u. t n > rg 5^ * \$.fy} \\1 r*-' f ^-.fTi **V '« HM , -.01)111 oft; ,-anr, ORQANi^cu Juut, 1799L N SURGEON GENERAL'S OFFICE Section,.. fUi3 Vs JVb.i..A.to.aj*4~. v >• r. "^ .APOAit.. -ANCV Caleb Winslow, M. D. 924 McCulloh Street, BALTIMORE, MO. ROBERT. A. "OK DON :U> LIBRAR;;. MEDICAL AND CHIBURGICAl FACULTY OF THE STATE OFMAftYLAtfD, ™«?»»»»ED JUNE* I78SU I I* • I ROBERT. A. GORDON. M.D THE PRINCIPLES OF* II 3D if II IF IB St 7 3 INCLUDING THE DISEASES OF WOMEN AND CHILDREN. BY JOHN &VRNS> c- M- REGIUS PROFESSOR OF SURGERY IS THE UNIVERSITY OF GLASGOW, &C. &C. FROM THE FIFTH LONDON EDITION, ENLARGED, WITH IN PROVEMENTS AND NOTES, BY T. C. JAMES, M. D. PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA. IN TWO VOLUMES. i-> V v6feu^SbN"G£FiERAL?S OFFICE| ^JUjlr"! 4.-1904 PHILADELPHIA.-----"—-—f--- PUBLISHED BY EDWARD PARKER, No. 178, MARKET-STREET. J. H. Cunningham, printer. 1823. BU7P h Eastern District of Pennsylvania, to wit: Ii BE IT REMEMBERED, That on the fourth day of February, [SEAL.l in the forty-seventh year of the Independence* of the United States 1 '■ of America, A. D. 1823, EDWARD PARKER, of the said district, hath deposited in this office the title of a book, the right whereof he claims as proprietor, in the words following, to wit: " The Principles of Midwifery ; by John Burns, C. M. Regius Professor of Sur* gery in the University of Glasgow, &c. &c. From the fifth London Edition, en- larged, with improvements and notes, by T. C. James, J\f. D. Professor of Mid- wifery, in the University of Pennsylvania." In conformity 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 co- pies during the times therein mentioned," and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. THE AUTHOR'S PREFACE. IN preparing this work, I have endeavoured to proceed as much as possible upon the method of induction. I have collected with care the different cases which have been made public, as well as my own private observations. To these I have added the, opinions and advices given by others, in so far as they seemed to be founded on facts, and supported by experience. From the whole I have deduced, in the different parts of my subject, both the symptoms and the practice. The anatomical descriptions I have given from dissections and preparations before me whilst writing. I intended to have added to the text copious references to the" opinions and cases contained in systems, or scattered through other publications. This would have rendered the present book, in some manner, an index to those already published, and been of considerable service to practitioners, who wished to consult them upon any particular point. But in spite of all my endeavours, the work has extended to a length which rendered it necessary to strike out many references, and shorten the account of cases, to prevent it from swelling to a size which would have rendered it less generally useful. Should this work fall only into the hands of those competent to jud^e in their profession, it would, if faulty or deficient,, do little- IV harm: But as it has been circulated extensively, it must, like- other systems and elements, have an influence on the opinions and future practice of the student of midwifery; and will prove useful or injurious to society, according to the correctness of the principles it contains. When I consider how important the dis- eases of women and children are, and how much depends on the prudent management of parturition, I feel the high responsibility which fells on those who presume to give lessons in midwifery. I do, however, sincerely trust, that the precepts 1 have inculcated will be found agreeable to experience;—and, on a review of the whole, I cannot say that I have either wasted the reader's time in idle theory, or misled his opinion by mere speculation. In preparing a fifth edition for the press, I have carefully re- vised the whole work, and have made additions, exceeding a hun- dred pages. The notes which were formerly thrown to the end of the book, I have now placed, for the convenience of the reader, at the foot of the pages to which they belong. Glasgow, Sept. 1820* MEDICAL AriD Cfc^lOAL FACULTY OF THE STATE CF MARYLAND^ ORGANIZED JUNE, {799. ADVERTISEMENT BY THE EDITOR. THE following highly flattering character of the ensuing work,, was given in the Edinburgh Medical and Surgical Journal, for the year 1810; since which it has passed through four successive edi- tions by the author, each of which has added considerably, not simply to the size, but also to the intrinsic value of the work. " The author, equally experienced as a teacher and practitioner has by a judicious arrangement, by a faithful exposition of facts and observations, and by a methodical induction of the principles and practice of the art, accomplished in this work all that could be expected, in the present state of the science, to give a new interest to the subject. - are covered with a very considerable quantity of cellular sub- stance, which is called the mons veneris. From this the two ex- ternal labia pudendi descend, and meet together about an inch be- fore the anus; the intervening space receiving the name of peri- naeum. On separating the great labia, we observe a small project- ing body placed exactly on the lower part of the symphysis. This is the clitoris, and it is surrounded by a duplicature of skin called its prepuce. From this duplicature, or rather from the point of the clitoris, we find arising on each side, a small flap, which is conti- nued down on the inside of the labia, to the orifice of the vagina. These receive the name of nymphae, or labiae minores or interiores. On separating them, we observe, about nearly an inch below the clitoris, the extremity of the urethra; and, just under it, the orifice of the vagina, which is partly closed up, in the infant state, by a semilunar membrane, called the hymen. These parts are all com- prehended under the general name of vulva, or external organs of generation. § 2. LABIA AND NYMPHJE. The labia have nothing peculiar in their structure, for they are merely duplicatures of the skin, rendered prominent by a deposi- tion of fatty matter. Externally they have just the appearance of the common integuments; and at the age of puberty, are, to- gether with the mons veneris, generally covered with hairs. Inter- nally they resemble the inside of the lips or eye-lids, and are fur- nished with numerous sebaceous glands. They are placed close- 43 together below than above; and at their junction behind, a small bridle called the fourchette, extends across, which is generally torn whenever a child is born. The nymphae at first appear to be merely duplicatures of the inner surface of the labia, but they are, in fact, very different in their structure. They are distinct vascular substances inclosed in a duplicature of the skin. When injected by filling the pudic ar- tery, each nympha is found to be made up of innumerable ser- pentine vessels, forming an oblong mass. This at the upper part joins the clitoris, to which, perhaps, it serves as an appendage; whilst the loose duplicature of skin in which it is lodged, by being unfolded, permits the labia to be more safely and easily distended, during the passage of the child. § 3. CLITORIS. The clitoris is a small body, resembling the male penis, but has no urethra. It consists of two corpora cavernosa, which arise from the rami of the ischia and pubis, and unite at the symphysis of the pubis. These are furnished with two muscles analogous to the erectores penis of the male. When the crura and nympha? are filled with wax, we find on each side, two vascular injected bodies, one of them in close contact with the bones, the other more internal with regard to the symphysis of the pubis. When the one is injected, tlie other is injected also, and both are con- nected together at the upper part. The clitoris, formed by the junction of its crura, is apparently about the eighth part of an inch long, a part of it not being seen, and it is supported by a pretty strong suspensory ligament which descends from the symphysis. When distended with blood, it becomes erected and considerably longer, and is endowed with great sensibility. § 4. URETHRA. On separating the nymphae, we find a smooth hollow or channel, extending down from the clitoris for nearly an inch; and at the termination of this, and just above the vagina, is the orifice of the 44 urethra, which although not one of the organs of generation, de- serves particular attention. The bladder is lodged in the fore part of the pelvis, immediately behind the symphysis pubis; but when distended, it rises up, and its fundus has been known to extend even to the umbilicus. The urethra is the excretory duct of the bladder; it is about an inch and a half long, and passes along the upper part of the vagina, through which it may be felt like a thick fleshy cord. The structure of the urethra is extremely simple, for little can be discovered except a continuation of the internal coat of the bladder, covered with condensed cellular substance. On slitting up the canal* numerous mucous lacunae may be discovered in its course, and two of these at the orifice are peculiarly large. The urethra is very vascular, and, when injected and dried, its ori- fice is perfectly red. In the unimpregnated state, it runs very much in the direction of the outlet of the pelvis; so that a probe, introduced into the bladder, and pushed on in the course of the urethra, would, after passing for about three inches and a half, strike upon the fundus uteri, and, if carried on for an inch and a half farther, would touch the second bone of the sacrum. The uterus being much connected with the bladder at its lower part, it follows, that when it rises up in pregnancy, the bladder will also be somewhat raised, and pressed rather more forwards, and the va- gina being elongated, the urethra, which is attached to it, is also carried a little higher, and, in its course, is brought nearer the in- side of the symphysis pubis. In those women who, from defor- mity of the pelvis, or other causes, have a very pendulous belly, the bladder, during pregnancy, is sometimes turned over the pubis, the urethra curved a little, and its opening somewhat retracted within the orifice of the vagina. When it is necessary to pass the catheter, it is of great consequence to be able to do it readily, and this is by no means difficult to do. The woman ought to be placed on her back, with her thighs separated, and the knees drawn a little up : a basin is then to be placed betwixt the thighs, or a bladder may be tied firmly to the extremity of the catheter to receive the urine. The instrument is then to be conveyed under the thigh, and the labia separated with the finger. The clitoris is next to be touched, and the finger run gently down the fossa that leads to the 45 orifice of the urethra, which is easily distinguished by its resem- blance to an irregular dimple, situated just above the entrance to the vagina. The point of the instrument is to be moved lightly down the fossa after the finger, and it will readily slip into the urethra. It is then to be carried on in the direction of the axis of the outlet of the pelvis, and the urine drawn off. This operation ought always to be performed in bed, and the patient is never to be exposed. In cases of fractures, bruises, &c. where the woman cannot turn from her side to her back, the catheter may be intro- duced from behind without moving her. When the bladder is turned over the pubis, as happens in cases of great deformity of the pelvis, it is sometimes requisite to use either a flexible catheter, or a male catheter, with its concavity directed forward. When the uterus is retroverted, if we cannot use a female catheter, we may employ a gum catheter. When the head of the child in labour has entered the pelvis, the urethra is pushed close to the symphysis of the pubis; then the flexible or flat catheter must be introduced pa- rallel to the symphysis, and the head of the child may be raised up a little with the "finger. This, indeed, of itself, frequently per- mits the urine to flow; and when the urine is retained after de- livery, it is often sufficient to raise up the uterus a little with the finger. § 5. ORIFICE OF VAGINA AND HYMEN. The orifice of the vagina is situated nearly opposite to the ante- rior part of the tuberosity of the ischium, about an inch and a half below the symphysis of the pubis, and in the direction of the axis of the outlet of the pelvis. It is, in all ages, but more especially in infancy, considerably narrower than the canal itself, and is sur- rounded by a sphincter muscle, which arises from the sphincter ani, and is accompanied with a vascular plexus, called plexus reti- formis. In children, it is always shut up by a membrane called the hymen, which consists of four angular duplicatures of the mem- brane of the vagina; the union of which may be discovered by corresponding lines on the hymen. At the upper part there is a semilunar vacancy, intended for the transmission of the menses. 46 Sometimes it is imperforated, or partially or totally absorbed. When the hymen is ruptured, it is supposed to shrivel into three or four small excrescences at the orifice of the urethra, called the carunculae myrtiformes.(Z) Immediately below the orifice of the vagina, there is a short sinus within the labia, which extends farther back than the vagina. This has been called the fossa navicularis, and reaches to the fourchette. CHAP. IX. Of the Internal Organs of Generation. § 1. VAGINA. The internal organs of generation consist of the vagina, with the uterus and its appendages. The vagina is a canal which extends from the vulva to the womb. It consists principally of a spongy cellular substance, endowed with some elasticity, and having an admixture of indistinct muscular fibres. It is lined by a continuation of the cutis from the inner surface of the labia; and this lining, or internal coat, forms nume- rous wrinkles, or transverse rugae, on the anterior and posterior sides of the vagina. They are peculiar to the human female, and are most distinctly seen in the virgin state; but after the vagina has been distended, they are more unfolded, and sometimes the surface is almost smooth. In the whole course of this coat, may be ob- served the openings of numerous glandular follicles, which secrete a mucous fluid. In the foetus this is white and milky; in the adult it is nearly colourless. The vagina is very vascular; and when the (l) Haller, in his Elementa Physiologiae, asserts that the hymen is peculiar to the female of the human species; but Duverney, in a Memoir read before the In- ' stitute and the School of Medicine, at Paris, asserts, that it is common to others of the mammalia. 47 parts are well injected, dried, and put in oil of turpentine, the ves- sels are seen to be both large and numerous. Just below the sym- physis pubis, we observe a great congeries of vessels surrounding the urethra and upper part of the vagina. The vagina forms a curved canal, which runs very much in the course of the axis of the outlet and cavity of the pelvis. It is not round, but considerably flattened; it is wider above than below, being in young subjects much contracted about the orifice. At its upper part, it does not join the lips of the os uteri directly, but is attached a little above them, higher up behind than before, so that the posterior lip of the uterus is better felt than the anterior. In the infant, the vagina is attached still higher up, so that the lips of the uterus project in it something like a penis. The inner coat of the vagina is reflected over the lips of the uterus, and passes into its cavity, forming the lining of the uterus. The junction of the uterus and vagina is so intimate, that we can- not make an accurate distinction betwixt them ; but may say, that the one is a continuation of the other. The vagina adheres be- fore very intimately to the urethra, behind, it comes gradually to approach to the rectum, and at its upper part it is pretty firmly connected to it. This union forms the recto-vaginal septum. These connections of the vagina are formed by cellular substance, there being only a very small part of its upper extremity covered with peritoneum. When the finger is introduced into the vagina in situ, the urethra is felt on its fore part, resembling a firm fleshy cylinder. Behind, the rectum can be traced down to the point of the coccyx. At the side, the ramus of the ischium and of the pubis, together with the obturator internus muscle are to be distinguished. In a well- formed pelvis, the finger cannot easily reach beyond the lower part of the sacrum ; during labour, however, the parts being more relaxed, the bone may be felt more easily, but its promontory can- not be touched with the fineer. 48 § 2. UTERUS AND ITS APPENDAGES. The uterus is a flat body somewhat triangular in its shape, being considerably broader at its upper than at its under part. It is scarcely three inches in length, about two inches broad above, and one below. It is divided by anatomists into the fundus or upper part, which is slightly convex, and lies above the insertion of the fallopian tubes; the cervix or narrow part below; the body, which comprehends all the space betwixt the fundus and cervix; and last of all, the os uteri, which is the termination of the cervix, and consists of a small transverse chink, the two sides of which have been called the lips of the uterus. The uterus contains a small cavity of a triangular shape, which opens into a narrow channel formed in the cervix, and is continued down to the os uteri. At the upper angles may be perceived the openings of the fallopian tubes. Both the cavity and the channel are lined with a continua- tion of the inner coat of the vagina, but it has a very different ap- pearance from that which it exhibits in the vagina. The surface of the triangular cavity is smooth, and the skin which covers it is very soft and vascular. The surface of the cervical channel again is rugous, and the rugae are disposed in a beautiful manner, so as to have some resemblance to a palm tree. This part is by no means so vascular as the cavity above; but it contains betwixt the rugae several lacunae, which secrete a mucous fluid. Where the cavity of the uterus terminates in the channel of the cervix, there is sometimes a slight contraction of the passage. The substance of the uterus is made up of numerous fibres,(m) disposed very irregularly, and having a considerable quantity of interstitial fluid interposed, with many vessels ramifying amongst them. A dense succulent texture is thus formed, which consti- tutes the substance of the uterus* On cutting open the womb, we observe that its sides are about a quarter of an inch thick, but are rather thinner at the fundus, than elsewhere, though the difference is very trifling. Several irregular apertures may be perceived on Cmj The reader is referred to a very interesting paper « on the muscularity . of the uterus, by Charles Bell, Esq. F. R. S. Ed. 8tc." published in the 5th vol. nf the Eclectic Repertory, p. 37, and § 9.. 49 the cut surface: these are the veinous sinuses. The fibres which we discover are muscular; but we cannot, in the unimpregnated state, observe them to follow any regular course. The arteries of the uterus are four in number, with correspond- ing veins. The two uppermost arteries arise either high up from the aorta, or from the emulgent arteries. They descend, one on each side, in a serpentine direction behind the peritoneum, and are distributed on the ovaria, tubes, and upper part of the uterus, These are called spermatic arteries. The two lowermost, which are called uterine, arise from the hypogastric arteries. They run, one on each side, toward the cervix uteri, and supply it and the upper part of the vagina. Thus the fundus uteri is supplied by the spermatic arteries, and the cervix, by the uterine arteries; and these, from opposite sides, send across branches which com- municate one with the other. But besides this distribution, the uterine artery is continued up the side of the uterus, and meets with the spermatic, so that, at the two sides, we have arterial trunks, from which the body of the uterus is liberally supplied with blood. The veins correspond to the arteries. The nerves of the uterus, like the blood-vessels, have also a double origin, and follow nearly the same course. Those which come from below are de- rived from the sacral nerves, especially from the fourth pair. Those from above come chiefly from the mesocolic plexus, and trunk of the intercostal. The renal plexus furnishes nerves to the ovarium. The lymphatics, in the unimpregnated state of the uterus, are small, and not easily discovered. Those from the upper part of the womb, and from the ovaria, run along with the spermatic ves- sels, terminating in glands placed by the side of the lumbar verte- brae. Hence, in diseases of the ovaria, there may be both pain and swelling of the glands. But the greatest number of lymphatics run along with the uterine artery, several of them passing to the iliac and sacral glands, and some accompanying the round liga- ment. This may explain why, in certain conditions of the uterus, the inguinal glands swell. Others run down through the glands of the vagina; and hence, in cancer of the womb, we often feel those glands hard and swelled, sometimes to such a degree, as almost to close up the vagina. 50 The uterus is covered with the peritoneum, which passes off from its sides, to reach the lateral part of the pelvis, a little before the sacro-iliac symphysis; and those duplicatures, which, when the uterus is pulled up, seem to divide the cavity of the pelvis into two chambers, are called very improperly the broad ligaments of the uterus. When the uterus is raised, and those lateral duplicatures of the peritoneum are stretched out, we observe, that at the upper part they form two transverse folds or pinions, one before and the other behind. In the first of these, the fallopian tubes are placed: in the second, the ovaria. Besides these duplicatures, we likewise remark other two which extend from the sides of the fundus uteri to the linea iliopectinea at the side of the pelvis, and then run on to the groin. These contain, on each side, a pretty thick cord, which arises from the fundus uteri, and passes out at the inguinal canal, being then lost in the labia pudendi. These cords, which are called the round ligaments of the uterus, consist of numerous blood-vessels, some lymphatics, small nerves, and fibrous matter. The fallopian tubes, in quadrupeds, are merely continuations of the horns of the uterus; but in the human female, they are very different in their structure from the womb. They appear to con- sist in a great measure, of spongy fibrous substance, which, as Hal- ler observes, may be inflated like the clitoris. They are hollow, forming a canal of about three inches long, lined with a continua- tion of the internal coat of the uterus; and as they lie in the ante- rior pinion of the broad ligaments of the uterus, they are covered of necessity with a peritoneal coat. They originate from the up- per corners of the uterine cavity by very small orifices, but termi- nate at the other extremity in an expanded opening with ragged margins, which are called the fimbriae of the tube. The internal surface of the canal is plaited, the plicae running longitudinally. The ovaria* lie in the posterior pinion of the broad ligament. They are two oval flattened bodies, of a whitish colour, and glan- * In birds, we find that the ovaria contain a great number of yolks of different , *sizcs. Those which are nearest the wide canal called the oviduct which leads 51 dular consistence. They are cellular, but not very vascular, al- though vessels run to their coat. After puberty, they contain numerous minute vesicles, the largest of which ar$ near the sur- face, and even form slight projections from it. These are the ova of the female, and are filled with a coagulable lymphatic matter. Their number is uncertain, but Haller says he never saw above fifteen in one woman. In old women they disappear or shrivel. The ovarium is covered with the peritoneum; but when the ovum is impregnated and becomes prominent, the peritoneum to the cloaca, are largest, whilst those remote from it are very minute. The full grown yolk is detached from the ovarium, and in its passage down is furnished both with the albumen and the necessary membranes and shell. In viviparous fishes, as the skate, ray, &c. the same structure obtains. These animals have two ovaria, containing eggs of different sizes; the smaller are white, the larger yellowish, and they pass down to an oviduct, which contains a glandular body that furnishes the covering of the egg. Each ovary has a separate ovi- duct, which forms a vast sac, that terminates in the sides of the cloaca, by orifices that have a duplicature like a valve. The cloaca itself forms an ample reservoir, that seems more like a continuation of the oviduct than the termination of the rectum. In oviparous fishes, the ovaria are known under the name of roes, and all the visible eggs are of the same size, and so numerous, that some contain above 200,000. They are enveloped in a fine transparent membrane; and septa from this envelope, divide the internal parts, and furnish points of attachment to the ova, which are expelled previous to fecundation. These are called oviparous fishes, and have, properly speaking, no oviduct. The ovaria of frogs resemble those of fishes, and the ova are, previous to expulsion, enveloped in a glary fluid. In the slug we find both testicles and ovaria. The ovarium is a grape-like tissue, containing numerous small grains, or ova, attached by pedicles, which are canals that lead into the oviduct. This is a serpentine canal, that after having adhered to the testicle, opens in the common cavity of generation, in which also the penis or duct from the testicle opens, and during copulation, the two individuals mutually impregnate each other. The ovaria of the adder are like strings of beads. In many quadrupeds, the ovaria contain ova almost as distinct as some of those animals I have just noticed. The hedgehog has an ovarium like a bunch of grapes; and the ovarium of the civet has a knotted surface, and resembles a packet of little spheres: the ovarium of the didclphis is also vesicular. The common sow has also an ovarium somewhat resembling, externally, that of ovi- parous animals. Most other quadrupeds have an ovarium more smooth and somewhat oblong in shape, and in general the tube and ovarium are unconnected, as in the human female ; but in the otter, my brother observed, that both were contained in a kind of capsule formed by the peritoneum, so that ventral extra uterine pregnancy cannot take place in this animal. 