching...........108
Irritability, defect of       ........330
           excess of       ........520
III appearance ot" tho discharges        ......    391
Inflammation, local    .........329
             of the uterus      .     .    .....    564
Instruments, general reflections on.....363. 367
            used in lessening the head    .....    399
Inversion of the uterus......,          508


                                 L

Labia, diseases of     .........    101
Labium, tumefaction of.......          561
Labour, distinctions of    ........     267
       natural..........268
       pains of.........272
       stages of      .........    277 
INDEX.
679
Labour, circumstances preceding      ....      260
       effect of climate on            -      -      -       -      316
Labours, difficult, definition of         -                           317
                 orders of     -      -      -      -       -      318
                from inert or irregular action of the uterus    -      318
                too great distention of the uterus     -       -      319
                partial action of the uterus    -                   321
                rigidity of the membranes    -      -       -      323
                imperfect discharge of the waters     -       -      324
                shortness of the funis umbilicalis     -       -      325
                weakness of the constitution         -       -      327
                fever or  inflammation        ...      329
                want of irritability          -                    330
                passions  of the mind         ...       331
                general deformity    -      -      -       -       331
                extreme  rigidity      -                            332
                first child     -      -       -     -       -       332
                age          .....       333
                too early rupture of tbe membranes   -       -       334
                obliquity of the os uteri        -      -       -       335
                rigidity of the os uteri         -                    337
                       of the external parts   ...       338
                disproportion         ...       -       339
                smallness of the pelvis         ...       339
                distortion of the pelvis        ...   340.455
                head large or ossified         -      -       -       341
                     enlarged by disease      ...      342
                face inclined to the pubes     ...       344
                     presenting        -                           345
                head presenting with arm     ...       346
                diseases of the soft parts       ...       347
                suppression of urine          ...      347
                stone in  the bladder          ...       349
                excrescences of the os uteri          -       -       350
                cicatrices in the vagina        -      -   *          352
                adhesion of vagina   -       -      "-.  •    -      352
                steatomatose tumours         -      -      - '     353
                enlargement of the ovaria     -      -      -      355
                rupture of the uterus          - '            -      356
            general observations on   -       -      -      -      360
        premature      ------      407
        preternatural           -----      432
                     distinctions of    -      -      -      -      440
        with hemorrhage       -----      463
        with convulsions        -----      517
              two or more children     -                           534
              a descent of the funis    -                           543
 Leg, swelling of       ------      597
 Lessening the head     ------      388
 Lives, comparison of   -----      -      3tt9


                                   M


 Membranes, protrusion of      -----       280
 Mollities ossium        ■                                  -       312
 Midwifery, necessity of                              „      -       306 
680                           INDEX.
 Menstruation    -      -      -      -
 Membrane, menstruous
 Menses, obstruction of        -      -
        cessation of
"Menstruation, painful   -
 Minerals        ....
 Membrana decidua
 Membranes     -
 Mole     -
 Mania lactea    -
 Mechanical weight of the uterus
 Meconium, evacuation of      -      -
 Membranes, rigidity of         -      -
            too early rupture of
 Milk, recession of
 Mind, ijts influence on labours
 Monsters
 Motion, want of        ...


                                    N

 Necessity of Midwifery
 Navel-string, tying of   -
 Nymphae, elongation of        -      -
 Natural labours         -
 Nut.....
 Needham       -      -      -    .  -


                                    o

 Ovaria
       enlargement of        -      -
       abscess of
       dropsy of
       inflammation of        -      -
       teeth, fcc-found in
 Oedopsophia   *
 Os uteri         ....
 Ossa pubis       ....
 Os sacrum       ....
   coccygis                         m
 Ossa innominata       -      -      -
 Os uteri, oblique position of
        extreme rigidity of
        excrescences of       .
        manner of dilating
Operation,  Cesarean
                   method of performing
 Ovum     .....
      waters of          ...
 Orders of difficult labours
                                   P

Pelvis
      separation of'bones of
      distortion of
Procidentia uteri
Perin«eum, dropsy of           .
           laceration of 
INDEX.
681
Placenta
Pregnancy, diseases of   .
Pains, distinction of
Parts, dilatation of
Propositions
Passions
Placenta, mode of extracting
Pelvis of women and brute creatures
Position, erect, of women
Pessaries
Polypus
Pruritus
Pudendum
Palfyn
Passions, influence of, on parturition
Pain in hemorrhages, a favourable symptom
Pelvis, original smallness of
       distortion of
Perforation of the head
Placenta, manner of its separation and exclusion
         retention of
         mode of extracting
         fu n i s se parated fro in
Presentation of the inferior extremities
                  arm
Preternatural labours
                    signs of
                    first order of
                    second order of
Pubes,  face inclined toward the
Puerperal fever
               treatment of
               dissections of
Quickening
Q
H
Rigors    -
Rachitis
Rhonhuysen       .      •      •
Rigidity, labours rendered difficult by
         of theos uteri
         of the external parts
Rupture, too early, of the membranes
         of the uterus
Strangury     .   •
Support of the perinaeum
Small Pox
Sleep, -.vant of
Sterility         •
Signs of a dead chdd
      convulsions
      twins
Smallness, original, of the pelvis
Spasm after delivery
86 
632
INDEX.
Stone in the bladder
Steatomatose tumours
Superfetation
Suppression of urine
Symphysis,  section of
Time ofuterogestation
Titsing
Tumours, steatomatose
Turning, method of
Twins
      signs of
      manner of delivering
      management of the placentae
T
U
Urine, suppression of
Uterus                  ,
      dropsy of
      retroversion of
      retroflection of
      diseases of
      disposition of, to cancerous diseases
      different forms of
        fravid contents of
        istention of
      action of
      insufficient action of
      too great distention of
      partial action of
      rupture of
      mechanical weight of
      contraction of
      on medicines for moderating the action of
      introduction  of the hand into
      irregular action of
      inversion of
      inflammation of
 Uterogestation, term of
 Urine, suppression of
13
5.YI
347
413
Various forms of uteri
             of placentae
Vagina
       abbreviation of
       cohesion of       .
       cicatrices of      .
Voice, different tones of
Vomiting
Vegetables
Vagina, cicatrices in
        adhesions of
Vectis, history and description of
       different kinds of
       comparison of with the forceps
       manner of using
 Vomiting in hemorrhages often beneficial 
INDEX.
683
w
Waters of tbe ovum
Walking, altered manner of
Waters, imperfect discharge of .
Weakness of constitution
Wind in the bowels
Women, consumptive
       management of in childbed
218
262
324
327
563
$•28
S57
THE END. 
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