52 which covers it is absorbed, the ovum passes into the fallopian tube, and the little scar which remains on the surface of the ova- rium, is called corpus luteum.* In the foetus, the ovaria and tubes are placed on the psoae mus- cles; but in the adult, they lie loosely in the pelvis, and the uterus sinks within the cavity. The os uteri is directed forward, and the fundus backward, being in general found opposite to, or resting on, the second bone of the sacrum. CHAP. X. Of the Diseases of the Organs of Generation. § 1. ABSCESS IN THE LABIUM. The labia are subject to several diseases: of these, the first which I shall mention, is phlegmonoid inflammation. This may occur at any period of life, and under various circumstances; but frequently it takes place in the pregnant state, especially about the sixth and seventh month of gestation. Sometimes it appears sud- denly, and oftener than once in the same pregnancy. Occasionally it makes its attack in childbed in consequence of the violence which the parts may have sustained in labour. It is marked by the usual symptoms of inflammation, namely, heat, pain, throbbing, and more or less swelling, not unfrequently attended with fever. The swelling is sometimes hard and moveable, like a gland, espe- cially when the progress is slower than usual. In general, the course of the disease is rapid, the pain and inflammation are at first very acute, and the part swells speedily. In a few hours, es- pecially if a poultice have been applied, the abscess b egins to point * Sir E. Home asserts, that the Corpora lutea exists previously to impregna- tion ; and, in the virgin state, that they are sohd, compact, glandular substances, jn which the ovum is formed; and after the ovum is expelled, the blood which fills up the cavity is gradually absorbed, leaving a small cavity, which marks the place where the ovum had been. Vide Pbilos. Transact, years 1817 & 1819. 53 at the inside of the labium, and the nympha either disappears, or if it remain, it is pushed out of its place. Sometimes it bursts within thirty-six hours from its appearance. By means of cold saturnine applications, and gentle laxatives, the inflammation may perhaps be resolved, but most frequently it ends in suppuration, which is to be promoted by fomentations and warm cataplasms. If necessary, an opiate may be given to abate the pain, and a pillow must be placed between the knees, to keep the part from pressure. If possible, abscess ought not to be punctured ; but, if the pain and tension be unbearable, we must indulge the patient by making a small open- ing ; a good deal of blood will in this case come with the matter. After the abscess bursts, the parts may be dressed with any mild ointment. Should the opening of the abscess be higher than its bottom, it will be necessary, if the discharge continue,* to lay it open, after which it will speedily heal. § 2. ULCERATION OF THE LABIA. The internal surface of the labia is often the seat of ulceration and excoriation, which may generally be avoided by the daily use of the bidet. The general form under which excoriation appears, is that of a raw surface, as if the cuticle had been peeled from a blistered part. Most frequently these sores are the consequence of acrimony, produced by inattention to cleanliness, especially in children; and in their case the labia, if care be not taken, may cohere. The treatment consists in keeping the parts clean, bathing the sore with a weak solution of the sulphate of zinc, and prevent- ing cohesion. Should the parts not heal readily, they maybe washed with brandy, or a very weak solution of nitrate of silver, or touched with caustic. When adhesion takes place, it may, if slight, be destroyed, by gently pulling the one labium from the other; if firmer, the parts must be separated with a knife. In either case, reunion must be prevented by washing the surface frequently with solution of alum, and applying a small piece of lint spread with simple ointment. Simple itching of the parts may be removed by * Vide Mr. Hey's Surgical Observations, p. 188, 54 the tepid bath, a dose of castor oil, and fomenting the parts with milk and water. Sometimes we meet with deeper ulcerations, which it is of great importance to the domestic happiness of individuals to distinguish from chancre. Nothing seems easier in a book, than to make the diagnosis, but in practice it is often very difficult. A well- marked chancre begins with circumscribed inflammation of the part; then a small vesicle forms, which bursts, or is removed by slough, and displays a hollow ulcer, as if the skin had been scooped away or nibbled by a small animal; its surface is not polished, but rough, and covered with pus, which is generally of a buff or dusky hue; the margins are red, and the general aspect of the sore is angry. But the most distinguishing character of the chancre is considered to be a thickening or hardness of the base and edges of the ulcer. The progress of the sore is generally slow either towards recovery or augmentation. When remedies are used, the first effect produced is removing the thickening by degrees, and lessening the discharge, or changing its nature, so that the surface of the sore can be seen; it has then in general a dark fiery look, which continues until all the diseased substance be removed, and the action of the part be completely changed. Now, from this description, we should, it may be supposed, be at no loss in say- ing, whether a sore were venereal; but in practice, we find many deviations from this description. The thickening may be less in one case than another, and may not be easily discovered, yet the sore may be certainly venereal. Peculiarity of constitution, or of the part affected, can modify greatly the effects of the virus. There may be extensive inflammation, or phagedaenic ulceration; and yet the action may be venereal. It is, however, satisfactory to know in these cases, that in a little time, unless extensive slough- ing have taken place, the appearance of the sore becomes more decided, the proper character of chancre appears, and the usual remedy cures the patient. Phagedaena is a very troublesome, and sometimes a formidable disease, especially to infants. I shall here only notice that form which appears in adults, and which, as it is infectious, may be mistaken for syphilis. It commences with a livid redness of the oo part, succeeded speedily by vesication and ulceration, which ex- tends laterally, and sometimes penetrates deep. The ulcer has an eating appearance, is painful, discharges a great quantity of mat- ter, and very often is attended with fever. A variety of this dis- ease is attended with superficial sloughing, which may be fre- quently repeated, and is generally preceded by a peculiar appear- ance of cleanness in the sore. This is not to be confounded with sloughing, produced by simple inflammation or irritation of the parts, which is similar in its nature and treatment to common gangrene. We must foment the sore with decoction of camomile flowers, mixed with a little tincture of opium, and then apply mild dressings. Rest is essential to the cure: and if a febrile state exist, it is to be obviated by laxatives, acids, mild diaphoretics, and decoction of bark. If there be no fever, mercury, or the nitrous acid, often effectually change the action of the parts. Sometimes irritable sores appear on different parts of the labia, or orifice of the vagina, in succession, healing slowly one after ano- ther. These have an inflamed appearance, the margins are some- times tumid, and the surface is at first irregular and depressed, buj afterwards it forms luxuriant granulations. There is another sore met with on the inside of the labium, and wThich generally spreads to the size of a sixpence. The surface is quite flat, and sunk a little below the level of the surrounding parts. The margins are thickened, and sometimes callous, the discharge thin, and the ulcer not in general painful, the surface soft and spongy without a hard base. These sores generally agree best with stimulants, especially caustic and escharotics. When they do not yield to this treatment, it will be proper to have recourse to a cautious course of mercury- Some of these, like the phagedaena, are infectious. Some of these sores are occasionally productive of secondary symptoms, such as ulcers in the throat. When these succeed a sore which has run its course differently from chancre, and been healed without the use of mercury, it is allowable to suppose, that they also may be cured, merely by attending to the general health, and perhaps by local applications. But if they continue without amendment, or threaten danger to any important part, we must not delay making trial of mercury. 56 § 3. EXCRESCENCES ON THE LABIA. Sometimes after a slight degree of inflammation, producing heat and itching of the parts, numerous excrescences appear with- in the labia. These are either soft and fungous, or hard and warty. Both of these states may be induced by previous venereal inflammation; but they may also occur independently of that dis- ease. Even where there is an offensive discharge from the fungi or warts, we are not always to conclude that they are syphilitic, but be guided in our judgment by concomitant circumstances. Warty excrescences are most readily removed, by the application of savin powder by itself, or mixed with red precipitate; andduring its operation, the parts may be washed with lime water. The powder must be applied to the roots of the warts, for their sub- stance is almost insensible. Fungous excrescences may sometimes be removed by ligature; but when the parts are sensible, they must be destroyed, by applying a strong solution of caustic with a pen- cil, or sprinkling them with escharotic substances. If these cannot be borne, we must first abate the sensibility by tepid fomentations with decoction of poppies, or water with a little tincture of opium, or decoction of cicuta, or weak infusion of belladona. Should there be ground for suspecting a syphilitic action, mercury must be given, at the same time that we make suitable local applica- tions; but in doubtful cases, I have seen this medicine given with- out any benefit. These excrescences, from their appearance, their great pain, and foetid discharge, may suggest an opinion of their being cancerous: but they begin in a different way, and generally yield, though sometimes slowly, to proper applications. § 4. SCIRRHOUS TUMOURS. Solid tumours may form in the labia, and are distinguished by their hardness, and by their moving under the skin, until adhesion from inflammation takes place. These tumours are sometimes scrophulous and have little pain, even when they have gone on to suppuration. Oftener, however, they are cancerous; and these are distinguished from the former, by their great hardness and ine- 5? quality, and by their shooting pain. If they are not removed, the cancerous abscess points to the inner surface of the labium, its top becomes dark coloured, sloughs off, a red fluid is discharged, and presently fungus appears. Soon after this, the glands at the top of the thigh, and sometimes those in the course of the vagina, swell. If all the diseased parts can be removed, an operation must be performed. If they cannot, we must palliate symptoms by proper dressing and opiates. (») § 5. POLYPOUS TUMOURS. Soft fleshy appendicular, or firm polypous tumours, sometimes spring from the labia. Both of these, especially the latter, may give trouble by their weight or size. They may also, by being fretted, come to ulcerate, and the ulceration is always of a disa- greeable kind. They ought to be therefore early removed by the knife or the ligature. If the base be broad, the double ligature must be employed: but should there be any hardness about the part where the ligature would be applied, it is best to dissect the whole growth out. Encysted tumours may form in the labia. They are elastic, and (n) An immense tumour was successfully extirpated from the labia of a negro woman by Dr. Hartshorne at the Pennsylvania Hospital, in December, 1815, said to be produced by the kick of a horse, and of upwards of ten years stand- ing. In this case, the labia were much enlarged, and almost as hard as cartilage. The hardness and enlargement of the integuments extended anteriorly three inches above the pubis, and posteriorly to within two inches of the anus. The patient walked with great difficulty, as the circumference of the middle of the tumour was at least twenty inches, and its lower part almost reached the knees. The weight of the tumour removed, was upwards of eleven pounds. On the evening of the third day after the operation, unequivocal symptoms of Tetanus appearing, and the violence of the spasms increasing, caustic potash was freely applied to the neck, over the cervical vertebrae. The effect of this appli- cation in lessening the convulsive action of the muscles was very evident. The woman was discharged well, on the 6th of April, ensuing. In Larrey's Memoirs, vol. I. p. 299, will be found a description of a simihv tumour; ami in plate X. an engraving. 9 58 contain a glairy fluid. The cyst may be laid open, or it is to be dissected out.(o) § 6. CEDEMA. OEdematous tumour of the labium is either a consequence of pregnancy, or a symptom of general dropsy. The tumour is va- riable in its size. When it depends on pregnancy, it is seldom necessary to do any thing; and even in time of labour, although the tumour be great, we need be under little apprehension, for it will yield to the pressure of the child's head. But if at any time, during gestation, the distention be so great as to give much pain, then one or two punctures may be made, in order to let out the fluid; but this is very rarely necessary. Gentle laxatives are generally useful. Blisters applied to the vicinity of the part have been proposed ; but they are painful and even dangerous. When the swelling depends on dropsy, diuretics are to be employed ; but if the woman be pregnant, they must be used cautiously. § 7. HERNIA, LACERATION, &c. Pudendal hernia is formed in the middle of the labium. It may be traced into the cavity of the pelvis, on the inside of the ramus of the ischium, and can be felt as far as the vagina extends. It differs farther from inguinal hernia, which also lodges in the la- bium, in this, that there is no tumour discoverable in the course of the round ligament from the groin. It sometimes goes up in a recumbent posture, or it may by pressure be returned. A pessary has little effect in keeping it up, unless it be made inconveniently large. It is not easy to adapt a truss to it, but some good is done with a firm T-bandage, or one similar to that used for prolapsus ani. If it cannot be reduced, we must support it by a proper bandage, which is not to be drawn tight. Sometimes the labia are naturally very small, at other times un- commonly large ; one side may be larger than the other. foj Would it not be more eligible, when practicable, to extirpate the cyst completely by the knife, to prevent the risk of its sloughing away ? 59 Laceration of the labia is to be treated like other wounds. When the hemorrhage is great, the vagina must be plugged, and a firm compress applied externally, with a proper bandage. § 8. DISEASES OF THE NYMPHS). The most frequent disease to which the nympha is subject is elongation. When the part protrudes beyond the labia, it becomes covered with a white and more insensible skin. But sometimes it is fretted, on which account, or from other causes, women submit to have the nympha cut away. This is done at once by a simple incision, but, as the part is exceedingly vascular, we must after- wards restrain the hemorrhage, either with a ligature or by pres- sure. By neglect, the patient may lose blood, even addeliquium. In some countries, this elongation of the nympha is very common.* In others, the nymphae, together with the preputium clitoridis, are removed in infancy.f The nymphae are subject to ulceration, tu- mour, and other diseases, in common with the labia. Sometimes by falls, but oftener J in labour, the vascular struc- ture of the nympha is injured, and a great quantity of blood is poured out into the cellular substance of the labium, producing a * The females amongst the Bosjesmans have the nymphae sometimes five inches long. Their colour is a livid blue, like the excrescence of a turkey. Vide Bar- row's Travels in Africa, Vol. 1. p. 279. f On the shores of the Persian gulph, among the Christians in Abyssinia, and in Egypt among the Arabs and Copts, girls are circumcised. Niebuhr says, that at Kahira, the women who perform this operation are as well known as midwives. Travels, Vol. II. p. 250.—Dr Winterbottom, in his account of Sierra Leone, Vol. II. p. 239, says it is practised among the Mandingo, Foola, and Soosoo women. $ M. Causaubon has inserted a memoir on this subject, in the 1st Vol. of Re- cueil Periodique, which contains several useful cases. In one of these, the tu- mour was produced on the seventh month by a kick, and terminated fatally by hemorrhage.—In another given by Sedillot, the labia became prodigidusly dis- tended during labour, and the head of the child could not be touched. The labia were torn by the attendant. Afterward the child was delivered with the lever.—In cases related by Baudelocque, Brasdor, &c. the tumours were opened, and the vagina plugged, whilst the wound was stuffed with lint dipped in solution of alum, to prevent hemorrhage. 60 black and very painful tumour.* This may take place even be- fore the child is expelled; and, in a case of this kind, the midwife, mistaking the swelling for the protruded membranes, actually per- forated the labium, and caused a considerable discharge of blood.f More frequently, however, the tumour appears immediately after delivery,{ and the attention is directed to it both by its magnitude and its sensibility, which is sometimes so great as to cause syn- cope. It is tense, throbbing, and may also be accompanied by severe pain in the legs, and violent bearing-down efforts,^ as if another child were to be born, or, as if the womb were inverted. It has, however, been known to advance so slowly, as not to at- tract attention for two days. There are also instances where the inflammation runs high, and the recto-vaginal septum sloughing, faeces are discharged by the vagina. || In the course of a short time the tumour bursts, and clotted and fluid blood is discharged. This process should be hastened by fomentations and poultices, and the pain be abated by opiates; but if it be very great, relief may be obtained by making a small puncture in the inside of the labium.1T Whether the tumour burst, • In a case related by Mr. Reeve, the tumour, which I suspect proceeded from the rupture of the nympha, was perceived first in perineo, but soon occupied all the left labium, which was enormously distended. The pain at first was so great as to cause syncope. The parts sloughed, and discharged pus and clotted blood. Bark was given, and she got well. Lond. Med. Journ. Vol. IX. p. 119. f Vide case by Dr. Maitland, in Med. Comment. Vol. VI. p. 95.—Dr. Perfect relates a case, where it burst itself before the child was born, and discharged much blood. Vol. II. p. 63.—In another, which ended fatally, the tumour burst after deliver)', and discharged five pounds of blood. Vide Plenk Elementa, p. 111.—Case by M. Sedillot, in Recueil Period. Tom. I. p. 260. + Vide cases by Dr Macbride in Med. Obs. and Inq. Vol. V. p. 89. § In Mr. Blagden*s case, related by Dr. Baillie, the woman soon after delivery had violent bearing-down pains, as if another child were to be born. A mon- strous swelling appeared in the right labium, extending to the perineum. A large incision was made, which did not heal till the 21st day. Med. and Physical Journal. Vol. 11. p. 42. fl Vide Fichet de Flechy, Observ. p. 375. The patient was cured by introduc- ing a compress into the vagina, and dressing the sore with digestive ointment. 1 Le Dran relates a case, where above 20 ounces of blood were evacuated by incision. Consultations, p. 413. 61 or be punctured, the previous inflammation may close the vessels so as to prevent hemorrhage; but if it do not, the vagina is to be gently filled with a soft cloth to prevent the fluid from extending along the sides of the pelvis. A compress is also to be firmly re- tained externally, to check all hemorrhage from the aperture. If inflammation run high, it is to be abated by the usual means. § 9. DISEASES OF THE CLITORIS. The clitoris may become scirrhous, and even be affected with cancerous ulceration. In this disease, it is generally thickened, enlarged,* and indurated, and the patient complains of consider- able pain. Presently ulceration takes place and fungus shoots out. In no case of this kind that I have met with, has an operation been submitted to; and, indeed, unless the whole of the diseased part can be removed, we must be satisfied with palliating symptoms. In one case, however, related by Kramer,-]- where the clitoris was enlarged, with cauliflower-like excrescences, and the right nym- pha indurated, the parts were successfully removed by the knife, after failing with the ligature, which produced insupportable pain. The clitoris sometimes becomes preternaturally elongated; and if this take place in infancy, and be accompanied with imperfect or confused structure of the other parts, the person may pass for an hermaphrodite.^ This is said to be most frequent in warm * Mr. Simmons cutoff a clitoris, which formed a tumour nine inches in length, and fourteen in circumference, at the largest end. The circumference of the stem was five inches. Med. and Phys. Journal, Vol. V. p. 1. f Schmucker's Miscel, Surg. Essays, art. XXXUI. t Upon this subject, see Arnaud on Hermaphrodites. In a child aged three years, I found the mons veneris prominent, and as well as the labia, covered with a considerable quantity of red hair. The labia were large and thick, like those of a grown woman, but shorter. Their inner surface was white and rugous, until near the orifice of the vagina, where the skin was red. At the top the labia divaricated, and showed a large clitoris, which hung down like the penis; it was upwards of an inch long, and about half an inch in diameter, and furnished with a thick wrinkled prepuce. It had a distinct glans,at the end of which was observed something like a perforation; but on raising it up, this was seen to be only the extremity of a deep sulcus, which extended all the way 62 riimates; and in these, extirpation is sometimes performed. Hal- ler assigns a cause for the enlargement. § 10. DISEASES OF THE HYMEN. The most frequent disease of the hymen is imperforation; in consequence of which the menses are retained,* the uterus is dis- tended, and the orifice of the vagina protruded, so as sometimes to resemble polypus or a prolapsus uteri;f or it becomes fretted and covered with scabs. Even the perineum may be stretched, as if the head of a child rested on it.J Menstruation is generally painful, and the uterus becoming enlarged, contraction at last takes place, and pains like those of labour come on, especially about the menstrual period $ such a case, may, therefore, by inattention, be mistaken for parturition. || The sufferings of the patient are, in to the urethra, or orifice of the vagina. It resembled the male urethra slit up. The sides of this were formed by the nymphae. A little before the orifice of the urethra, there was a longitudinal eminence, like the veru montanum. The vagina was shut up by the hymen. The uterus was large like that of a girl of fourteen years of age, and was shaped like hers. The ovaria were of corres- ponding size ; one of them lay on the psoas muscle, the other was loose in the pelvis. The tubes were fimbriated at the extremity, but in their course were knotted and serpentine, like the commencement of the vas deferens. The ute- rus was very vascular, and had an inflamed appearance. Its mouth was appa- rently impervious. In a male child that I lately saw, the external parts resemble those of the fe. male. The scrotum is cleft like the vul\a, the penis consists only of corpora cavernosa, and the urethra opens between the labia formed by the scrotum. * The same effect may be produced, by a continuation of the skin being ex- tended over the parts. It must be cut up. See a case by M. Larrey, in Rapport General de la Societe Philomatique, Tom. II. p. 86. f Vide case of a patient of Dr. Chamberlain's, in Cowper's Anatomy.—Case by Mr. Fryer, in Med. Facts and Obs. Vol. VIII. p. 132. * Case by Mr. Sherwin, in Med. Records, &c. p. 279. § Case by Mr. Kaeymer, in Med. Annals, Vol. VI. p. 347. By Mr. Eason, in Med. Comment. Vol. II. p. 187. and a variety of other cases. This, in every in- stance I have known, has been the greatest complaint. || Dr. Smellie candidly acknowledges, that in one instance he took the protru- sion of the hymen for the membranes of the ovum forced down by labour pains. These pains were accompanied with suppression of urine. He let out about two quarts of blood. Coll. I. n. i. c. 6. 63 some instances, increased by the addition of suppression of urine,* or pain in passing the faeces,f or convulsions.J Imperforated hy- men is by no means uncommon, and the treatment is very simple, for the part is easily divided.^ The retained fluid is thus evacu- ated, sometimes in very great quantity. It has very rarely the ap- pearance of blood, being generally dark coloured, and pretty thick, or even like pitch. Febrile and inflammatory symptoms may follow the operation. || The hymen is sometimes perforated as usual, but very strong, so as to impede the sexual intercourse; yet in those cases impreg- nation has taken place, aiid the hymen has been torn,1T or cut in the act of parturition. Conception may take place, although the hymen be imperforated.** * In a case related by Benevoli, the belly was very much swelled, and the urine suppressed. He attempted to pass the catheter, but without success. Next day he repeated his endeavour, and pushing with more force than prudence, considering his object, he ruptured the hymen, and immediately a great quan- tity of dark matter was evacuated, .even to the extent of 32 pints.—See also Mr. Fryer's case.—Mr. Warner relates the case of a little girl, where the hymen was continued half way over the orifice of the urethra. The effects were at first at- tributed to stone in the bladder; but the nature of the case being made out, she was cured by dividing the hymen. Cases, p. 75. f In a case by Mr. Bardy, the patient, who was 15 years of age, had every month, for some days, pain in the uterine region. The external parts were great- ly protruded and stretched as in labour, and the nymphae formed merely two lines. The anus was thrust backward and distended, and she passed the urine and faeces with great pain ; the hymen from irritation was covered with scab, the health had suffered. Six pounds of thick gelatinous matter were evacuated by incision. Med. and Chir. Review for September, 1807. t Vide Case by Mr. Eynney, in Med. Comment. Vol. HI. p. 194. § In Mr. Fynney's case, the part to be divided was very thick ; and in Dr. M'Cormick's case, the vagina seemed to be in part impervious. Med. Comment. Vol. II. p. 188.—In general the membrane is thin. || Vide Mr. Niven's case, in Med. Comment. Vol. IX. p. 330. The symptoms gradually abated. 11 M. Baudelocque mentions an instance where the hymen resisted, for half an hour, the strong action of the uterus. Note to section 341. ** Vide Ambrose Pare, Hildanus, cent. III. ob. 60.—Ruysch, ob. 22.—Mau- riceau, ob. 439. In a case lately published by Champion, the urethra was greatly dilated, and had served as a substitute for the vagina, notwithstanding which the female became pregnant, and was delivered by dividing the hymen. Jour, de Med. T. LXVIU. p. 84. 64 When the hymen is torn in coitu, some blood is evacuated, which, in many countries, is considered as a mark of virginity. But as even the presence or absence of a hymen cannot be looked upon as affording any certain proof relative to chastity, this test must be considered as altogether doubtful. When the hymen is ruptured, and there is an inflammation about the external parts, some have, in cases of alleged rape, considered the crime as proven. But whoever attentively examines the subject must admit, that these are very fallacious marks; that they may exist without any violence having been employed; and that a woman may have, if previously stupified, been violated without exhibiting any mark of injury. Practitioners therefore ought, in a legal question of this nature, to be cautious how they give any opinion, especially if they have not seen the person immediately after the crime has been committed.* § 11. LACERATION OF THE PERINJEUM. The perineum may be torn during the expulsion of the head or arms of the child. In many cases, the laceration does not extend fartherl>ack than to the anus, nor even so far. This is a very sim- ple accident, and requires no other management than rest, and at- tention to cleanliness. But as the recto-vaginal septum is carried forwards and downwards, when the perineum is put on the stretch previous to the expulsion of the head, it sometimes happens, that the laceration extends along this septum, and a communication is formed betwixt the rectum and vagina. In some cases, the sphinc- ter ani remains entire, although the rectum be lacerated; in others it also is torn. This accident is attended with considerable pain and hemorrhage, and succeeded by an inability to retain the faeces, which pass rather by the vagina than the rectum. Prolapsus uteri is also, in some instances, a consequence of this laceration. This accident is sometimes produced by attempts to distend the parts previous to delivery, or by the use of instruments; but it may also * Vide Baudelocque, I'Art, &c. sec. 342, et Fodere Med. Legale. Tome II. p. 3. 65 take place, even to a great degree, in a labour otherwise natural and easy, and in which no attempts have been made to accelerate de- livery. The most effectual way to prevent laceration is by sup- porting the perineum with the hand, when it is stretched, and keep- ing the head from being suddenly forced out. When the parts have been actually torn, our first attention is to be directed to the re- pressing of the hemorrhage, which is sometimes considerable: and this is best effected by compression and rest, which favour the for- mation of coagula. Next, we are to consider how the divided parts may be united. Rest, and retaining the thighs as much together as possible, together with frequent ablution, in order to remove the urine, which sometimes for a few days flows involuntary, or the lochia and stools, are requisites in every mode of treatment. As there is nothing in the structure of the parts to prevent their re- union, it has very feasibly been proposed to induce a state of cos- tiveness, and prevent a stool for many days. But with only one or two exceptions, this method has failed; the subsequent expulsion of the indurated faeces tearing open the parts, if adhesion had taken place. An opposite practice, that of keeping the bowels open, and the stools soft or thin, by gentle laxatives, has been much more successful, the parts, in some instances, healing in a few weeks; and this is the practice I would recommend to be adopted, taking care, at the same time, to keep the parts in contact, by confining the patient to bed, with the thighs kept together. During this pe- riod, the stools are, at least for a time, passed involuntary; but in other instances, they can from the first be retained, if the patient keep in bed. Sutures have been also employed, and ought cer- tainly at last to be had recourse to, if re-union cannot otherwise be effected.^ The edges of the divided parts must previously be made raw. It would appear that there is no occasion for putting a ligature in the recto-vaginal septum. It is sufficient to place two in the perineum. When the sphincter ani remains entire, but the septum is torn, some have considered it necessary to divide that muscle; but others, with more reason, omit this practice. During CpJ Sutures should be rarely had recourse to, as they occasion considerable irritation, and are liable to be torn, or to slough out. 10 66 the cure, some introduce a canula into the vagina, to support the parts, and others apply compresses dipped in balsams; but it is bet- ter to apply merely a pledget, spread with simple ointment to the part. If the radical cure fail, the patient must use a compress, with a T-bandage, if the stools cannot be retained. But it sometimes happens that the torn extremity of the rectum, or the anterior part, forms a kind of flat valve, which rests on the posterior surface at the coccyx, so that the orifice now resembles a slit, and the faeces, unless very liquid, remain in the hollow of the sacrum, and do not pass through the valvular orifice till an effort be made to expel.* § 12. IMPERFECTION OF THE VAGINA. The vagina may be unusually small. I have known it not above three inches long, and sometimes it is very narrow. The size, it necessary, may be enlarged with a tent of prepared sponge.f Should pregnancy take place before it be fully dilated, we need be under no apprehension with regard to delivery ; for during labour, or even long before it, relaxation! takes place. Sometimes the vagina is wanting or impervious, or all the middle portion of the canal is filled up with solid matter. More frequently, however* there is only a firm septum stretched across, behind the situation of the hymen, or higher up in the vagina; and this^ it may be ne- cessary to divide. In some cases, there is a great confusion of * Upon this subject, vide La Motte's Traite"; and cases and observations by Noel, Saucerote, Trainel, and Sedillot, in the fourth and seventh Vol. of the Re- cueil Periodique. Dr. Denman mentions an instance where the perineum was not torn up, but perforated by the head. Both Petit and Gardien notice the fact that the stools may ultimately come to be retained, but do not seem aware that this depends on the formation of a valve. They think it owing to the sphincter regaining its power. f Vide Van Swieten Comment, in aph. 1290. $ In a case where the vagina would not admit the point of the little finger, the child was delivered after eighteen hours labour. Plenk Elementa, p. 113. See also Van Swieten. § This may produce bad effects, from retention of the menses. M. Magnan relates the case of a girl, aged 22 years, who had been subject to monthly colics and suppression of urine. An incision was made through the membrane, and two pounds of blood let out. Hist, de la Societe" de Med. pour 1776, art. II. 67 parts, and indeed, it is impossible to describe the varieties of con- formation ; for the vagina may follow a wrong course, or commu- nicate with the urethra, or the rectum* may terminate in the va- gina, &,c. Malformation does not always prevent pregnancy.^ § 13. INFLAMMATION AND GANGRENE OF THE VAGINA. In consequence of very severe labour, inflammation, followed by gangrene of the vagina, may be produced. If the sloughs be small, then partial contraction of the diameter of the canal may take place, and cause much inconvenience from retention of the menses,J or during a subsequent labour; but in this last case, the parts gradually yield, and it is seldom necessary to perform any operation: the pain, however, is sometimes excruciating till the part yield.^ In some instances the sloughs are so extensive, that the whole vulva is destroyed, or part of the urethra and vagina come away, or general adhesion takes place, leaving only a small opening, through which the urine and the menses flow. Should this, by • In this case the faeces do not always pass continually. The patient has been known not to have a stool once in a fortnight; which probably depended on the faeces being indurated, and the communication small. j- In the 33d Vol. of the Phil. Trans, p. 142, there is a case related, where there was a kind of double vagina, separated by a transverse septum or mem- brane. The orifices were very small. During labour, the pain was so great as to produce convulsions. She was delivered, by laying the two passages into one. Chapman relates a case of malformation, where the woman was impregnated, and in labour all the forcing was felt at the anus. From this an opening was made through into the vagina, and the child was born per anum. Portal men- tions a girl, who had only a very small aperture at the vulva, for the evacuation of the urine ; the menses came from the rectum; nevertheless, she became preg- nant. Before delivery, the orifice of the vagina appeared, and she bore the child the usual way. Precis de Chirurgie, Tom. II. p. 745. t Richter in Comment. Gotting. Tom. III. art. 2. relates a case of a girl aged 20 years, who for three years had been subject to violent pains about the sacrum, with tremours and syncope every month. The vagina was found to be closed at the upper part, inconsequence, it was imagined, of a variolous ulcer in infancy. Fluctuation was felt in the vagina, when pressure was made with the other hand on the abdomen. The contraction was opened, and a quantity of blood let out. § Harvey, exercit. LXXllI.p. 492. 68 any means be obstructed, the discharges cannot take place; and sharp pains, or even convulsions, may be the consequence. Some- times calculous concretions form beyond the adhering part.* Whenever we have reason to expect a tender state of the parts after delivery, we must be exceedingly attentive ; and if the vagina, or any other organ, be inflamed or tender, we must bathe the parts frequently, and inject some tepid water gently, to promote clean- liness. Saturnine fomentations and injections are often of service, but they must not be thrown high. The urine must be regularly evacuated; and should a slough take place, we must, by proper dressings, or the use of a thick bougie, prevent coalescence of the vaginal canal.f Abscesses and sinuses connected with the vagina, must be treated on the general principle of surgery; but it is proper to mention that sometimes the orifice of the sinus is excessively ten- der to the touch, insomuch as almost to produce syncope. In all cases of extreme sensibility of this canal, it ought to be carefully examined, and the painful spot may point out the seat of the dis- ease. The sinus should be laid open, and hemorrhage prevented by the injection of cold water, or insertion of lint, wet with cold water. § 14. INDURATION, ULCERATION AND POLYPI. The vagina may be contracted by scirrhous glands in its course, or induration of its parietes, which become thick and ulcerated, and communicate with the bladder or rectum. This disease is generally preceded by, or accompanied with, scirrhous uterus, and requires the same treatment. Foreign bodies in the vagina produce ulceration, and fungous excrescences. The source of irritation being removed, the parts * Vide Puzos Traits, p. 140.—Case by Mr. Purton, in Med. and Phys. Jour. Vol. VI. p. 2. | In some parts of Africa, the vagina is made impervious, in order to prevent coition. This operation is generally performed betwixt the age of eleven and 1*velve years. Brown's Travels, p. 349. 69 heal; but we must, by dressing and injections, prevent coales- cence. Polypous tumours may spring from the vagina, and are to be distinguished from polypus of the uterus by examination. The diagnosis betwixt polypus and prolapsus, or inversio uteri, will be afterwards pointed out. The cure is effected by the application of the ligature more solito. § 15. INVERSION. The vagina may be inverted or prolapsed, without any material change in the state of the womb, and without symptoms of uterine irritation, farther than slight pain in the back, and a little mucous discharge. We find a fleshy substance protruding at the back part of the vulva, having an opening before leading into the vagina. If the procidentia be considerable, the rectum is carried forward, and in every instance is relaxed. At first the tumour is soft; but after some time, if the part has been irritated, it may inflame, in- durate, or ulcerate. It is cured by strict attention to the state of the bowels, thereby preventing accumulation in the rectum, by astringent injections into the vagina, the cold bath, the internal use of tincture of kino, and, if these fail, by a globe pessary, or a spring-bandage similar to that employed for prolapsus ani, or by pregnancy ; but it sometimes returns after delivery.* § 16. WATERY TUMOUR. Water sometimes passes down from the abdominal cavity, be- twixt the vagina and rectum, protruding the posterior surface of the vagina in the form of a bag; and the accumulation of water in the cavity of the pelvis is sometimes so great as to obstruct the flow of the urine, or produce strangury. When the person lies * Burton relates a case, where the prolapsed vagina was mistaken for part of the placenta, and rudely pulled away, by which the vagina and bladder were torn. System, p. 170. Stollers relates a case, where this was complicated with calculi. These being removed, the parts were reduced, and a cure obtained. Cases, Obs. 2. 70 down, the swelling disappears. If large, a candle held on the op- posite side, sometimes shows it to be transparent; and in every case, fluctuation may be felt. As this symptom is connected with ascites, the usual treatment of that disease must be pursued, and, if necessary, the water may be drawn off by tapping the abdomen, or rather by piercing* the tumour, which is to be rendered tense, by pressing it with the finger. § 17. HERNIA. Sometimes the intestine passes down betwixt the vagina and rectum, forming perineal hernia, or protrudes either at the lateral or posterior part of the orifice of the vagina, like the watery tu- mour ; but is distinguished from it by its firmer and more doughy feel, and by the manner in which it can be returned. By handling it, a gurgling noise may be heard, and sometimes indurated faeces may be felt. As the os uteri is pushed forward, and the posterior part of the vagina occupied by the herniary tumour, this complaint may put on some appearance of retroverted uterus. A case of * Mr. Henry Watson, in the Med. Communications, Vol. I. p. 162, called the attention of practitioners to this disease. In a case he relates, he drew off in the month of June, four gallons of fluid, by tapping the vagina; and immediately after this she passed the urine freely, which she could not do before. She re- quired again to be tapped in two months, and died in November. The left ova- rium was found to be converted into a cyst about the size of a sow's bladder, but it had not been touched by the trocar. In one case, he punctured with a lancet instead of a trocar, but this was succeeded by troublesome hemorrhage. The good effects of tapping are also seen in a case related by Mr. Coley,in Med. and Phys. Journal, Vol. VII. p. 412. In this two gallons of water were drawn off, and she continued well for five months, after which dropsical symptoms returned, and although diuretics gave her some relief, yet she was at last cut of!'. In the case of Mrs. Jarritt, related by Sir W. Bishop, in Med. Commun. Vol. II. p. 360, pain was felt in the right side of the belly, after parturition, accompanied with tumefaction. In two years the vagina became prolapsed, the tumour being four inches in diameter. The tumour was punctured twice; the first time 46 pints, the second 51, were drawn off. Diuretics had no effect. In a case related by Dr. Denman, the woman was pregnant, and no operation was performed. On the fourth day after her delivery, after a few loose stools, she expired, lntrod. Vol. I. p. 150. 71 this kind is mentioned by Dr. John Sims, in Mr. Cooper's work on Hernia. This complaint is frequently attended with a bearing- down pain; and on this account, as well as from its appearance, it has also been mistaken for prolapsus uteri. Sometimes the tu- mour does not protrude externally; but symptoms of strangulated hernia may appear, the cause of which cannot be known, unless the practitioner examine the vagina. In a case occurring to Dr. Maclaurin, and noticed by Dr. Denman, the patient died on the third day, and the disease was not discovered till the body was opened. Should a woman have vaginal hernia during pregnancy, we must be careful to return it before labour begin, for the intes- tine may become inflamed, and the faeces obstructed, by the head entering the pelvis; or the labour itself, if the head cannot be raised and the intestine returned, may be impeded so much as to require the use of instruments. Vaginal hernia requires the use of a pessary, or a spring-support. The rectum sometimes protrudes into the vagina, and always does so more or less in an inversio vaginae. This is remedied by the globe pessary, after all the indurated faeces have been removed. The farther accumulation is prevented by laxatives. § 18. ENCYSTED TUMOUR AND VARICES. Indolent abscess, or encysted tumours, may form betwixt the vagina and neighbouring parts. These are distinguished from hernia and watery tumours by being incompressible, and not dis- appearing by change of posture. The history of the disease assists the diagnosis, and examination discovers the precise seat and connections of the tumour, though it cannot with certainty point out the nature of the contents. These tumours seldom afford obstinate resistance to delivery; by degrees they yield to the pres- sure of the head, but sometimes they return after delivery. The treatment is similar to that required in other cases of tedious la- bour, and the tumour must be opened, if we cannot deliver the woman otherwise, with safety to the child. Even in the unim- pregnated state, if it cause irritation, or if the bulk of the tumour 72 be so great as to impede the evacuation of urine or faeces, an open- ing must be made. After delivery, in those cases where no ope- ration is performed, the tumour sometimes inflames and indurates even so low as the perineum. Friction on the perineum, has, in these circumstances, done good. Varicose tumours, of a knotted form, disappearing or becom- ing slack by pressure, and aneurismal tumours, distinguishable by their pulsation, may form about the vagina, and ought not to be interfered with, except by supporting them with a globe in the vagina. § 19. SPONGOID TUMOUR. A very dreadful disease, which I have called spongoid tumour, may form either within the pelvis, or about the hip-joint, or tube- rosity of the ischium, and spread inwards, pressing on the bladder and rectum, sometimes so much as to require the use of the cathe- ter. We recognise the disease, by its assuming very early the appearance of a firm elastic tumour, as if a sponge were tied up tightly in a piece of bladder. Presently it becomes irregular, and the most prominent parts burst, discharging a red fluid, which is succeeded by fungous ulceration. But I have never known it pro- ceed to this last stage within the pelvis. I know of no remedy, and would dissuade from puncturing, except in the very last ex- tremity. I have never met with a case where it was necessary. § 20. ERYSIPELATOUS INFLAMMATION. The orifice of the vagina, together with the labia, and indeed the whole vulva may be affected by erysipelatous inflammation. This appears under two conditions: 1st, it may originate in the vulva, and spread inwards, even to the uterus; or, 2dly, it may begin in the womb, and extend outwards. The parts are tumid, painful, and of a dark red colour. The second affection is most frequent after parturition; but the first may occur at any age, and under a variety of circumstances. It may be confined to the ex- 73 ternal parts alone, or it may quickly spread within the pelvis, and destroy the patient; for this disease generally terminates in gan- grene. Vigarous* says, this state may be distinguished from ab- scess of the labium, by both labia being equally affected. The general history of the case, and proper examination, will point out the difference. When the disease is confined to the external parts, we may hope for a cure, and even for the preservation of the parts, by giving early, bark and opium internally, and applying to the surface, pledgits dipped in weak solution of sulphate of zinc, with the addition of a tenth part of camphorated spirit of wine. When this application gives continued pain, fomentations with milk and water, or with decoction of chamomile flowers may be substi- tuted. A highly sensible or inflamed state of the parts may occur in nymphomania, or libidinous madness, either as a primary or secon- dary affection; and should the patient die under the disease, the parts are generally found black. The tepid bath and fomentations give relief, and sometimes saturnine applications are beneficial. The acetite of lead has also been given internally. If the patient be feverish, she ought to be blooded, and have cathartics admin- istered, and be put on spare diet. Nauseating doses of tartar emetic, or full doses of the medicine, given so as to operate briskly, are of service, especially if followed by sleep. Strict and prudent atten- tion must be paid to the mind. A constant heat and tenderness of the parts, if not occasioned by uterine disease, may be relieved by bathing with solution of sulphate of zinc, and using laxatives. Prurigo is often symptomatic of disease in the uterus, or irrita- tion in the neighbouring parts; and in these cases can only be re- moved by acting on the cause. When it is not dependent on any evident local disorder, it is allayed or cured by keeping the bowels open, avoiding stimulants, and applying to the affected parts ung. hyd. nit. or bathing frequently with very weak solutions of oxymu- riate of mercury, or the same salt mixed with lime water, or lime water alone, or solution of sulphate of zinc alone, or with laudanum. * Maladies des Femmes, Tome II. p. 169. 11 74 &c. This affection may attend the early period of pregnancy, or the cessation of menstruation. Prurigo affecting the anus alone, or along with the pudendum, may arise from ascarides or other removable irritations; but in el- derly females this symptom should always lead to an examination of the rectum, for it often attends stricture or alteration of the in- testine, which should be early attacked by suitable means. So far as itching and local uneasiness require prescription, nothing often succeeds better than a suppository consisting of three grains of ex- tract of hemlock and one of opium. § 21. FLUOR ALBUS. The vagina is always moistened with a fluid, secreted by the la- cunae on its surface. To this is added the secretion from the glands of the cervix uteri, and the serous exhalation from the membrane of the uterine cavity. Naturally, the balance between secretion and absorption is such, that except on particular occasions, no fluid is discharged from the vagina. But in a diseased state, the quan- tity of the secretion is greatly increased, and the discharge, whether proceeding solely from the vagina, or partly also from the womb, receives the name of fluor albus, leucorrhoea. Some confine the term strictly to a discharge from the inner surface of the womb; and in order to determine whether the secretion proceeds from the uterus or not, it has been proposed to stuff the vagina completely for some time, and then inspect the plug, to ascertain whether that part corresponding to the os uteri be moistened.* But this test is not satisfactory, and will seldom be submitted to. When the discharge proceeds from the womb, it sometimes in- jures the function of that organ so much, or is dependent on a cause influencing the uterus so strongly, as to interfere with menstru- ation, either stopping it altogether, or rendering it too abundant or irregular in its appearance ; and in such cases, the woman seldom conceives. Very frequently, however, the menses do continue pretty regularly; and in those cases, the other discharge disappears * Chambon, Malad. des Filles, p. 104. 75 during the flow of the menses, but is increased for a little before and after menstruation. When the menses are obstructed, it is no1 uncommon for the fluor albus to become more abundant, and to be attended with more pain in the back, about the monthly period. In such cases it has been thought that the leucorrhcea served as a substitute for menstruation, and that it was dangerous to check it. If a woman, who has uterine leucorrhcea conceive, the discharge stops, but a vaginal secretion is, on the contrary, not unfrequently increased. This it has been thought dangerous to check suddenly, but it ought not to be allowed to continue profuse, as it causes abortion. Fluor albus may occur in two very different states of the consti- tution, either as an effect of these, or produced in them by acciden- tal causes. These are, a state of plethora, or disposition to vas- cular activity, and a state of debility. The one is marked by a full habit, a good complexion, and a clear healthy skin. The other by a pale countenance, a sallow surface, a feeble pulse, and generally a spare habit. The one is attended with vertigo, or disease pro- duced by fulness. The other by dyspepsia, palpitation, and those complaints which are connected with debility. The discharge is produced either by the lacunae of the vagina, or the glandular and exhalent apparatus of the uterus. The most ample and the most frequent source is from the vagina. The dis- charge itself may consist simply of the natural mucus of the part increased in quantity, in which case it is glairy and transparent; or it may be so far changed as to become opaque, and white like milk, which is particularly the case when the organs of secretion of the upper part of the vagina and cervix uteri are affected, or it may be purulent. These may all occasionally be mixed with a little blood from the uterine vessels, if there be a tendency to menorrhagia, but not otherwise, unless there be organic disease. In those cases where the discharge is yielded by diseased structure, it is modified by the nature of that structure, and by the existence of ulceration and erosion. When it proceeds from the morbid part itself, and not from the irritating effects of that part on the vagina, by sym- pathy, it is generally foetid, and purulent, often of a dark colour 76 mixed with blood, and alternated by uterine hemorrhage. There is often heat about the parts, and other symptoms of disease. In all ambiguous, and in every chronic case, it is necessary to ex- amine carefully the state of the uterus and vagina. We must bear in mind that fluor albus may be caused by local irritation, including the effect of diseased structure, or mis- placed uterus; by a state of increased vascular action; and by de- bility, either preceded by increased action, or directly produced by weakening causes. Fluor albus is usually accompanied with pain, and sense of weakness in the back. The functions of the digestive organs are always ultimately injured, and in those women who are of a weak habit, they are impaired from the first. In them the discharge adds greatly to the debility, and all the diseases arising from that state increase, such as indigestion, derangement of the hepatic secre- tion, torpor of the bowels, palpitation, swelling of the feet, he. In the more plethoric patients, the debilitating effects are longer of appearing, but they are not exempted from affection of the stomach. Fluor albus may be excited by the presence of a polypus in utero, or in consequence of prolapsus uteri, or of disease of the womb; but in such cases it is symptomatic, and is not at present to be considered. The idiopathic fluor albus may be produced by various exciting causes, such as abortion, menorrhagia, frequent parturition, excessive venery, cold or fatigue after a miscarriage or a delivery at the full time, and whatever can weaken the action of the uterus.* It was at one time supposed, that it might also be produced by a bad state of the fluids of the body, a bilious caco- chymy, a leucophlegmatic habit, passions of the mind, he. The application of cold, or rather circumstances exciting irritation of the vaginal membrane, may produce it in the same way as they produce catarrh. Worms may cause it. In treating fluor albus, we must consider whether it be sympto- matic of polypus, prolapsus, or cancer, &ic. If it be not, we have then to attend to the general state of the constitution. Should the * Chambon, Malad. des Filles, p. 104. 77 patient be plethoric, or robust, it is necessary, in the first instance, to diminish the fulness and activity of the vessels, by mild and perhaps, spare diet, by moderate doses of laxative medicine, and even, if requisite, by the lancet. Regular exercise is, in this view, of benefit, but in all cases, fatigue increases the discharge. Then we give bitters with alkali, to improve the state of the stomach and bowels, and employ an injection of solution of acetite of lead, which is to be thrown three or four times a day into the vagina, and this may afterwards be exchanged for one of a more astringent quality. I agree with those who think that, in cases connected with plethora, astringent injections, especially if used early, are hurtful, and may give a disposition to uterine diseases.. If the disease occur in a weak habit, or if the plethoric state, though it existed at one time, have now been removed, the inter- nal remedies must be more directly tonic, and injections of various astringents must be employed; of these the two best are solution of sulphate of alumin, and decoction of oak bark. The action of cold and damp is to be avoided, as these are hurtful in every af- fection of mucous membranes, whether chronic or acute. Of the internal remedies, some are intended to act by sympathy on the secreting parts, as emetics, others as general tonics. Emetics are of very considerable advantage, on account of their operation on the stomach and alimentary canal, and are accordingly advised by most writers ;* but they are not to be repeated, nor employed at all, during the existence of plethora. Purges have also been used,f in order to carry off noxious matter; but they are only to be given, so as to keep the -bowels regular,! for brisk and repeated purging is hurtful.^ Tonic medicines, and those which improve the action of the chylopoetic viscera, such as lime water, myrrh, bark, steel, rhubarb, uva ursi, &cc. are also of much utility, and * Smellie, Vol. I. p. 67.—Vigarous, Tome I. p. 261.—Mead, Med. Precepts, chap. XIX. sect. 3d.—Denman, Vol. II. page 104.—See, also, Etmuller, Rive- rius, &c. &c. f Chambon, Malad. des Filles, p. 107.—Mead, Med. Precepts, chap. XIX. sect. 3d. i Stoll Praelectiones, Tomus II. p. 383. § Vigarous, Malad. desFemmes, Tome I. p. 261-. 78 along with them we may, with great advantage, employ the cold bath. Kino has been advised by Vigarous and Gardien, and when astringents are proper, it may be employed in the form of tincture. The diet is to be light and nourishing, and the patient ought not to indulge in too much sleep. Various medicines have been proposed with a view of acting specifically on the secreting parts, such as cicuta, balm of Gilead, diuretic salts, calomel, resins, cantharides, electricity, arnica, he.; but they have very little good effect, and sometimes do harm. Of all these, the tincture of cantharidesfoj and oil of turpentine, by exciting the uterine vessels in chronic secretions, seem to be the best, but no internal medicine can be much depended on, in this view. By suckling a child, the discharge has in some instances been removed. Plasters and liniments have been applied to the back, and sometimes relieve the aching pains. Opiates are occa- sionally required, on account of uneasy sensations. When it has succeeded to some eruptive disease, sulphureous preparations have been advised. When the discharge is very opaque, and attended with consi- derable pain in the back and loins, there is reason to think that the cervix uteri is in a state of irritation, and by examination it may be found tender to the touch, and the mouth soft and enlarged a little. This state does not constitute disease of structure, though it may lead to it, but it consists merely in an affection of the glands. It is to be managed in the first stage, by the warm sea-water hip- bath, mild mercurial preparations, laxatives, and avoiding all irri- (~gj Mr. Roberton, a surgeon of Edinburgh, in a paper published in the Lon- don Medical and Physical Journal, Vol. XV. and also in a distinct work on the Effects of Cantharides, when taken internally, strongly recommends this pow- erful article of the materia medica, in obstinate cases of Leucorrhoea ; and re- cites a number of instances, in which it appears to have produced the best effects. In his exhibition of this medicine, he generally begun with about jij or ^ijss of the tincture, in §vj of water; a table spoonful of which was given thrice a day. He continued gradually increasing the dose, until his patient had taken giv of the tincture in 24 hours, gj of the tincture being added to §vj of water. It was generally given, until considerable pain, and a puriform discharge from the vagina was produced. I cannot say, that in the few trials I have made of it in this complaint, the beneficial effects have been so conspicuous. 79 tation. After the tender state is nearly subdued, and the discharge has become more chronic, the cold bath, tonics, and mild vegeta- ble astringent injections, are proper. Purulent discharge implies previous inflammation, and the pre- sent existence either of abscess, ulceration, or a morbid change of a secreting surface. The two first states are ascertained by exami- nation. The last chiefly by the smarting in making water, and other symptoms excited by the action of a virus. To this species belongs the gonorrhoea, which is to be cured by mild laxatives, and injections, first of acetite of lead, and then of sulphate of zinc, dis- solved in water. The two first states are to be managed according to the causes which give rise to them. On the whole, then, our practice in fluor albus, unaccompanied with organic affection, consists in rectifying the constitution, bring- ing it as far as possible to a state of perfect health, employing topi- cal applications in the form of injections, and avoiding the farther operation of exciting causes. § 22. AFFECTIONS OF THE BLADDER. The bladder is subject to several diseases. The first I shall mention is stone. This excites very considerable pain in the region of the bladder, remarkably increased after making water. There is also irritation about the urethra, with a frequent desire to void the urine; but it does not always flow freely, sometimes stopping very unexpectedly. The urine deposits a sandy sediment, and is often mixed with mucus. These symptoms lead to a suspicion that there is a stone in the bladder, but we can be certain only by passing a sound. By means of the warm bath,(Vj opiates, and the (~rj Our author has omitted to mention the efficacy of magnesia in calculous complaints, as recommended by Messrs. Brande and Hatchet. The result of the inquiries of these ingenious gentlemen, on this very interesting subject has been communicated to the scientific world in a paper printed in the Philosophical Transactions for the year 1810, entitled " Observations on the Effects of Magne- sia, in preventing an increased formation of the Uric Acid, by William T. Brande." This gentleman (in a communication to Sir John Sinclair) says, that the beBt method of giving the magnesia, is in plain water, or milk, to be taken in the morning early, and at mid-day. If the stomach is weak, and this produ 80 medicines improperly called lithontriptics, much relief may be ob- tained, and very often the stone may be passed, for the urethra is short and lax, so that calculi of great size have been voided. But when these means fail, an operation must be performed. This has been done during pregnancy,* but is only allowable in cases of great necessity. Sometimes the stone makes way, by ulceration, into the vagina.f It has even been known to ulcerate through the abdominal integuments. J In many cases the symptoms of stone are met with, although none can be found in the bladder. This is most frequently the case with young girls, previous to the establishment of the catamenia, or with women of an irritable habit. There is no organic disease,, nor have I ever known it, in such people, end in a diseased struc- ture of the bladder or kidneys; indeed, they rarely complain of uneasiness about the kidneys. I have tried many remedies, such as soda, uva ursi, narcotics, antispasmodics, tonics, and the warm and cold bath, but cannot promise certain relief from any one of these.^ In process of time, the disease subsides and disappears. The use of a bougie may be of service, for the state of the urethra ces flatulency or uneasy sensations, some common bitters, such as gentian, may be taken with it; if it purges, a little opium may be added. He supposes its beneficial operation depends, on preventing the formation of acid in the stomach. The dose of magnesia, he observes, must always depend upon the circum- stances of the case ;—generally, five grains twice or thrice a day to children ten years of age ; fifteen or twenty grains to adults. Mr. Brande has always given the common magnesia, although he remarks, that, the calcined may be occasionally used with advantage. For fuller informa- tion on this subject, the reader is referred to Brande's paper, above quoted, in the Phil. Trans, and to a letter from Sir John Sinclair, vide Eclectic Repertory, Vol. III. p. 120. Dr. Gilbert Blane, so well known in the medical world, has also written an in- teresting paper on the effects of large doses of mild vegetable alkali, or potassa carbonata in gravel, and the beneficial effects of opium combined with it. * Deschamps, Traite de l'Oper. de la Taille, Tome IV. p. 9. | Hildanus, cent. I. obs. 68 and 69. $ Vide Case by Mr. Caumond, in Recueil Period. § In a case of this kind, described by Mr. Patton as a spasmodic affection of the neck of the bladder, calomel appeared to cure the complaint. London Med. Journal, Vol. X. p. 560. The use of the bougie may be proper. 81 often produces pain, not only in its course, but general uneasiness in the neighbouring parts, and, indeed, is the most frequent cause of sympathetic pain, or sensibility of the vagina or vulva. Spasm of the orifice of the bladder, with an irritable state of the urethra, may succeed labour, or attend female diseases, and occa- sions great pain in voiding the urine. It requires anodynes, tepid fomentations, laxatives, and sometimes the gentle introduction of the catheter. Induration, or scirrhus of the bladder, produces symptoms some- what similar to calculus, but there is a greater quantity of morbid mucus mixed with the urine; and blood with purulent matter is discharged, when ulceration has taken place. No stone can be found, but the bladder is felt to be hard and thick. Sometimes it is much enlarged with such appearances, as give rise to an opinion, that the uterus is the part principally affected.* The scirrhus and ulceration may extend to the uterus and vagina. In this disease we must avoid all stimulants, and put the patient on mild diet; avoid every thing which can increase the quantity of salts in the urine ; keep the bowels open, with an emulsion containing oleum ricini; and allay irritation by means of the tepid bath and opiates. Mercury, cicuta, uva ursi, he. with applications to the bladder it- self, have seldom any good effect, and sometimes do harm. Chronic inflammation of the mucous membrane of the bladder,. produces frequent desire to void urine, and the discharge of vis- cid mucus, which sometimes has a puriform appearance. Cicuta and balsam of copaiba seem to be the best remedies. Polypous tumoursf may form within the bladder, producing the * Morgagni relates an important case, where there was a hard painful tumour in the hypogastric region, accompanied with fluor albus,'uterine hemorrhage, and stillicidium of urine. After death, the bladder was found very large and scirrhous, with two large bodies in the cervix, preventing the urine from being retained. The uterus was diseased only in consequence of its vicinity to the blad- der. Epist. XXXIX. art. 31. f Of this disease I have never seen an instance; but Dr. Baillie mentions a case, in which the greater part of the bladder was filled with a polypus. Morb'd Ann*. p. 298. 19 82 usual symptoms of irritation of that organ. Most dreadful suffer- ings have been caused by worms in the bladder. In consequence of severe labour, or the pressure of instruments, the neck of the bladder may become gangrenous, and a perfora- tion take place by sloughing. The woman complains of soreness about the parts, and does not void the urine freely. In five or six days the slough comes off, and then the urine dribbles away by the vagina. In all cases of severe labour, and indeed in every case when the urine does not pass freely and at proper intervals, and especially if there be tenderness of the parts, we must evacuate the water, in order to prevent distension and farther irritation of the bladder ; and the parts must, if there be a tendency to slough or to ulcerate, be kept very clean, and be regularly dressed, in order to prevent improper adhesions. If the bladder should give way, we must try, by keeping in attentively an elastic catheter,* to make the urine flow by the urethra, and then perhaps the part may heal. This is materially aided by introducing a sponge into the vagina so as to press on the aperture. It would appear that a very good method of doing so, is to fix a thin piece of sponge on the side of an elastic-gum bottle, which is to be placed in the vagina, so that the sponge be applied to the aperture. The urine is thus retained and should be drawn off at short intervals. The aperture, if the treatment have been begun as early as the tenderness of the parts permit, may thus gradually contract, an3 at last be shut altogether.f If it remain small and callous, it may be touched with caustic. In a curious case I met with, there was an attempt by nature, to plug up the opening.J Puzos justly remarks, that it is always the blad- der, and not the urethra, that suffers. * This succeeded in a very bad case related by Sedilliot, Recueil Period. Tome I. p. 187. f Vide some cases in Med. Chir. Trans. Vol. VI. p. 583. * The patient to whom I allude had, I understood, four years before her death, been delivered with the forceps, and soon afterwards had incontinence of urine! I found a large perforation in the bladder, exactly resembling the fauces without an uvula. The uterus was a little enlarged and indurated; and its mouth, which was ulcerated and fungous, lay in this opening, projecting into the bladder, and closing up the communication betwixt the bladder and vagina. 83 Sometimes, after a severe labour, the woman is troubled with in- continence of urine, although the bladder be entire. This state is often produced directly by pressure on the neck of the bladder; sometimes it is preceded by symptoms of inflammation about the pelvis, and, in such cases, the os uteri is often found afterwards to be turned a little out of its proper direction, and the patient com- plains much of irregular pains, about the hypogastrium and back. When she is in bed, some of the urine collects in the vagina, and comes from it when she rises; after she is up, it comes from the urethra alone, which distinguishes this from the complaint last des- cribed. Time sometimes cures this disease. The cold bath is useful, unless it increase the pain; and in that case, the warm bath should be employed. It may be proper to use the bougie daily, and also tincture of cantharides, and pressure. The bladder may descend, in labour, before the uterus, pro- ducing much pain; or it may prolapse for some time previous to labour, attended widi pains resembling those of parturition, and sometimes with convulsive or spasmodic affections.* When the prolapsus vesicae takes place as a temporary occurrence during labour, or antecedent to parturition, we must be careful not to mistake the bladder for the membranes, for thus irreparable mis- chief has been done to the woman. The bladder, when protruded, is felt to be connected with the pubis. It retires when the pain goes off. If the patient he, not in labour, the uneasiness is to be mitigated by keeping the bladder empty, and allaying irritation with opiates, and taking a little blood, if feverish or restless. If labour be going on, the bladder must likewise be kept empty, and may, during a pain, be gently supported, by pressing on it with two fingers in the vagina, by which the bladder is preserved from injury. In the unimpregnated state, it sometimes descends be- twixt the vagina and pelvis, so as to form a tumour within the vagina, or at the vulva. It produces a procidentia of the vagina, but the tumour is formed at the anterior part of the vulva, instead * In a case related by Sandifort, the suppression of urine was always attended with convulsive cough. Lib. I. cap. 5. And in a case related by Dr. J. Hamil- ton, where prolapsus took place before parturition, the muscles of the body were spasmodically agitated. Cases, &c. case 9.- 84 of the back part, as in the ordinary procidentia. There is some degree of bearing-down pain in walking, particularly when the bladder is full. Some patients complain of pain in the groin, others at the navel, and some suffer little or no inconvenience, ex- cept pain about the bladder when it is distended. If the disease have continued long, or if the procidentia of the anterior part of the vagina be considerable, the os uteri is directed backward : and when the finger is introduced into the vagina, the anterior part of that canal can be pushed up farther than usual over the fore part of the cervix uteri, which then appears to be elongated, and per- haps in some cases the anterior lip is actually lengthened. In a case dissected by my brother, the bladder was found to form a hernia on both sides of the pelvis, hanging like a fork over the urethra. This procidentia is called a hernia* vesicalis, and is often attended with suppression of urine. If this be inattentively ex- amined, it may be taken for prolapsus uteri; but it will be found to diminish, or even disappear, when the urine is voided ; and by pressure the urine may be forced through the urethra. The hernia, or procidentia vesicalis, is to be remedied by the use of a globe pessary, or one of an egg-shape; and if there be much relaxation of the vagina or parts of the outlet of the pelvis, astringent injections and an elastic support acting on the perineum will be useful. Straining and all muscular exertion should be avoided. Sometimes it is combined with calculus in the bladder. In this case, it has been proposed to open the bladder, extract the stone, and keep up a free discharge of urine through the urethra, in order to allow the communication with the vagina to heal. Des- champs advises, that the opening should be made near the pubis, and not at the posterior part of the tumour, lest that part of the bladder be cut, which when the tumour is reduced, would com- municate with the abdominal cavity. I can see no necessity for making any change in the mode of extracting the stone on account of the procidentia. • Vide the Memoirs and Essays of Verdier and Sabbatier, and Hoin. Sandi- fort, Diss. Anat. Path. lib. 1. cap. iii.; and Cooper on Hernia, part II. p. 66. 85 § 23. EXCRESCENCES IN THE URETHRA. • Excrescences may, notwithstanding the opinion of Morgagni, form in the course, or about the orifice of the urethra,* and gene- rally produce great pain, especially in making water; on which ac- count, 4he disease has sometimes been mistaken for a calculous affection. The agony is at times so great, as to excite convulsions, and it is not uncommon for the patient to have an increase of her suffering about the menstrual period. The tumour is vascular, florid, moveable, and exceedingly tender. When excrescences grow about the orifice of the urethra, they are readily discovered; but when they are high up, it is much more difficult to ascertain their existence. Dr. Baillief says, they cannot be known, but by the sensation given by the catheter passing over a soft body. They, however, in one case, were discovered, by turning the in- strument to one side, so as to open the urethra a little. J When their situation will permit, it is best to extirpate them with the knife or scissors; or if near the orifice, as they generally are, a ligature may •be applied. Sometimes they have yielded to the bougie, though they had returned after excision.^ The removal of large excrescen- ces, has occasionally been attended with very severe symptoms.|] * Mr. Sharp mentions a case where they grew in small quantity upon the ori- fice, producing excruciating torment till they were extirpated. Critical Inq. p. 168. f Morbid Anatomy, p. 321. tin the instance related by Mr. Warner, the urine was voided in drops with great pain, especially about the menstrual period, and she sometimes even had convulsions. He dilated the urethra, by inclining the catheter to one side, and thus saw two excrescences near the upper end. He divided or laid open the urethra, and cut off the excrescences successfully with scissors. Cases, p. 309, § Broomfield's Surgery, Vol. II. p. 296. | In the patient of Mr. rfughes, the disease was taken at first for prolapsus uteri, for there was a substance filling the os externum, and appearing without the vulva. It was a spongy excrescence, from the whole circumference of the meatus. It was drawn out with a thread passed through it, and then cut oft". Strangury, with pain above the pubis, and fever, took place, on which account the catheter was introduced. Suppression of urine repeatedly occurred; and as it was often difficult to introduce the catheter, the semicupium was employed, and always with advantage ; but once after it she became faint, and the limb$ 86 The daily use of the bougie, for some time after extirpation, is of service.* Sometimes the urethra is partially, or totally inverted,-]- forming a tumour at the vulva, attended with difficulty and pain in voiding urine. A slight inversion may be relieved by a bougie; when there is a considerable prolapsus, the part may be cut off. The urethra is sometimes contracted by a varicose state of its vessels, or by a stricture; but these are not common occurrences. In continued irritation of the urethra, with difficulty of voiding water, the bougie is often of great service, even although there should be no contrac- tion of the canal itself- Sometimes the urethra is preternaturally dilated,J Dut tms does not necessarily cause incontinence of urine. The mucous coat of the urethra is sometimes thickened, and its vessels become varicose. This produces general swelling of the urethra, felt by the finger in the course of it, pain on pressure, and in coitu, with a discharge of mucus, and tormenting desire to make water. When the patient bears down, the urethra is partially inverted, and appears swelled and vascular. These vessels should be scarified, the part bathed with an astringent lotion, and gentle' pressure made with a thick bougie. were convulsed. A stricture being suspected at the upper part of the urethra, a bougie was introduced, and kept in the canal, which removed the symptoms. Med. Facts and Obs. Vol. III. p. 26. * In Mr. Jenner's case the irritation of the bladder was great, and the menses were irregular. A fungus was found, filling the orifice of the urethra; this was cut off, and the bougie used for an hour every day for a fortnight; a little before the extirpation, a hemorrhage took place from the excrescences. Vide Lond, Med. Journal, Vol. VII. p. 160. f M. Sernin relates a case of a girl, eleven years of age, who from her fifth year had been subject to frequent attacks of difficulty in voiding the urine. He had an opportunity of examining her after a violent attack, and found a cylindrical body, 4 inches long, projecting from the vulva; and whenever she attempted to make water, this projection swelled up. It was amputated with success. Recueil Period. Tom. XVII. p. 304. $ In Dr. Chamberlain's patient, who had the hymen imperforated, the urethra was so dilated as to admit the finger; and Portal found it, in an analogous case, dilated so as to form a cul-de-sac, admitting the point of the thumb. Couxs d'Anat. Medicale, Tom. III. p. 476. 87 § 24. DEFICIENCY AND MALFORMATION OF THE UTERUS. The uterus may be larger than usual, or uncommonly small,* or it may be altogether wanting.f Unless these circumstances be combined with some deficiency, or unusual conformation of the external parts or vagina, the peculiar organization is not known till after death. It is, however, not uncommon for the external parts to be very small, when the uterus is of a diminutive size; and when it is altogether wanting, the vagina is either very short, or no traces of it can be found. In either of these cases, no at- tempts should be made to discover a uterus by incisions, unless, from symptoms of accumulation of the menses, we are certain that a uterus really exists.J In some instances, the skin at the point, corresponding to the situation of the orifice of the vagina, has been pressed in, so as to form a short sac, which, in the erect posture, prolapsed like a bag. This has been cut in search of the uterus, and nothing found but cellular substance. It has been sup- posed that peculiar feelings about the monthly period, or the ex- istence of sexual desire, indicated the presence of ovaria. These • Morgagni mentions a porter's wife, in whom the uterus was found not above an inch long, and without any ovaria. The pudendum was extremely small, and there was scarcely any appearance of a clitoris. In the Phil, Trans, for 1805, there is a case where the uterus of a woman, 29 years of age, was not larger than in the foetal state, and scarcely any appearance of ovaria. She ceased to grow at ten years of age, had no hair on the pubis, never menstruated, and had an aversion to men. I have seen the uterus of the adult not larger than that of a child; the woman never menstruated, and had very flat breasts. f Columbus dissected a woman who always complained of great pain in coitu. The vagina was very short, and had no uterus at its termination. Fromondus relates an instance, where the place of the os externum was occu- pied with a cartilaginous substance. Morgagni was consulted by a barren woman, whose vagina was only a third part of the usual length, and its termination felt firm and fleshy. He advised a dissolution of the marriage. M. Meyer, in Schmucker's Essays, mentions a case where the vagina and uterus were wanting, but the ovaria existed. The labia and clitoris were small, and there was no nymphae. Mr. Ford dissected a child who had no vagina, uterus, or ovaria. The urethra and rectum terminated close to each other. Med. Facts, Vol. V. p. 92. t Nabothus mentions a rash operator, who undertook, by incision, to find the uterus; but after cutting a little, he came to some vessels which obliged him to stop. 88 have sometimes been found attached to a mass of cellular sub- stance, or even to the bladder. The uterus may be double:* in this case there is sometimes a double vagina, but generally only one ovarium and tube to each uterus. This conformation does not prevent impregnation. The uterus is sometimes divided into two, by a septum stretch- ing across at the upper part of the cervix ,f or the os uteri, is al- most, or altogether shut uptf by a continuation of the lining of the womb or vagina, or by adhesion, consequent to ulceration, or by original conformation ; and in this last case, the substance of the os uteri is sometimes almost cartilaginous. The menses either come away more or less slowly, according to the size of the aper- ture, or are entirely retained when there is no perforation. As long as the menses are discharged, nothing ought to be done; but if they are completely retained, and violent and unavailing efforts made for their expulsion, an opening must, as a matter of neces- sity, be made from the vagina. In such cases, the uterus has been tapped with success & but it has also happened, that fatal inflam- mation has succeeded the operation. The vessels are sometimes enlarged; and I have seen the sper- matic veins extremely varicose, in an old woman who had been subject to piles; but I do not know that any particular inconveni- ence results from the veinous enlargement. * Vide Hist, de l'Acad. de Sciences, 1705, p. 47.—Haller Opusc. path. 60. Acrell's cases.—Purcell in Phil. Trans. LXIV. p. 474.—Canestrini in Med. Facts, Vol. III. p. 171.—Valisneri met with a double uterus and double vulva. Opera, Tom. III. p. 338.—Dr. Pole describes a double uterus, in the 4th Vol. of Mem. ©f Medical Society, p. 92. •j- Baillie's Morbid Anatomy, chap. xix. t Littre found it almost closed, by a continuation of the inner surface of the vagina, Mem. de l'Acad. de Sciences, 1704, p. 27; and in the seventh month of pregnancy, closed by a glandular substance. 1705, p. 2.—Morgagni found it shut Avith a membrane. Kpist. XLVI. art. 17.—Boehmer quite shut up.—Obs. Anat fasc. 2. p. 62.—Ruysch saw it so small as scarcely to admit a pin ; and Sandifort so well closed, that nothing but air could be forced through it. Obs. Anat. Path. hb. II. c. ii. p. 67. § The menses being retained, and great pain excited, they were let out with :i trocar by Schutzcr. Vide Sandifort, p. 69. 89 § 25. HYSTERITIS. The uterus is subject to inflammation; but in the unimpreg- nated state, it is not common for the womb to be the original seat of acute inflammation. After parturition, it is very frequently in- flamed ; and this will hereafter be considered. Inflammation is discovered by pain in the hypogastric region, accompanied with tenison, and the part is tender to the touch; there is acute pain stretching to the back and groins; the bladder is rendered irritable; and acute fever accompanies these symptoms. Blood-letting, purges, fomentations, and blisters are to be used, as in other cases of peritoneal inflammation. Wounds of the uterus are dangerous, in proportion to the inflammation they excite.* Chronic inflammation of the cervix uteri is not uncommon. The os uteri is open, soft, and tender to the touch. The cervix is not materially affected in size or hardness. There is a considerable discharge of white mucus, which sometimes becomes puriform, and this is often mixed with blood; or there may be very con- siderable uterine hemorrhage. The patient feels pain in the uterine region, but often complains more of pain in some distant part of the abdomen, not unfrequently near the liver. There is little fever, but the patient becomes weak from discharge, irritation, and those hysterical affections which may accompany the complaint. Examination discovers the uterus to be swelled, and it is painful when pressed with the finger. The warm sea-water hip-bath, gentle saline purgatives, injection of decoction of hemlock, mild diet, and the use of cicuta as an anodyne, are proper at first. Gardien, I find, recommends the use of emollient injections, conveyed by a pipe, connected with a receptacle so large as to contain as much fluid as will permit of a continued flow for eight or ten minutes. Of this I have, as yet, no experience. Afterwards, when the symptoms are so far sub- dued, the use of the cold sea bath, bark combined with bitters, * In one instance the woman was murdered, by thrusting a piece of glass up the vagina; and Haller notices a fatal case, in which a piece of lead was thrust into the uterus. 1C\ a 90 and mild injections of vegetable astringents, are proper. In ob-«.r- stinate cases, mercury ought to be tried, with a view of altering the action of the parts; but it must be done cautiously, as it is hurtful when it excites without rectifying the action. When there is considerable uterine pain, or much sensibility of the neighbouring parts, the introduction, at night, into the vagina, of a few grains of extract of hemlock, is of service. Pain about the groin is relieved by leeches, and the application of a blister kept open by savine ointment. § 26. ULCERATION OF THE UTERUS. The uterus may, from irritation, become ulcerated like any other part; purulent matter is discharged, the patient feels pain in coitu, or when the uterus is pressed, and sometimes the finger can discover the ulcer. Simple ulceration is very rare, and I ap- prehend, will always heal, by keeping the parts clean with mild injections. Ulceration from morbid poison is more frequent. Of this kind is the phagedena, a most obstinate and dreadful disease of the womb, which begins about its mouth, and goes on, gradually destroying its substance, until almost the whole of it be removed ; and sometimes it spreads to the neighbouring parts. This disease is marked by excruciating pain of the burning kind, in the region of the uterus; copious, foetid, purulent, or sanious discharge, al- ternating with some hemorrhage ; small but frequent pulse, wast- ing of the flesh, and occasionally swelling of the inguinal glands : no tumour is felt externally, but the belly is flat. Examination, per vaginam, discovers the destruction which has taken place, and how far it has proceeded. It also ascertains, that the part which remains is not enlarged. On inspecting the body after death, the pelvis is generally found filled with intestines, matted, and adhering to the pelvis, and to one another. In the midst of the mass, there are sometimes one or two simple abscesses, containing healthy pus. On tearing out the mass, the uterus is discovered to be eat away all to the fun- dus, or a small part of the body. The substance is very little thickened, but resembles soft cartilage, with here and there small 91 -cysts, not larger than pin heads. The ulcerated surface is dark, •flocculent, and has a dissolved appearance, whilst the substance in its immediate vicinity is vascular and livid. The rapidity of the destruction is various in different cases. It is very difficult to cure this ulcer, or even to check its progress. Sometimes mercury has effected a cure, either by itself, or combined with cicuta; or hyo- cyamus, or other narcotics, have been given alone. Nitrous acid occasionally gives relief, and when greatly diluted so as to be Weaker than vinegar, forms a very proper injection. A very weak solution of nitrate of silver, is also a good topical application. Should the pain be great, tepid decoction of poppies, or water with the addition of tincture of opium, will be of service as an injection. Fomentations to the lower belly, and friction with camphorated spirits on the back, also give relief; but very frequently opium, taken internally, affords the only mitigation of suffering, and the quantity required is often great. There is another kind of ulcer, which attacks the cervix and os "Uteri. It is hollow, glossy, and smooth, with hard margins; and the cervix, a little beyond it, is indurated, and somewhat enlarged, but the rest of the uterus is healthy. The discharge is serous, or sometimes purulent. The pain is pretty constant, but not acute; and the progress is generally slow, though it ultimately proves fatal, by hectic. In this, and all other diseases of the uterus, the morbid irritation generally excites leucorrhcea, in a greater or less degree ; but examination ascertains the morbid condition of the part. Although this disease be very different in its nature from the former, yet the mode of treatment is much the same. Material benefit may be derived from the warm salt-water bath, and the regular use of a solution of some saline purgative, or a laxative mineral water, such as that of Harrowgate or of Cheltenham. This is especially the case, when the ulcer is small, or when the part is only indurated, ulceration not having yet taken place. In this stage, the cervix is felt hard and sensible to the touch, and there is leucorrhcea, and pain in the uterine region. A gentle mercurial course is occasionally of service. Some may consider this disease a--; a species of cancer, but the ulcer is never fungous. 92 Excrescences of a firm structure, arid broader at the extremity than at the attachment, may spring from the os uteri, and gene- rally, I apprehend, originate from a lobulated or fissured state of the parts. They bleed readily and profusely ; but when not irri- tated the discharge is serous, and so great, that thick folds of cloth are soon wet as if the liquor amnii had been coming away. It is evident that astringents cannot effect a cure, as they do not alter die nature of the substance which secretes. If a ligature could be passed so as to destroy the circulation in the excrescence, a cure might be expected. When this is impossible, we can only palliate symptoms. A peculiar growth is described by the late Dr. Clarke,* under the name of cauliflower excrescence, which is probably of the na- ture of that I speak of. It springs from the os uteri, the base is broad, the surface granulated, the substance brittle, and the frag- ments broken off are white. Pressure does not give much pain, but the patient has more or less at all times; yet not of the lanci- nating kind. The discharge is at first like fluor albus, and stiffens the linen, though frequently it becomes watery and transparent. It is so great, that when the excrescence is large, it wets ten or twelve napkins daily, and occasions much debility. The pro- gress is variable, and sometimes is so rapid, that the pelvis is filled by it in nine months. The only treatment that bids fair to give relief, is the application of the ligature; but the peculiarity is, that when the vessels are constricted by this during life, or col- lapse after death, the solidity of the tumour is lost, and it resem- bles merely a glairy substance. Venereal ulceration may, although the external parts be sound, attack the uterus, producing a sense of heat with pain. There is at first, very little discharge, and this consists of mucus ; but if the disease be allowed to continue, foetid purulent matter comes away. The ulcer is at first small, and there is no hardness about the os uteri, nor is it perceived to be dilated; but it is painful to the touch, and sometimes bleeds after coition. The purulent dis- charge appears earlier than in cancer, but the health for a time is * Vide Trans, of a Society, 8cc. Vol. III. p. 321. 93 not affected. Then the ulcer spreads, and may destroy a great part of the womb and bladder, and occasion fatal hectic. The history of the patient may assist the diagnosis. The cure consists in a course of mercury, which I have always found produce a good effect soon after the commencement.* § 27. SCIRRO-CANCER. Scirro-cancer generally, or rather I may say always, begins in the cervix uteri. It may take place in the prime of life, but is most frequent about the time of the cessation of the menses. It begins with leucorrhoeal discharge, succeeded, after a longer or shorter time, by a feeling of heaviness or heat, and darting pains about the hypogastrium, aching in the back, dull pain about the upper and inner part of the thighs, with a sense of bearing down, together with dysuria and mucous discharge with the urine; glow- ing heat, or sometimes stinging pain betwixt the pubis and sacrum, with itchiness of the vulva. Menorrhagia very early attends the complaint, and sometimes is the most prominent symptom for a considerable time, as the pain, and other effects of the disorder, may be late of appearing. The patient is often troubled with flatu- lence, heartburn, and sometimes with vomiting, and cutaneous eruptions from sympathy with the stomach. The general health soon suffers, the countenance becomes sallow, the pulse quickens, the strength declines, and the body wastes. Presently a foetid, purulent, or bloody matter is discharged, which indicates that a cyst has burst, and the disease has proceeded to ulceration. Re- peated hemorrhages are now apt to take place, and hectic is es- tablished. The pain is constant, but subject to frequent aggrava- tions, and the weakness rapidly increases. At length the pain, fe- ver, want of rest, discharge, and loss of blood, completely exhaust the patient; and death terminates at once both her hopes and suf- ferings. As first, by examination per vaginam, the uterus is felt as if it were enlarged; the cervix is apparently expanded, and the os uteri hard, open, irregular, and more sensible to the touch, a cir- * Vide Med, Comment. Vol. XIX. p. 257.—Pearson on Cajicer, p. 119. 94 cumstance which causes pain in coitu. A little blood is often ob- served on the finger after an examination. In some time after this, the os uteri is turgid, with many irregular projections like piles, as if it contained small cysts, and presently it is felt to be ulcerated and fungous; but sometimes the fungi are less perceptible, deep excavations being formed, the sides of which, however, after death, are found to be fungous. The cervix uteri is sometimes totally indurated, and considerably enlarged, before ulceration takes place, or has imbedded in it a small tumour; but, in other cases, the augmentation is much greater after ulceration, than before it.* If the disease originally formed a distinct tumour in the cervix, that tumour may become as large as the fist, adhering to the pelvis so that it cannot be moved, and pressing so much on the rectum or bladder, according to its situation, as to give rise to much obstruction in the evacuations from either of these parts. The uterus itself is seldom much en- larged in genuine cancer; but it is possible whilst the cervix is af- fected with this disease, that the body of the uterus may have un- dergone a different morbid change. The tubes and ovaria have been said to participate in the disease.f In some patients the disease proves fatal very early, if there be profuse hemorrhage ; in others great devastation takes place, and the bladderj or rectum^ are opened. In most cases, the va- * Vide Stalpart Vander Wiel, obs. 87.—Segerus in Mis. Cur. 1671, obs. 121. Notwithstanding these cancerous excrescences about the os uteri, a woman may conceive. Dr. Denman relates a case where there was a large excrescence in the gravid state, with profuse bleeding. The head of the child was lessened, but the woman died undelivered. Vol. II. p. 65. When the os uteri has been affected with scirrhous, and the woman has conceived, the uterus has sometimes been ruptured, or the woman died undelivered. Hildanus, cent. I. obs. 67. Horstius Opera, Tom. II. lib. 2. obs. 5. Blancard Anat. p. 233. Hist, de l'Acad. des Sciences, 1705, p. 52. | Vide Prochaska Annot. Acad. fasc. 2d. t Le Dran attended a patient who had all the symptoms of scirrhous uterus, and, by examination, fungous excrescences were found shooting down into the vagina. The pain was continual, and could only be mitigated by the constant use of opium. Urine was discharged by the vagina, and after death the bladder was found to be perforated. The fundus and body of the uterus were not much diseased. § M. Tenon found, in a case of cancerous uterus, all the posterior part of the 95 gina becomes hard and thickened, or irregularly contracted with swelled glands, in its course. On examining the diseased part after death, it is found to be thickened and indurated, and sometimes its cavity is enlarged. The substance is of a whitish or brownish colour, intersected with firm membranous divisions; and betwixt these are numerous small cytts, the coats of which are thick and white. They contain a vascular substance, which, when wiped clean, assumes a light olive colour. In proportion as the disease advances, some of the cysts enlarge and thicken still more; and, when opened, are found to contain a bloody lymph, and to have the inner surface covered with a spongy vascular substance, similar to that which fills the small cysts, but rather more resembling fungus. Presently some of these cysts augment so much as to resemble abscesses, though r they are not, properly speaking, abscesses, and soon afterwards they burst. It is extremely rare for a cyst to burst, or fungi to shoot out on the exterior surface of the uterus, which is covered with the peri- toneum. The position of the uterus is often natural, but some- times it is inclined to one or other side, or approaches to a state of retroversion. As this disease is apt to be mistaken for fluor albus, menorrhagia, nephritis, or dyspepsia, it is of great importance that the practi- tioner should be on his guard, and examine early and carefully per vaginam. Much harm is done by the use of extringent injections' meant to cure the supposed fluor albus. This is a very hopeless disease, but still much may be done to check its progress, or mitigate its symptoms. When uneasy sen- sations, about the cessation of !.he menses, indicate a tendency to uterine disease, we find advantage from the insertion of an issue in the arm or leg, the use of laxative waters,* and spare diet,f and womb ulcerated, the rectum diseased, and a communication formed betwixt them. * Rcederer relates a case where scirrhous swelling was cured by keeping the bowels open, and giving every third evening, from ten to twenty grains of calo- mel.—Haller Disp. Med. Tomus IV. p. 670. f Absolute abstinence has been recommended by Pouteau, CEuvres Post. Tom. I. p. 105. He relates a case, which was cured by confining the patient to eau de 96 •flannel dress. If by examination we discover any alteration in the shape, size, or sensibility of the womb, we must have recourse to the daily use of from two to three drachms of sulphas potassa? cum sulphure; and if this lose its effect, some other laxative must be added. The tepid sea water bath every night is likewise of great service. When there is much sense of throbbing, heat, or pain about the pelvis, taking blood from the loins by cupping is of ser- vice, and the patient should keep in a horizontal posture as much as possible. When the disease has evidently taken place, we must still persevere in the same plan, and avoid such causes as excite action in general; for the longer we can keep a scirrhus from going into a state of activity and inflammation, the longer do we keep the disease at bay. It is therefore scarcely necessary to add, that if the patient be married, she must not sleep with her husband. We keep the parts clean by injecting tepid water, or decoction of ca- momile with hemlock or opium; allay pain by anodynes; attend to the state of the bowels; and correct stomachic affections by bitters, and other suitable remedies. Mercury, antimony, iron, gold, arsenic, sarsaparilla, aconitum, cicuta, &c. have been given internally, but have seldom a good effect. Indeed, no medi- cine can be depended on for even suspending the progress of the disease, but many may do harm. The most rational practice is, to adopt such a mild system as shall keep down action, and pre- vent the parts from passing on to ulceration. Whilst every stimu- lus is shunned, we may, in the more vigorous constitution, find it useful to enjoin considerable abstinence in diet, and even all such mild articles of food or beverage as ferment in the stomach, as this state of the aliment aggravates the symptoms. On the other hand, if we find that the abstemious plan, in any case, by weakening too much, permits, tbe morbid action to make progress, we must change the regimen. When ulceration has taken place, much may still be done by attention to the use of the syringe, and the removal of acrid matter. It has been said, that very weak phosphoric acid, injected to the uterus, allays pain more effectually than anodynes, ■glace.—Mr. Pearson, p. 113. gives two successful cases. In the first, the uterus was enlarged and retroverted) but by very spare diet, was restored to its natural state. 97 but this I am unable to confirm by experience. It has been pro- posed to produce, with an extracting instrument, a prolapsus uteri, and then cut off the protruded womb. Several years ago, Dr. Osiandcr of Gottingen, published an account of his mode of extir- pating the cancerous neck of the womb, by transfixing it with liga- tures, and thereby pulling it so low, and keeping it so steady, as to enable him, with a history, to cut off the diseased part. The bleeding is restrained by astringents. At the time of publication, he says he had performed the operation nine times, with success. Dupuytren has also performed the operation. In one instance, he required to remove, at two different times, the diseased substance, as it still returned. Recamier tried the effect of caustic conveyed by a speculum, but the result has not yet been published.* This operation has not yet been performed in this country, but this much may be said in favour of it, that genuine cancer is, if left to itself, always a mortal disease.f § 28. TUBERCLES. Tubercles are common in the uterus, insomuch that M. Bayle says, that in seven months he met with fourteen cases. They con- sist at first of fleshy matter, but in process of time become more like cartilage, or even bony, especially on their surface.^ On ex- amining the tumour, it is sometimes found to be intersected with membranous divisions; and a section always exhibits a pretty compact granulated surface without vessels. A tubercle may take place in one spot, and all the rest of the uterus may be healthy, and nearly of the natural size. The magnitude of the tubercle is very variable, and it may either project on the outer surface,^ or * Vide Diet, des Sciences Medicales, art, Matrice et Hysterotomie. | Vide Edin. Journal for July, 1816. $ Sandifort Obs. Anat. Path. lib. I. cap. viii.—Bayle in Jour, de Med. Tome V. p. 62.—Murray de Osteosteamate, p. 14. et. seq. Gardien, T. 1. p. 421. § Professor Francis gives the history of an enormous fleshy tubercle, proceed- ing by a small pedicle from the fundus of the uterus, which, together with thf*. excrescences connected with it, weighed rather more than 100 pound?. Ed. 14 98 within the cavity of the womb; and in this last case, the adhesion to the surface of the cavity is generally slight* after the tubercle has fully projected. In this it differs, even in its most detached state, from polypus, which is attached not by cellular substance, but by a pedicle. One or more of these may be thrown off, with pains like those of labour. Sometimes there are a great many tu- bercles, which are found in various stages of projection, and the uterus may become greatly enlarged, and very irregular exter- nal! y.f In one case the size of the womb was large, and two thick hard ridges could be felt in the abdomen, extending obliquely up by the sides of the umbilicus. The lower and anterior part of the womb was large, and filled the brim of the pelvis like a child's head; whilst near the promontory of the sacrum, the os uteri was felt healthy, though compressed. This woman had no complaint ex- cept what proceeded from bulk; the bladder, contrary to expecta- tion, was not in any degree affected; the stools easy, and menstru- ation regular. I have never seen the tubercle end in ulceration, nor the sub- stance of the uterus, although thickened, have abscess formed in it. This observation I find confirmed by other practical writers, who state that it tends not to suppuration, but ossification. The ef- fects of this disease are chiefly mechanical, and often altogether trifling; at other times, we have a pain in the back, and some- times in the hypogastrium, which, if there be much enlargement of the womb, is swelled, hard, and irregular, dyspeptic symptoms, leucorrhcea, and at length feverishness, and gradual loss of strength. The progress is generally slow, unless the cervix uteri, which is always sound with regard to this disease, be affected with phage- dena or cancer, or unless simple inflammation be excited by pres- sure on some neighbouring part. That is to say, this disease, oc- curring by itself, is not dangerous or hurtful, except by mechani- cal or sympathetic irritation. During the active stage, pain is per- * Baillie's Morbid Anatomy, chap. xix. f I have found the uterus as large as a child's head of a year old, with many projections and tubercles.—Peyer has a similar case, Parerg. Anat. p. 131. 99 haps felt, but it ceases when the tumour ceases to grow, which it often does. I have stated that the cervix is not attacked by this disease; but it may commence in the lower part of the body of the uterus, and extend downwards as well as outwards, so as to appear to have begun in the cervix. Menstruation may be ren- dered irregular, but sometimes continues unaffected. This disease can only be confounded with diseased ovarium, but it is harder when felt through the belly, not so moveable at first, and a difference may generally be felt per vaginam. It may be combined with tumour of the ovarium. On introducing the finger into the vagina in the early stage, the uterus is felt enlarged, and bulging either before or behind; and the lump is a little painful when pressed. It is felt to make a part of the womb, and very often is situated on the anterior surface, in contact with the blad- der. The cervix may be a little developed, but is healthy. No remedy has any power in removing the diseased substance, and therefore our treatment consists in palliating symptoms, espe- cially in attending to the bladder and bowels. We also upon gene- ral principles keep down activity, and guard against inflammatory action. The antiphlogistic regimen should be pursued in modera- tion. The bowels especially should be kept open, and every source of irritation removed. The tepid bath is useful. Women may live a long time, even although these tumours acquire consi- derable magnitude. Sometimes the whole uterus is a little enlarged, and changed into a white cartilaginous substance, with a hard irregular surface; or it may be enlarged and ossified,* and these ossifications may take place even during pregnancy.f Steatomatous or atheromatous * Vide Mem. de l'Acad. de Chirurg. Lieutaud relates a case of a woman who had a tumid belly, and complained of great pain. The womb was not much larger than usuaj, but it was almost bony. Hist. Anat. Med. p. 320.—Grandchamp found an osseous tumour, as large as the fist, inclosed in a sac, betwixt the uterus and bladder. It produced constant ischuria, relieved only by lying on the back. Med. and Phys. Journal, Vol. III. p. 587. f Vide Observ. on Abortion, 2d edition, p. 37. 100 tumours of various sizes*, or sarcomatousf or seirrhus-likej bodies, may be attached to the uterus. All these diseases sometimes at first give little trouble. Even their advanced stage has no pathog- nomonic mark, by which they can be discovered, as they produce the usual effects of uterine irritation. I must also add, that they are very little under the power of medicine. The most we can do, is to palliate symptoms; by which, however, we greatly meliorate the condition of the patient. § 29. SPONGOID TUMOUR. The uterus is more frequently affected with spongoid tumour than is supposed; many cases of that disease passing for cancer. This is a firm, but soft and elastic tumour, the substance of which bears some resemblance to brain, and contains cysts of different sizes, filled with red serum or blood, or bloody fungus, according to circumstances. There is no certain way of distinguishing or discovering this disease in its early stage, for it often gives very little trouble, and any symptoms which do occur, are common to other diseases of the womb. The tumour, however, enlarges, and can at length be felt through the abdominal parietes. It is soft and elastic, and on the first application of the hand, feels very like a tense ventral hernia. There may be two or more tumours of un- equal sizes in different parts of the belly, which can be felt to have a connexion with each other, and may frequently be traced to the pubis. Per vaginam, the state varies in different cases; but by pressing on the external tumour at the same time, we discover its connection With the womb below. We may find ulceration, or the os uteri soft, and tumified, and opened, or the posterior lip may be lost in a soft elastic tumour, and quite obliterated, whilst the * Vide Rhodius, cent. III. ob. 46.—Boehmer Obs. Anat. fasc. 2d.—Stoll Ratio Med. part II. p. 379. t Vide Friedus, in Sandifort's Observ. lib. I. c. viii. and a case by Sandifort himself, where the tumour adhered by a cord, lib. IV. p. 113. t Baader Obs. Med. ob. 29. p. 170. 101 anterior one, after a pretty careful examination, is felt high up, and apparently sound. Pressure seldom gives pain, till ulceration is about to take place, and no blood is usually observed on the fin- ger after examination, unless a fungous has protruded. So far as I have seen, fluor albus is a rare attendant on this disease in the early stage, and little inconvenience is at that period produced, ex- cept what may sometimes result from pressure on the bladder, causing strangury or suppression of urine, attended with fits of considerable pain, like those excited by a stone. Slight dischar- ges of blood generally attend the formation of the disease; and at this early stage, the os uteri, and sometimes the cervix, may be felt tumid, smooth, and elastic. The complexion is sallow, but the health is tolerably good, till ulceration or inflammation take place. Ulceration may happen in different parts; it may be di- rected to the vagina, and then we have foetid bloody discharge, or sometimes considerable hemorrhage, and ultimately the bladder or rectum is involved in the destruction: or bloody fungus may pro- trude from the exterior surface of the uterus into the general cavi- ty of the abdomen, and at length the bowels become inflamed and glued together: or the tumour may adhere to the parietes of the abdomen, and the skin after becoming livid gives way, and a fun- gus shoots out from the belly. As the disease advances towards ulceration, the health is more impaired, hectic fever takes place, and the patient is ultimately cut off. The whole treatment, I am sorry to say, consists in palliating such sympathetic or local symptoms as may arise in the course of the disease. [§ 30. CAULIFLOWER EXCRESCENCE FROM THE OS UTERI. Dr. John Clarke of London considers himself as the first writer who has taken notice of this disease. The cauliflower excrescence, according to him, arises always from some part of the os uteri. As several of the early symptoms are not very distressing to the patient, the tumour in the beginning is rarely the subject of medical attention. The first changes of structure have therefore not been observed. In general the tumour 102 i.-. not less dian the size 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 on 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 the 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 appear to be very white. Sometimes, though no violence has been used, small portions of a white substance come away with the urine of the patient, 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 dis- charge 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 trans- parent 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 suffi- cient to wet thoroughly ten or twelve napkins in a day. Now and then a discharge of pure blood appears. When this ceases, the dis- 103 charge of thin transparent fluid re-appears. An offensive odour generally accompanies the discharge, which is greatest when there has lately been an evacuation of pure blood, or of the catamenia. Mucus has sometimes been found in the fluid discharged, but puss never. Patients labouring under this disorder, are variously affected with regard to pain. In the commencement none is felt; but dur- ing its progress pain is in some cases experienced. Generally in the advanced stage, the patient feels pain in the back, and in the direction of the round ligaments of the uterus. The pain is not de- scribed to be lancinating, as in cancer, and is without any sensible aggravation by paroxysms; but on the whole, it is most felt after the patient has been 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 from the above cause. It always terminates fatally. Respecting the treatment of this disease, nothing satisfac- tory can be offered. All stimulating substances either in diet or me- dicine, seem to aggravate it, by increasing the discharge; and no as- tringents internally given appear to lessen it. The only means from which any benefit has been derived, is the injecting into the vagina three times a day, a strong decoction of cortex granati, or of cor- tex 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 offen- sive. The use of anodynes must be resorted to for the mitigation of pain, and the occasional symptoms of suppression of urine, and eostiveness, are to be relieved by the use of a catheter and mild laxatives.(s)] («) Vide a paper on the Cauliflower excrescence from the os uteri, &c. by John Clarke, M. D. Transact, of a society for the improvement of Medical and Chirurgioal knowledge, 1812. And new Medical and Physical Journal, July 1812. 104 § 31. CALCULI. Earthy concretions are sometimes formed in the cavity of the uterus, and produce the usual symptoms of uterine irritation ; and Vigarous considers them as very apt to excite hysterical affections. As in the bladder of urine, the constant presence of a calculus tends to thicken its coats, so the irritation of a stone in the uterus can ex- cite a disease of the substance of the womb, and produce ulcera- tion, which may extend to the rectum. The disease in question is very rare, and can only be discovered by feeling the concretion with the finger, or a probe introduced within the os uteri, which is sufficiently open to permit of this examination. Nature, it would appear, tends to expel the substance ;* and we ought to co-operate, if necessary, with this tendency. We must al?o relieve suppression of urine,f or any other urgent symptom which may be present. § 31. POLYPI. Polypous tumours are not uncommon, and may take place at any age; they are not, however, often met with in very young women. They always affect the health, producing want of appe- tite, dyspeptic symptoms, uneasiness in the uterine region, a vari- able swelling of the abdomen, aching pain in the back, bearing- down pains, tenesmus, and a dragging sensation at the groins. When these symptoms have continued some time, the strength is impaired, and the pulse becomes more frequent. At first, there is generally a mucous discharge; but at length blood is discharged, owing to the rupture of some of the veins of the tumour, or some- times from the uterine vessels themselves, and the permanent dis- charge not unfrequently becomes foetid. Mr. Clark, in his late work, very properly notices, that the blood often coagulates over * Gaubius relates a case, where it was complicated with prolapsus uteri. After a length of time, severe pains came on, and in an hour a large stone was ex- pelled ; next day a larger stone presented, but could not be brought away until the os uteri was dilated. From time to time after this, small stones were ex- pelled; but at last she got completely well. f. This proved fatal in a child of five years old* 105 the polypus, and comes off like a ring. These symptoms, however, cannot point out to a certainty, the existence of a polypus; we must have recourse to examination, by which we discover that the uterus is enlarged, its mouth open, and a firm, but generally move- able body within it. If the os uteri have not yet opened, so as to admit the finger, the diagnosis must tye incomplete. By degrees the polypus descends from the uterus, or painful efforts are made more quickly to expel the tumour, the body of which passes into the vagina,* and sometimes occasions retention of urine.f The pedicle remains in utero, and the had consequences formerly produced, still continue, except in a few cases, where the tumour has dropped off,J and the patient got well. In such cases it has been supposed that the os uteri acted as a ligature; and to the same cause is attributed the bursting of the veins, which pro- duce, in many instances, copious hemorrhage. But, although hemorrhage be most frequent after the polypus has descended, yet it may take place whilst it remains entirely in utero. It sometimes happens that the uterus becomes partially invert- ed,^ before or after the polypus is expelled into the vagina; and this circumstance does not seem to depend altogether on the size * In a case which occurred to the late Mr. Hamilton of this place, the polypus was expelled by labour pains, but the woman died exhausted.—In a case related by Vater, it was expelled when the woman was at stool. Haller, Disp. Chir. Tom. III. p. 621. See also a case in the same work, p. 611. by Schunkius.— In the patient of Vacoussain, the polypus was expelled after severe pain; its pedicle was felt to pulsate very strongly, but a ligature being applied, the tu- mour was cut off. Instantly the ligature disappeared, being drawn up within the pelvis, but on the third day it dropped off. Mem. de l'Acad. de Chir. Tom. III. p. 533. f Vide case by Vater, in Haller, Disput. Chir. Tom. III. p. 621.—In the case furnished by M. Espagnet, an attempt was made to introduce the catheter; but a straight one being employed instead of a curved one, or an elastic catheter, it was found necessary previously to make an incision in the fore part of the poly- pus, which had protruded. Mem. de l'Acad. de Chir. Tom. III. p. 531. t Mem. de l'Acad. de Chir. Tom. III. p. 532. § Vide case by Goulard, in Hist, de l'Acad. des Sciences, 1732, p. 42.—Dr. Denman, in his engravings, gives two plates of inversion, one from Dr. Hunter's Museum, the other from Mr. Hamilton. 15 106 of the polypus, or its weight. Polypus may also be accompanied with prolapsus uteri.* Polypi may be attached to any part of the womb, to its fundus, cervix, or mouth; and it hasjbeen observed, that there is less ten- dency to hemorrhage, when they are attached to the cervix, than either higher up, or to the os uteri itself. If there be a union be- twixt the os uteri and the tumour,f or if they be in intimate con- tact, polypus may pass for inversio uteri; but the history of the case, and attentive examination, will point out the difference, which will be noticed when I come to consider inversion and prolapsus of the uterus. Here I may only remark, that the womb is sensible, but the polypus is insensible, to the touch, or to irritation ; but it should be recollected, that if the polypus be moved, sensation can be produced by the effect on the womb. Polypi are of different kinds. The most frequent kind is of a firm, semi-cartilaginous structure, covered with a production of the inner membrane of the w,omb; and indeed it seems to proceed chiefly from a morbid change of that membrane, and a slow subsequent enlargement of the diseased portion: for the sub- stance of the uterus itself is not necessarily affected. The enlarge- ment is generally greatest at the farthest extremity of the tumour, and least near the womb; so that there is a kind of pedicle formed, which sometimes contains pretty large blood vessels, and the tu- mour is pyriform. But if the membrane of the uterus be affected to a considerable extent, and especially if the substance of the uterus be diseased, then the base, or the attachment of the polypus, is broad. The vessels are considerable, especially the veins, which some- times burst. In every instance, I believe, if the patient live long, the tumour is disposed to ulcerate. The ulcer is either superficial and watery, or it is hollowed out, glossy, and has hard margins, or it is fungous. The two last varieties are most frequent. Some polypi are soft and lymphatic, but these are rare in the uterus. Some are firm without, but contain gelatinous fluid, or sub- * Med. Comment. Vol. IV. p. 228. f Mem. of Med. Society in London, Vol. V. p. 12 107 stance like axunge within. Some are solid, others cellular, with considerable cavities. Polypi are hurtful at first, by the irritation they give the uterus, and by sympathetic derangement of the abdominal viscera. In a more advanced stage, they are attended with debilitating and fatal hemorrhage, and often with febrile symptoms, especially if the discharge be offensive, or the surface ulcerated. Notwithstanding the existence of polypus, however, it is possible for a woman to conceive.* Various means have been proposed for the removal of polypi, such as excision, caustic, or tearing them away; but all of these are dangerous and uncertain; and therefore the only method now practised, is to pass a ligature round the base or footstalk of the polypus, and tighten it so firmly as to kill the part. The ligature consists of a firm silk cord, or a well twisted hemp string, properly rubbed with wax, or covered with a varnish of elastic gum. This is better than a silver wire, which is apt to twist or form little spiral turns, which impede the operation, and may cut the tumour. It is difficult to pass the ligature properly, if the polypus be altogether in utero; and it ought not even to be attempted, if the os uteri be not fully dilated. On this account, if the symptoms be not ex- tremely urgent, it is proper to delay until the polypus have wholly, or in part, descended into the vagina; and when this has taken place, no good, but much evil may result from procrastination. It has even been proposed to accelerate the descent of the polypus, and produce an inversion of the uterus.f A double canula has been long employed for the purpose of passing the ligature, one end of which was brought through each tube; and the middle portion, forming a loop, was carried over the tumour, either with the fingers, or the assistance of a silver probe with a small fork at the extremity. By practice and dex- terity, this instrument may doubtless be adequate to the object in view ; but without these requisites, the operator will be foiled, the * In M. Guiot's case, the polypus was expelled.—M. Levret adds other cases, Mem. de l'Acad. de Chir. Tom. III. p. 543. f M. Baudelocque observes, " Nous regardions ce renversement necessaire pour obtenir la guerison de la malade." Recueil Period. Tome IV. p. 137. 108 ligature twisting or going past the tumour, every attempt giving much uneasiness to the patient, and not unfrequently, after many trials and much irritation, the patient is left exhausted with fatigue, vexation, and loss of bloodf This is very apt to happen, if the polypus be so large as to fill the vagina. The process may be fa- cilitated by employing a double canula, but the tubes made to se- parate and unite at pleasure * by means of a connecting base, or third piece, which can be adapted to them like a sheath. The ligature is passed through the tubes, which are to be placed close together, and no loop is to be left at the middle. They are then to be carried up along the tumour, generally betwixt it and the pubis. Being slid up along the finger to the neck of the polypus, one of them is to be firmly retained in its situation by an assistant, and the other carried completely round the tumour, and brought again to meet its fellow. The two* tubes are then to be united by means of the common base. The ligature is thus made to encircle the polypus, and, if necessary, it may afterwards be raised higher up with the finger alone, or with the assistance of a forked probe. When the ligature is placed in its proper situation, it is to be gradually and cautiously tightened, lest any part of the uterus which may be inverted be included. If so, the patient complains of pain, and sometimes vomits, and if these symptoms were neglected, and the ligature kept tight, pain and tension of the hypogastrium, fever and convulsions would take place, and in all probability the woman would die.f In some instances, however, the womb has been in- cluded without a fatal effect.^ * An instrument of this kind is proposed by M. Cullerier, and is described by M. Lefaucheux in his Dissert, sur les Tumeurs Circonscrites et Indolentes du tissu cellulaire de la matrice et du vagin. f Dr. Denham, Vol. I. p. 94. mentions a young lady who had suffered long from uterine hemorrhage. A polypus was found just to have cleared the os uteri; a ligature was applied, but as she felt severe pain, and vomited, it was slackened. Every attempt to renew the ligature had the same effect. In six weeks she died, and it was found that the uterus was inverted. J M. Herbiiuaux, Tom. II. obs. 17. relates a case. The ligature seemed to act on an inverted portion of the womb, producing pain, fever, and convulsions; it was slackened, but afterwards, notwithstanding a renewal of dreadful suffering, it was, with a perseverance hardly to be commended, employed so as at last to 109 Even when the uterus is not included, fever may succeed the operation, and be accompanied with slight pain in the belly ; but the symptoms are mild, and no pain is felt when the ligature is first applied. If the first tightening of the ligature, by way of trial, give no pain, it is to be drawn firmly, so as to compress the neck of the tumour sufficiently to stop the circulation. It is then to be secured at the extremity of thecanuk; and as the part will become less in some time, or may not have been very tightly acted on at first, the liga- ture is to be daily drawn tighter, and in a few days will make its way through. After the polypus is tied, it is felt to be more tur- gid, and harder; and, if visible, it is found of a livid colour, and presently exhales a foetid smell. These are favourable signs. The diet is to be light, and all irritation avoided during the cure. The bowels and bladder must be attended to, and, if there be sympa- thetic irritation of the stomach, soda water is useful, with small doses of laudanum.fw) § 33. MALIGNANT POLYPI. There are other tumours still more dangerous,* as they end in incurable ulceration, and are so connected with the womb, that the whole of the diseased substance cannot be removed. These al- ways adhere by a very broad base,f and cannot be moved freely, remove the polypus.—Desault found, after having applied a ligature round a polypus, and cut the tumour off next day, that part of the fundus uteri was at- tached to the amputated substance ; the patient did well. Baudelocque supposes that some cases, related as examples of amputation ofinverted uteri, were merely polypi, accompanied with inversion. Recueil Period. Tom. IV. p. 115. (w) The reader is referred to the following interesting paper on the subject of the preceding article, viz : " Memoir sur ^organization des polypes uterus, &c. par P. J. Roux, Tom. III. des ceuvres chirurgicales de P. J. Desault, par Xav. Bi- chat, p. 370. * Vide Mem. de l'Acad. de Chir. Tome HI. p. 538.—Herbiniaux Observations, Tome I. ob. 39.—Baillie's Morbid Anatomy, chap. xix.—Vigarous, Malad. des Femmes, Tome I. p. 425. f Dr. Denman, Vol. I. p. 95. relates a case of polypus with broad stem, which was supposed to be a cancer of the uterus. The ligature was applied, and in 110 or turned round like the mild polypus. They are sometimes pret- ty firm, but generally they are soft and fungous, or may resemble cords of clotted blood. When dissected, they are found to be very spongy, with cells or cavities of various sizes; sometimes they are laminated. These, which have been calted vivaces by M. Levret; are always the consequence of a diseased state of the womb; but they are not always, as that author supposes, vegetations from an ulcerated surface. They do, however, very frequently spring from that source, being generally of the spongoid nature. Occasionally they have been mistaken for a piece of a retained placenta, and portions of foetid fungi have been torn away, in attempts to extract the supposed placenta, or ovum. The hypogastric region is tumid, and painful to the touch, even more so than the tumour itself, which, felt per vaginam, is less sen- sible than the womb. Sometimes little pain is felt in this disease, except when the womb is pressed. The tumour often bleeds, dis- charges a sanious matter, and may shoot into the vagina: but in this it differs from polypus, that it comes into the vagina generally by growth, and not by expulsion from the womb, which does not decrease or become empty as the vagina fills. The treatment must be palliative, for extirpation does not succeed, the growth being rapidly renewed. Opiates and cleanliness are most useful. § 34. MOLES. Moles* are fleshy or bloody substances contained within the cavity of the uterus. They acquire different degrees of magni- eight or nine days it came away ; but when the polypus was removed, another substance nearly of the same size, was found to have grown into the vagina. The woman died in a month. I have seen the common polypus combined with an indurated thickening of the uterus, and fungous or flocculent state of the cavity. In one case of this kind, the uterus and rectum freely communi- cated by ulceration. See also some cases in Trans, of a Society, &c. Vol. III. * Sandifort Obs. Path. Anat. lib. II. p. 78.—Schmid. de Concrement. Uteri, in Haller's Disp. Med. Tomus IV. p. 746. Ill tude, and are found of various density and structure* They may form in women who have not born children,f or they may suc- ceed a natural delivery,{ or follow an abortion, or take place in a diseased state of the uterus.^ It is the opinion of many, that these substances are never formed in the virgin state, and no case that I have yet met with contradicts the supposition. The symptoms produced by moles are at first very much the same with those of pregnancy, such as nausea, fastidious appetite, enlargement of the breasts, he.; but the belly enlarges much faster, is softer, and more variable in size than in pregnancy, being sometimes as large in the secoud month of the supposed, as it is in the fifth of the true pregnancy. Pressure occasionally gives pain. Petit observes, that the tumour seems to fall down when the woman stands erect, but this is not always the case. It must be confessed, that the symptoms are at first, in most cases, ambiguous, nor can we for some time arrive at certainty. In general, the mass is expelled within three months, or before the usual time of quickening in pregnancy; and more or less hemorrhage accompanies the pro- cess, which is very similar to that of abortion, and requires the same management.j| Sometimes the expulsion may be advanta- geously hastened, by extracting the substance with the finger; but we must be careful not to lacerate it, and leave part behind. If the mole be retained beyond the usual time of quickening, we find that the belly does not increase in the same proportion as formerly, and the womb does not acquire the magnitude it pos- sesses in a pregnancy of so many months standing. There is also no motion perceived. Many of the symptoms of mole may pro- * Sometimes the mass appears to be putrid, and is expelled with great hemor- rhage. Vide case by Dr. Blackbourn, Lond. Med. Journal, Vol. II. p. 122.__ Sometimes it has a kind of osseous covering, as in the case by Har.koph, in Hal- ler. Disp. Med. IV. p. 715. f La Motte, chap. vii. This chapter contains several useful cases, one of which proved fatal from hemorrhage. t Hoffman. Opera, Tomus III. p. 182.—Stahl. Coleg. Casuale, cap. lxxvi. p. 797. § With scirrhus of the uterus, Haller's Disp. Med. IV. p. 751 et 753. i Puzos advises blood-letting, Traite, p. 211.—Vigarous recommends emetics and purgatives, to favour the expulsion, Tome I. p. 115. 112 ceed from polypus; -but in that case, the breasts are flaccid and the symptoms indicating pregnancy are much more obscure. The os uteri is not necessarily closed in a case of polypus ; whereas ininat of a mole, if there have been no expulsive pains, it is gene- rally shut. When a woman is subject to the repeated formation of moles, I know of no other preventive, than such means as improve and invigorate the constitution in general, and the uterus in conse- quence thereof. This is of no small importance, as a weak state of the uterine system predisposes to more formidable diseases, and may be followed by scirrhus of the womb or of the breast.* § 35. HYDATIDS. Hydatids may also enlarge the womb, and these frequently are formed in consequence of the destruction of the ovum at an early period,f or of the retention of some part of the placenta, after de- • In the Hist, of Acad, of Sciences for 1714, is the case of a woman who re- ceived a fall in the third month of pregnancy. The belly however increased in size till the fifth, when it began to lessen. In the sixth she was delivered of a bag, as large as the fist, with a placenta and foetus of the size of a kidney-bean. T;> this case, hydatids were not formed ; but in the History for 1715, is a case, where the woman, falling in the second month, had the ovum converted into hydatids, which were expelled in the tenth month. As hydatids often succeed to genuine pregnancy; the symptoms may at first be exactly the same with those of preg- nancy, nay, even motion maybe felt, but afterwards the child may die, and hy- datids form.—Mr. Watson in the Phil. Trans. Vol. XLI. p. 711. gives a case, where there was, for a long time before the expulsion of hydatids, a quantity of blood discharged every night; pains at last came on, and expelled many hydatids. In this case, the symptoms of pregnancy were evident from Nov. to Feb. When the ovum is blighted, the belly ceases to enlarge in the due proportion, and the breasts become flaccid. f Dr. Denman gives an engraving of a diseased ovum : and Mr. Home relates a case, where the patient, after being attacked with flooding, and vomiting, and spasm in the abdomen, died. On opening her, the womb was found filled with hydatids, and its mouth a little dilated. Trans, of a Society, &c. Vol. II. p. 300.— Such cases as I have seen have been attended with considerable discharge ; but as a great part of it was watery, it made a greater appearance than the real quan- tity of blood would have caused. In a case related by Valleriola, p. 91, the woman had at first her usual symp- tom of pregnancy, but in the eighth month expelled hydatids.—Pichart in Zod. 113 livery or abortion. We possess no certain diagnostic; when they are formed in consequence of coagula^ or part of the placenta re- maining in utero, the symptoms must be such as proceed from the bulk of the womb, or from its irritation, as if by a polypus or mole. The remarks in the preceding section are therefore applicable here ; but in a great majority of cases, hydatids are formed in con- sequence of the destruction of an ovum ; and accordingly, the symptoms at first are exactly the same with those of pregnancy. These cease when the ovum is blighted, and the time when this happens is marked by the breasts becoming flaccid, and the sick- ness and the sympathetic effects of pregnancy going off. The con- ception remains, and the belly either continues nearly of the same size, or if it increase, it is very slowly. Menstruation does not take place; but there may occasionally be discharges of blood in different degrees, and there always is at one period or other, a very troublesome discharge of water, so that cloths are required^ Med. Gall. an. 3, p. 73, relates a similar case, but the hydatids were expelled in the fourth month without hemorrhage. Other cases of hydatids are to be found in Tulpius, lib. 111. c. 32. Schenkius, p. 685. Mercatus de Mulier. affect, lib. III. c. 8. Christ, a Veiga Art. Med. lib. III. § 10. c. 13. relates an instance of 60 hydatids, as large as chesnuts, being expelled. Stalpart Vander Wiel, Tom. 1. p. 301. mentions a woman who, in the ninth month, after enduring pains for three days, expelled many hydatids, and the pro- cess was followed by lochia. Lossius, Obs. Med. lib. IV. ob. 16. mentions a widow who for several years had a tumid belly : after death, hydatids were found in utero. See also Mauriceau's Observations, obs. 367. Ruysch, Obs. Anat. Chir. p. 25. Albinus Anat. Acad. lib. I. p. 69. and tab. III. fig. 1. describes in an abortion, the commencement of this change. The vesicles are not larger than the heads of pins. Wrisberg describes a more advanced stage in Nov. comment. Golting. Tom. IV. p. 73 ; and Sandifort, in his Obs. Anat. Path. lib. II. c. 3. tab. VI. fig. 5. has a case extremely distinct. See also Haller Opusc. Path. ob. 48. Vigarous, Malad, &c. Tom. I. p. 385, proposes mercury to kill the hydatids. He knew an instance where the woman discharged hydatids always when she went a la garde-robe. Mr. Mills relates a case, where the woman betwixt the second and third month, had symptoms of abortion, and afterwards, in the fifth or sixth, expelled above three pints of hydatids. Vide Med. and Phys. Journal, Vol. II. p. 447. When the mass is expelled, it is found either to consist entirely of small vesi- cles, or partly of vesicles, and partly of more solid remains of the ovum, or coagu- lum of blood. 10 114 and even with these, the patient is uncomfortable. No motion is> perceived by the woman, and the size of the belly and state of tho womb do not correspond to the supposed period of pregnancy. In some instances, the health does not suffer; in others feverish- ness and irritation are produced. After an uncertain lapse of time, pains come on, and the mass is discharged, often with very con- siderable hemorrhage. This expelling process may sometimes be advantageously assisted by introducing the hand to remove the hydatids, or to excite the contraction of the womb ; but this must be done cautiously, and only when hemorrhage or some other ur- gent symptoms occur. These must be treated on general princi- ples. In some cases, milk is secreted after the hydatids are expelled. fn others, a smart fever, with pain in the hypogastrium, follows. It requires laxatives and fomentations. When hydatids form in a blighted ovum, their number varies greatly in different cases. In some, I have seen only a little bit containing vesicles, often only the under part which had been for some time detached in a threaten- ed abortion. In others, almost the whole is changed, and the mass much enlarged. This, I presume, is connected with the womb, by the unchanged portions alone; and therefore, in examin- ing the inner surface of such a uterus after the mass was expelled, we should expect to find it more or less similar to the gravid state, according to the greater or less change in the ovum. The relative magnitude of the vessels in the two states has not been ascertained, few opportunities being afforded of dissection in this disease.^ fxj Ruysch in the first volume of his valuable works, has given two very curious and accurate plates of these hydatids of the placenta or uterus. There is also a representation of these vesicles in Baillie's plates of Morbid Anatomy, exe- cuted with great truth and elegance. It is now generally considered by natural- ists, that the hydatids found in the human body, are a sort of imperfect animals; and as Dr. Baillie has observed, although there may be some difference between them in simplicity of organization, this need be no considerable objection to the opinion, as life may be conceived to be attached to the most simple form of or- ganization. For further information on the subject of hydatids, particularly those of the uterus, the student is referred to a paper by the editor, inserted in the Eclectic Repertory, Vol. I. p. 499, and seq. Also to Monro's Morbid Anatomy of the human gullet, stomach and intestines. Edin. 1811, p. 255. 115 Sometimes there is only one large hydatid, or, at most, a very few in the womb, and the preceding remarks will also be applica- ble, in a great measure, to this case. In the advanced stage, we find the belly swelled, as in pregnancy; but the breasts, although sometimes tense, are oftener flaccid, and no child can be discover- ed in utero, nor does the woman perceive any motion. There may be pain in the abdomen, and obscure fluctuation is discernible externally, whilst per vaginam it is more distinct. The neck of the womb is small, and the case much resembles ovarian dropsy, except that the tumour occupies the region of the uterus. The duration of this complaint is uncertain ; but the water is at last dis- charged suddenly, and after making some exertion. The bag af- terwards comes away, and the process is not attended with much pain.* It is most prudent to be patient; but if the symptoms be troublesome, the fluid can be drawn off by the os uteri. This disease, a solitary hydatid, is oftener combined with pregnancy, or with a mole, than met with alone. The first combination! is not uncommon, and I have seen the hydatid expelled some weeks before labour. Hildanus gives an instance of the second, where the ovum was converted into a mole intimately connected to the uterus, and complicated with a collection of fluid to the extent of six pounds. In this case, so much irritation was given, as to ex- haust the strength, and produce local inflammation. § 36. AQUEOUS SECRETION. A different disease from that described in the last section, is an increased secretion from the uterus itself, accompanied generally with symptoms of uterine irritation; and if the woman menstruate, * Hildanus, I think, relates the history of a woman who was supposed to be pregnant, but dum noctu cum marito rem haberet, a sudden inundation swept away her hopes. ■J; Hildanus relates a case of this kind in his own wife, dulcissima et chanssim^ conjux mea. Hydatids may also be combined with pregnancy. The same author tells us of a woman who, in the fifth month, was delivered of a mola aquosa, or vesicles containing ten pounds of water; she did not miscarry, but went to the full time. 116 the menses are pale and watery. There may be a constant stilli- cidium of water,* or from some obstructing cause the fluid may be for a time retained,f and repeatedly discharged in gushes; I do not know to a certainty, that this can take place without some or- ganic affection of the womb, or some substance within its cavity. At the same time, I have met with this where no hydatids were discharged, where the womb felt sound, and a cure was at last ac- complished. We must always examine carefully, for it may pro- ceed from hydatids, or from disease, or excrescences about the os uteri. If nothing can be discovered, we must proceed upon the general principle of improving the health, and injecting mild as- tringents. I need scarcely caution the practitioner not to confound a discharge of urine from an injury of the bladder, with this com- plaint.;]; § 37. WORMS. Worms^ have been found in the uterus, producing considerable irritation; and generally, in this case, there is a foetid discharge. We can know this disease only by seeing the worms come away. It is cured by injecting strong bitter infusions. * Hoffman mentions a woman who had a constant stillicidium, a pint being dis- charged daily. It at last proved fatal. Opera, Tom. HI. p. 160. f Kirkringius, p. 28. considers dropsy of the uterus as impossible, and says, that every case of collection of water depends on a large hydatid. Dr. Denman seems to be much of the same opinion. But we find instances where water is accumulated and repeatedly discharged, apparently from the removal of a tem- porary obstruction. Fernelius relates a case, where the woman always before menstruation discharged much water. Path. lib. VI. c. 15. And M. Geoff'roy describes a case of repeated discharge. Vide Fourcroy la Med. Eclaree, Tom. II. p. 287 A case is related by Turner, where the external membrane of the uterus was said to be distended with water. The menses were suppressed, and a secretion of whitish fluid took place from the breasts. Phil. Trans. No. 207. $ Vesalius, Tom. I. p. 438, says, that he found a uterus containing 180 pints of fluid, and its sides in many places scirrhous. I wish he may not have mistaken the ovarium for the womb. § Vigarous, Malad. Tome I. p. 412.—Mr. Cockson mentions a case, where mag- gots were discharged before the menstrual fluid. The woman was cured, by injecting oil, and infusion of camomile flowers. Med. Comment. Vol. III. p. 86. 117 § 38. TYMPANITES. Sometimes* air is secreted by the uterine vessels, and comes away involuntarily, but not always quietly. Tonics, and astringent injections, occasionally do good; and, as this disease rarely causes sterility, it is sometimes cured permanently by pregnancy. It is said, that the air is in certain cases, retained, and the uterus dis- tended with it, producing a tympanitis of the uterus. § 39. PROLAPSUS UTERI. f The prolapsus, or descent of the uterus, takes place in various degrees.f The slightest degree, or first stage, has been called a relaxation; a greater degree, a prolapsus; and the protrusion from the external parts, a procidentia. It is necessary to attend care- fully to this disease, to ascertain its existence, as it may, if neglect- ed, occasion bad health, and many uneasy sensations. The symp- toms at first, if it do not succeed parturition, are ambiguous, as some of them may proceed from other causes. They are princi- pally pain in the back, groins, and about the pubis, increased by walking, and accompanied with a sensation of bearing down. There is a leucorrheal discharge, and sometimes the menses are increased in quantity. In a more advanced state, there is stran- gury, or the urine is obstructed, and the patient feels a tumour or fulness toward the orifice of the vagina, with a sensation as if her bowels were falling out, which obliges her instantly to sit down, or to cross her legs, as if to prevent the protrusion. This is accom- panied with a feeding of weakness. There are also, during the whole course of the complaint, but especially after it has continued for some time, added many symptoms, proceeding from deranged action of the stomach, and bowels, together with a variety of those called nervous. On this account, an inattentive practitioner may * Vide Vigarous' Maladies, Tome I. p. 401. t Vide Memoir by Sabatier, in 3d. vol. of the Memoirs of the Academy of Sur- gery. 118 obstinately consider the case as altogether hysterical, until emacia- tion and great debility are induced. But if the woman have been recently delivered, there is less like- lihood of the practitioner being misled. She feels a weight and uneasiness at the pubis and hypogastric region, with an irritation about the urethra and bladder; and sometimes a tenderness in the course of the urethra, or near the vulva. A dull dragging pain is felt at the groins, and when she stands or walks, she says she feels exactly as she did before the child was born, or as if there was something full and pressing. Pains are felt in the thighs, and the ~back is generally either hot, or aches. These symptoms go off in a great measure, when she lies down, though, in some cases, they are at first so troublesome, as to prevent rest. In some instances, no pain is felt in the back; but whenever the patient stands, she complains of a painful bearing-down sensation, or sometimes of pressure about the urethra, or orifice of the vagina. By examination, the uterus is felt to be lower down than usual, and the vagina always relaxed. In certain circumstances, it pro- lapses, forming a circular protrusion at the vulva. Next, the os uteri descends so low as to project out of the vagina. In the greatest degree, or procidentia, the uterus is forced altogether out, invert- ing completely the vagina, and forming a large tumour betwixt the thighs. The intestines descend* lower into the pelvis, and even may form part of the tumour, being lodged in the inverted vagina, giving it an elastic feel. In some instances, this unnatural situa- tion of the bowels gives rise to inflammation. The uterus is par- tially retroverted, for the fundus projects immediately under the perineum, and the os uteri is directed to the anterior part of the tumour. The orifice of the urethra is sometimes hid by the tu- mour, and the direction of the canal is changed; for the bladder, * Sometimes the situation of the abdominal viscera is very much altered. In Mr. White's case, the liver was found to descend to the lower part of the belly, and the diaphragm was lengthened so as to allow the stomach to reach the umbi- lical region. Vide Med. Obs. and Inq. Vol. III. p. 1. in a complicated case, re- lated by Schlincker, the pylorus hung down to the pubis. Haller, Disp. Med. IV. 419. 119 if it be not scirrhous, or distended witfi a calculus of large size, is carried down into the protruded parts;* and a catheter passed into it, must be directed downwards and backwards. The procidentia- is attended with the usual symptoms of prolapsus uteri, and also with difficulty in voiding the urine, tenesmus, and pain in the tu- mour. If it have been long or frequently down, the skin of the va- gina becomes hard, like the common integuments, and it very ra- pidly ceases to secrete. The mouth and neck of the womb also, in such cases, elongate. Sometimes the tumour inflames, indurates, and then ulceration or sloughing takes place. This procidentia may occur in consequence of neglecting the first stage, and the uterus is propelled with bearing-down pains; or it may take place all at once, in consequence of exertion, or of getting up too soon after delivery. It may also occur during pregnancy, and even during parturition. Sometimes it is complicated with stone in the bladder,f or with polypus in the uterus.| Some have, from theory, denied the existence of prolapsus,^ and others have disputed whether the ligaments were torn or re- * This point is very well considered by Verdier, in his paper on Hernia of the Urinary Bladder, in the first Vol. of Mem. de l'Acad. de Chir. See also a paper by M. Tenon, in Mem. de l'Institute, Tom. VI. p. 614.—Mr. Paget relates a very interesting case of prolapsus uteri, in which the bladder became retrovert- ed, lying above the uterus. It could not descend before it, or along with it, being filled with a calculus, weighing 27 ounces, and others of a smaller size. Some parts of the bladder were an inch thick; a catheter could not be intro- duced. Med. and Phys. Journal, Vol. VI. p. 391. f Ruysch, feeling some hard bodies in the tumour formed by the protruded parts, cut out 42 calculi from the bladder. M. Tolet extracted fifty, and after- wards cured the woman with a pessary, Duverney met with large calculus in the bladder, with procidentia uteri; and Mr. Whyte relates a similar fact. Med. Obs. and Inq. Vol. 111. p. 1. See also Deschamps Traite de la Taille, Tom. IV. p. 158. $ Vide the case of a girl aged 21 years, related by Mr. Fynney. The poly- pous excrescence was extirpated from the os uteri, and then a pessary was em- ployed. Med. Comment. Vol. IV. p. 228. § Kirkringius says, .Vemo vidit nemo sensit decepti omnes imagine falsa, alios deei- piunt; laxitas qiuedam colli qu) In the lying-in hospital, called l'Hospice de la Maternite", at Paris, about one in eighty-nine had twins, as appears from Baudelocque's Tableau des Ac- couchemens. In the lying-in ward of the Philadelphia alms-house, as appears from a regular record kept for 1? years, ending 1815, one woman in about 52 had twins. The proportion of males to females, born within the above period, was about 10 males to 8 females. A different average, particularly as it regards the proportion of twin cases, was stated in the former edition of this work, but that was taken from the result of five years only, in which twin cases had very rarely occurred. 24. 178 thousand and fifty times.(q) More than three are not met with, once in twenty thousand times. The proportion of male children, born in single births, is great- er than of females. In an extensive parish in this place, the num- ber of males born in a given time, was to that of females, as 3716 to 3177. In the Westminster hospital, it was as 972 to 951 ; but in the same hospital, it is worthy of remark, that the number of male twins was only 16, whilst that of females was 30. (VJ § 7. PECULIARITIES OF THE FCETUS. The foetus has many peculiarities which distinguish it from the adult, and which are lost after birth, or gradually removed during gestation. In particular, the liver is of great size, by which the ab- domen is rendered more prominent than the thorax. It appears very early, and increases rapidly till the fourth month, after which its growth is slower. In the child, after birth, the greatest quantity of blood in the liver is venous, and from this the bile seems to be secreted. But in the foetus, the blood is more nearly approaching in its nature to arterial; and no bile, but a fluid dif- ferent in its properties, is secreted. The gall bladder is filled with a green fluid, which, before birth, becomes darker, with a tinge of blue, but is said not to have a bitter taste. The umbilical vein, which contains blood, changed in the placenta, enters the liver,' and sends large branches to the left side; the vena porta? enters the liver, and ramifies on the right side ; whilst a branch, or canal of communication, is sent from the umbilical vein to the vena porta?. By this contrivance, the left side is supplied altogether with pure blood from the placenta, and the right side is supplied with a mix- ture of pure and impure blood, which does not form perfect bile. After birth, as the circulation from the placenta is stopped, the branches of the umbilical vein, which supplied the left side, would be empty, did not the canal, which formerly served to carry a por- (9) In l'Hospice de la Maternite at Paris, triplets occurred but twice in 12,605 women. (r) Of 12,751 infants born in the lying-in hospital at Paris, above alluded to, 6,524 were males, and 6,227 females. 179 lion of blood from this vein to the vena portae, now permit this lat- ter vessel to fill the branches in the left side, which henceforth form a part of the vena portae. The whole liver is thus supplied with blood entirely venous. Bile is formed, and sometimes in very considerable quantity. { The blood of the foetus differs from that of the adult. It forms a less solid coagulum, for in place of fibrous matter, it yields a soft tissue, almost gelatinous. It is not rendered florid by exposure to air,* and it contains no phosphoric salt. But soon after the foetus has respired, the colouring matter, exposed to oxygen, acquires the vermilion tint; and salts are formed, particularly the phosphate of lime. The stomach is smaller in the foetus, than in the child after birth. The intestines, which at first are seen like threads arising from the stomach, are redder, and said to be longer in proportion to the body in the foetus, thanjn the child. They are at first un- covered, but, after some time, the abdominal muscles and integu- ments form a complete inclosure. They contain a soft substance like ointment, of a dark green colour, called meconium. The testicles of the male, and the ovaria of the female, lie on the psoae muscles; but, before birth, the testicles pass into the scrotum. The kidneys are large and lobulated, and the ureters thick. The glandulae renales are large, and contain a reddish fluid. The blad- der is more conical and lengthened than in the adult. The lungs are dense and firm, and a large gland, called thymus, is contained in the thorax. The heart is very different from its adult state. In the chick, we find that there is in the situation of the heart, a single cavity which afterwards corresponds to the left ventricle. At the forty-sixth hour the ventricle and bulb of the aorta are visible. Then an auricle is formed by the vena cava : this auricle does not adhere directly to the ventricle, until the sixth day, but is connect- ed with it till that time by a short duct, called canalis auricularis. In about ninety-six hours the auricle begins to exhibit marks of a division into two cavities, or a right and left side, and some time afterwards, the right ventricle and lungs are evolved. The struc- * Bichat made experiments to ascertain this upon Guinea pigs, and always found the foetal blood black. Anatomie Generate, Tome II. p. 343. 180 ture of the heart, however, is still different from that which obtains after birth; for though the auricles are divided into two cavities, yet these are seen, in the human fcetus, to communicate freely by a vacancy in the septum ; and even after this is supplied, it is only with a valve, which allows the blood to pass from the right to the left side. This is the foramen ovale, which is shut up after birth. Another peculiarity of the foetal heart is, that the pulmonary artery, although it divide into' two branches for the lungs, yet sends a third, and still larger branch, directly into the aorta just at its curvature, and this is the ductus arteriosus. The blood is received in a puri- fied state from the placenta, by the umbilical vein, which, after giving off branches in the liver, sends forward the continuation of the trunk, to terminate in the vena cava, or largest of the hepatic veins, and this continuation is named ductus venosus. The mixed blood which is thus found in the vena cava, is carried to the right auricle, and thence to the corresponding ventricle. By the pulmo- nary artery it ought to be conveyed to the lungs, but this would be useless in the foetus, and therefore the greatest part of it passes on by the ductus arteriosus to the aorta. But it follows from this, that as little blood is carried to the lungs, so little can be brought from them by the pulmonary veins to the left auricle. Now, to obviate this, and fill that auricle at the same time with the right, the fora- men ovale is formed; and thus, as the blood can pass freely from the right to the left, the two auricles are to be considered as one cavity, being filled and emptied at the same time. The aorta is distributed to the different parts of the body; but this singularity prevails, that the hypogastric vessels run up all the way to the navel, and pass out to form the umbilical arteries. Af- ter birth, these arteries are obliterated in their course to the navel; and the foramen ovale, and ductus arteriosus become impervious. The head of the foetus is, at first, membranous, and the brain a pulp, soluble in aqua kali puri. By degrees, distinct cartilaginous plates are formed over the brain, which are gradually converted in- to bones. These, at birth, are only united by intermediate mem- branes. The pupil of the eye, till the seventh month, is shut up by a membrane; and the eyelids, for some months, adhere together. 131 The skin is covered with a white substance, which, though unc- tious to the feel, does not melt, but dries and crackles by heat. It is miscible with spirits, or with water, through the medium of soap or of oil. The male foetus differs from the female, in havingthe head larger, but less rounded, and flatter at the back part. The thorax is longer, and more prominent, and formed of stronger ribs than in the fe- male. In her, it is wider from the upper part to the fourth rib, and narrower below; the belly, also, in the female, is more prominent, and the symphysis pubis projects more. The upper extremities are shorter than those in the male; the thighs are thicker at the top, and more tapering to the knees. Dr. Soemmering says, that the spinous processes of the lower dorsal, and upper lumbar vertebra?, make in the male an eminence like a yoke, in the female a sinuo- sity. I may remark, that as the clitoris is large in the young foetus, females sometimes pass in abortions for males. When in utero, the foetus assumes that posture which occupies least room. The trunk is bent a little forward, the chin is pushed down on the breast, the knees are drawn up close to the belly, and the legs are laid along the back part of the thighs, with the feet crossing each other. The arms are thrown into the vacant space betwixt the head and knees. This is the general position, and the child thus forms an oval figure, of which the head makes one end, and the breech the other. One side of it is formed by the spine and back part of the head and neck, and the other by the face and con- tracted extremities. The long axis of this ellipse measures, at the full time, about ten inches, and the short one, five or six. In the eighth month, the long axis measures about eight inches. In the sixth, betwixt four and five. In the fourth month, it measures nearly three inches and a half; and in the third, about an inch less. In the early months, however, there is no regular oval formed, and these measurements are taken from the head to the breech, which afterwards forms the ends of the distinct ellipse. The ex- tremities are at first small and slender, and bend loosely toward the trunk. 182 § 8. UMBILICAL CORD. The umbilical cord is an essential part of the ovum, connecting the foetus to its involucra. It is found in oviparous and viviparous animals, and also in plants; but in these different classes, it ap- pears with many modifications. In the human subject, it consists of three vessels; of which two are arteries, and one is a vein. These are imbedded in gluten, and covered with a double mem- branous coat. The two arteries are continuations of the arteriae hypogastricae of the child, and passing out at the navel, run in dis- tinct and unconnected trunks, until they reach the placenta, where they ramify and dip down into its substance. When they reach the placenta, the one artery, in some cases, sends across a branch to communicate with the other. The vein commences in the sub- stance of the placenta, forms numerous rays on its surface, corres- ponding to the branches of the arteries; and near the spot where the arteries begin to give off branches, these rays unite into a sin- gle trunk, the area of which is rather more than that of the two ar- teries. None of these vessels are furnished with valves. The umbilical vessels run in a spiral direction, within the co- vering of the cord, and the twist is generally from right to left. Besides this twisting, we also find, that the vessels, especially the arteries, form very frequently coils, loosely lodged in the gluten. The cord does not consist entirely of vessels, but partly of a tenacious transparent gluten, which is contained in a cellular struc- ture ; and these numerous cells, together with the vessels, are covered with a sheath, formed by the reflection of both chorion and amnion from the placenta; and of necessity the amnion forms the outer coat of the cord. The chorion adheres firmly to the cord every where, but the amnion does not adhere to the chorion; it is not even in contact with it at the placental extremity, but forms there a slight expansion, which, from its shape, has been called by Albinus, the processus infundibuliformis. The proportion of gluten is larger in the early than in the ad- vanced stage of gestation; and the vessels, at first, run through it in straight lines. In some instances, the cells distend or augment 183 in number, so as to form tumours on the cord, which hang from it like a dog's ear. There is a small sac, or bladder, found on the placenta, at or near the extremity of the cord, in the early part of gestation. It is most distinct betwixt the third and fourth month of pregnancy, and is placed exterior to the amnion. It is filled, though not quite disi tended, with a whitish fluid, on which account it is called the ve- sicula alba.* From this a very fine vessel proceeds along the cord, adhering firmly to the amnion; but, without a glass, it cannot be traced all the way to the navel. It has been supposed to be sub- servient to the nourishment of the foetus in its early stage. A small artery and vein pass along the cord from the navel, to the vesicle which is between the chorion and amnion. These are the ompha- lo-mesenteric vessels. Besides the blood vessels, there is in brutes another vessel, which is a continuation of the fundus vesicae. It passes out at the navel, and, running along the cord, terminates in a bag, which is placed betwixt the chorion and amnion. The bag is called the allantois, and the duct the urachus. In the human subject, in place of the urachus, we find only a small white impervious cord. There is of course no allantois. When the ovum is first visible in the uterus, there is no cord, the embryo adhering directly to the involucra, but it soon recedes; and about the sixth week, a cord of communication is perceptible. The cord at the full time varies in length, from six inchesf to four feet;J but its usual length is two feet. When it is too long, it is often twisted round the neck or body of the child, or occa- sionally has knots formed on it,^ most frequently, perhaps, by the child passing through a coil of it during labour. j| * Vide Albinus, Annot. Acad. lib. I. cap. xix. p. 74, et tab. I. fig. 12. f Hildanus, cent. II. obs. 50. + Mauriceau has seen it a Paris ell and a third, obs. 401.—Hebenstreit 4Q inches.—Haller Disp. Anat. Tom. V. p. 675.—Wrisberg 48 inches.—Vide Com. Gotting. Tom. IV. p. 60. § Vide Mauriceau, obs. 133. and 156. U Dr. Hunter thinks he has twice seen these formed previous to birtb. 184 The vessels of the cord sometimes become varicose, and form very considerable tumours. These, occasionally, so far impede the circulation, as to interfere with the growth of the child, or even to destroy it altogether. Sometimes the vessels burst, and blood is poured into the uterus, which produces a feeling of distention, and excites pain. There can, however, be no certainty of this ac- cident having taken place until the membranes burst, when clots of blood are discharged. If the foetal and maternal vessels should communicate, the mother is weakened, and may even faint; and, in every instance, the child suffers, but does not always die.* De- livery must be resorted to, either on account of the effects pro- duced on the mother, or to prevent the destruction of the child. The cord may, by a fall, or violent concussion of the body, be torn at a very early period of gestation. In this case, the child dies, but is not always immediately expelled It may be retained for several weeks; afterwards the ovum is thrown off, like a con- fused mass, inclosing a foetus, corresponding in size to the period when the accident happened.f The cord may be filled with hydatids. The cord has been found unusually small and delicate, or, on the contrary, very thick. In the latter case, it is always proper to apply two ligatures, instead of one, on the portion which remains attached to the child.f It has happened, that by the shrinking of the cord under the ligature, the child has died from hemorrhage.^ Two cords have been met with, connected with one placenta, or with two placentae belonging to one child. In other instances, the vessels are supernumerary or deficient. Stories have been told of the cord being altogether wanting, but these are incompati- ble with the foetal economy. * Vide Baudelocque l'Art, note to section 1084. f Vide Case by M. Anel, in Mem. of Acad, of Sciences, 1714. $ This was proposed by Mauriceau, in consequence of meeting with an hv stance, where the child suffered much from loss of blood, obs. 256. § Vide Case by M. Degland, in Recueil Period. Tome V. p. 343. 185 § 9. PLACENTA. A placenta, or something equivalent to it, is to be found con- nected with the young of every living creature. We find it requisite that a pabulum should be supplied to every animal, and that certain changes should be performed on the blood, qualifying it for supporting life. In oviparous animals, two differ- ent parts of the ovum perform these separate functions. The um- bilical vessels of the chick ramify on the membrane of the albu- men, and thus come in contact with the air, which is absorbed through the pores of the shell; and, by this contrivance, changes analagous to those effected by respiration, are produced on the blood. From the inner surface of the membrane of the vitellus, a nourishing fluid is absorbed, which is conveyed to the intestine by a proper duct; and, before the chick is hatched, the remainder of this fluid, inclosed in the membrane of the vitellus, is taken within the abdomen, and covered with the abdominal integu- ments.* * In the eggs of fowls, we observe the following circumstances. 1st. Upon removing the porous shell, we find the albumen inclosed in a membrane, consist- ing of two layers, and called sacciform by Levielle". These are separated from each other at the large end of the shell, so as to form a small sac, called the fol- liculus aeris. The albumen is divided into three strata ; the first, or cortical, is most liquid; the second or middle, is more abundant, and thicker than the first, but less so than the third or central. The middle and central strata are inclosed in a delicate membrane, called leucilyme by Levielle", which separates them from the cortical. 2d. Within the albumen we have the vitellus or yolk, which is in- closed in a vascular membrane, called chlorilyme, or membrana vitelli, which again is enveloped by a membrane common to it and the intestines of the chick, called entro-chlorilyme. 3d. To each end of the vitellus, we have connected a portion of the central albumen, called chalaza; and in each of these a membra- nous substance is discovered, attached to the membrane of the vitellus, and a vas- cular structure, which can absorb the albumen into the vitellus, to contribute to the nutrition of the chick. 4th. Upon the vitellus, we observe the cicatricula, or small sac, called by Harvey the eye of the egg, and which was supposed to con- tain the foetus, the rudiments of which are allowed by Malpighi, Haller, and Spallanzani, to be pre-existent to fecundation. This cicatricula was considered as analogous to the amnion, and supposed to contain a transparent fluid, called by Harvey colliquamentum candidum, or liquor amnii. More modern observations 25 186 In many quadrupeds we find, that, after impregnation, certain portions of the inner surface of the uterus enlarge, and form pro- ascertain that the embryo is not formed in the cicatricula, but very near it on the vitellus, and that the amnion inclosing it can at first scarcely be distinguished from the embryo. The cicatricula soon disappears. Harvey's account must therefore be transferred to the amnion. 5th. During incubation, the vitellus be- comes specifically lighter than the albumen ; and rises toward the folliculus aeris. Two arteries and two veins go from the meseraic and hypogastric vessels of the foetus, to the membrane of the yolk, and are supposed to absorb the vitellus, which therefore is carried to the vena porta of the chick, and nourishes the foetus. There is also a connection betwixt the intestines and vitelline membrane, by means of a ligamentous substance, which was supposed by Haller and Vicq. D'Azyr to be a tube, and called vitello-intestinal canal, for it is said that air has been passed through it. It was supposed to absorb the yolk, by many villi on the inner surface of the vitelline membrane; but these are said by Levielle not to be vessels, but soft lamellated plates. At the end of the second day, red blood is observed on the membrana vitelli. A series of dots are formed, which are con- verted firstinto grooves, and then into vessels, which go to the foetus. This ap- pearance has been called figura venosa, and the marginal vessel vena terminalis. 6th. The vitello-intestinal ligament, and these vessels, form an umbilical cord. But besides these, we find, after the fourth day, a vascular membrane at the um- bilicus, called membrana umbilicalis, which rapidly increases, and comes pre- sently to cover the inner surface of the membrane of the shell. It is the chorion, and has numerous vessels ramifying on it, like the chorion of the sow, and con- nected in like manner with the foetus. The blood of the umbilical artery is dark- coloured, that of the vein bright. 7th. As incubation advances, the amnion en- larges, and comes in contact every where with the chorion. The albumen is all consumed, being taken into the vitellus, which is in a great measure absorbed 5 and what remains is taken, together with the sac, into the abdomen of the chick, and the parietes close over it. On the 21st day, the chick breaks the shell and escapes. By increasing or diminishing the temperature within a certain extent, the process may be somewhat accelerated or retarded. The eggs of large birds require a longer time to be hatched; those of the ostrich, for example, take six weeks. Hence it appears, that the vitellus and albumen contribute to the increment of the foetus, whilst the exterior membranes act as lungs, the air being transmitted through the pores of the shell. The eggs of fishes have a general resemblance to those of fowls, and consist of a vitellus and albumen, with their membranes; but in place of being furnished with a shell, they have a tough, or sometimes a horny covering; and some, as those of the shark, torpedo, &c. are quadrangular in shape. The yolk is connect. ed to the intestines of the foetus, and its membrane is very vascular. As in fowls, so, in fishes, it is ultimately inclosed within the abdomen of the young. In the s^ate, numerous blood vessels are formed in the albumen, which supply the place 187 tuberances, having many hollows -or foramina, from which a milky fluid can be squeezed. From the chorion, corresponding vascular of gills, and are supposed by Dr. Monro, to be afterwards covered and converted into gills. The two functions of a placenta, then, are still more distinctly fulfilled here than even in fowls, for the apparatus for nutrition and respiration has dif- ferent or distinct terminations; whereas in fowls and quadrupeds, all the vessels enter at one place. A similar fact is observed in the ova of frogs, for the umbilical cord in the tadpole goes to the head. The egg of the serpent is nearly the same with that of the fish, and is inclosed in a flexible membrane. The foetus is coiled up spirally within it, and the chorion is vascular, as in the egg of the fowl. The adder is a viviparous animal; its uterus is membranous, and divided, I find, into eight or nine cells, each of which, in September, contains an ovum as large as a chesnut. This consists of an exterior membrane, which incloses a foetus about six inches long, and coiled up. About an inch from the tail, the umbilical cord passes out,t which consists of vessels that go to ramify on the exterior membrane, which resembles the chorion of the sow. There is also a connection with a vitel- lus, which is as large as a hazel nut. The coluber natrix is said, by Valmont-Bomare, to have a placenta and cord within the egg, but this is contrary to the general structure of eggs; most likely the chorion has been taken for the placenta. The eggs of reptiles are often de- posited in packets, the eggs being glued together. The egg of the turtle is as large as a hen's, and is inclosed in a covering like parchment. It is deposited in the sand, and is hatched in about 24 days. The egg of the alligator is similar in structure to that of the turtle : it is rather larger than a goose's egg, and covered with a thin skin, so transparent, however, that the foetus may be seen through it. Those animals which are called oviparous, hatch their eggs out of the body, either by sitting on them, as we see in fowls, or by exposing them to the heat of the sun, as the turtle, crocodile, and many serpents. Oviparous fishes, which comprehend all those called osseous, expel their ova into the water, where they are fecundated by the male, but without copulation. Many fishes leave the sea, and come up the rivers to spawn. Others remain in the ocean ; and the eggs, specifically lighter than the water, float on the surface. Many fishes attach them to marine plants, and in some cases the ova are fixed to the body of the pa- rent. The ova are covered with a kind of mucus, which has been supposed to defend them from the water. The ova of frogs, &c. are likewise fecundated and hatched out of the body. They are enveloped in a glairy matter, which perhaps contributes to their in- crease; for during incubation, the egg both enlarges and changes its shape. Those animals which hatch their eggs within the body, are called ovo-vivipa- rous, such as cartilaginous fishes, as the shark, skate, and torpedo, &c. The scor- pion and venemous serpents also belong to this class. Ovo-viviparous animals ex- pel the young fully formed, and therefore have been sometimes considered as 188 efflorescences arise, which shoot into these apertures; and thus an union is effected betwixt the mother and foetus. having uteri like quadrupeds, and a cord attached directly to it. Spallanzani at first supposed that the foetus of the torpedo was attached directly to the uterus, but afterwards found that it was contained in a distinct ovum. Experiences, p. 294. See also Cuvier Legons d'Anat. Comparee, Tom. V. p. 142. The shark is said to have an uterus like the bitch, and Belon says he saw a female deliver- ed of eleven young attached by a cord. Its mode of gestation most likely is simi- lar to the torpedo. This class expel their young often very quickly. A female syngnatus hyppocampus was observed to expel at least a hundred in a very short time. Analogous to ovo-viviparous animals, are those which receive the ova into cells on the surface of the body, where they are hatched. This is well seen in the pipa, a species of toad. Even the tadpoles, are said to be metamorphosed in these cells. The opossum tribe has a modification of this gestation; for in them the foetus, when very small, is expelled into a bag situated on the belly, and imme- diately attaches itself to a nipple. The utero-gestation of the opossum of North America lasts only from 20 to 26 days, and the embryo, when expelled, does not exceed a grain. It remains in the sac about 50 days, and acquires the size of a mouse. In other animals, as for instance the bat, the young, after birth, attach themselves to the nipple, partly for the convenience of being transported or car- ried about. In plants we find likewise a placenta or structure, intended for the nourishment and respiration of the foetus. To take the kidney bean for an example, we find within the membranous covering two parenchymatous lobes, or cotyledons; and at the margin betwixt these, there is the corculum or cicatricula. During incu- bation, we find that this sends up a small shoot called the plumula, and down a radical into the earth. But to support the plant until the root and leaves are ca. pable of maintaining it, we find the cotyledons rise up out of the earth, on each side of the plumula, forming what are called seed leaves. These both serve for the respiratory organs, and also supply pabulum, which is absorbed by proper vessels, and in consequence thereof they presently are destroyed. When there are more lobes than two in the seed, there are a corresponding number of seed leaves. In many cases these cotyledons do not rise out of the ground, but the plumula alone appears. This is the case with the garden pea, but the cotyledons still perform their functions below the ground, and exist until the foliage of the plant, or adult organs, be formed. The greatest part, then, of a vegetable seed or ovum, consists, like the eggs of fowls, of an apparatus intended for the nutri- ment and respiration of the foetus, whilst the embryo itself is very small. The cotyledon consists, in many cases, of a farinaceous substance. In other seeds it is oily and farinaceous, and in some is almost all oily. Vegetable ova sometimes are contained in a dry pericarpium, and are shed in- to the earth when it bursts. But others have an apparatus provided, not only for their present growth, but also for accelerating their incubation in the earth. In 189 In the sow and the mare there is no projection from the uterus, but its surface is every where smooth and vascular. There is no efflorescence from the chorion, but it has numerous vessels dispo- sed over it, which are the extremities of the umbilical arteries and veins. In these animals, then, we have no distinct placenta, the chorion alone serving that purpose. The cetaceae have uteri like quadrupeds, but I am unacquainted with the precise mode of connection betwixt the mother and the fcetus. The monkey differs from other quadrupeds, in having no perma- nent papillae; but the maternal part of the placenta is deciduous, like that of women. In the human subject, the placenta is a flat circular substance about a span in diameter, and, when uninjected, an inch in thick- ness. It becomes gradually thinner from the centre to the circum- ference, by which it ends less abruptly in the membranes. Its common shape is circular; but it is sometimes oblong, or divided into different portions. The umbilical cord may be fixed into any part of the placenta, or sometimes into the membranes, at a distance from the placenta. When this happens, the vessels run in distinct branches to the pla- centa, without forming any spongy substance on the membranes. Most frequently, however, the cord is inserted at a point about half way between the centre and the circumference of the placenta. From this the umbilical vessels spread out, like a fan, ramifying stone fruit and nuts, we find that vessels pierce the shell at the bottom, and pass on toward the top, and reach the kernel or lobes, which are contained within the shell, enveloped in a soft membrane. They are inserted very near the embryo. Now, for the farther support of these parts, we find that stone fruits are covered with a quantity of nutritious matter. The almond, for example, has its ligneous nut covered with a fleshy substance about an inch thick, inclosed in a proper membrane. The rhamnus lotus has the stone surrounded with farinaceous matter, which tastes like gingerbread. Other seeds are contained in a parenchymatous or succulent substance, as the apple or pear; or in a firm white substance, like cream or marrow, or in a mucilaginous matter as the gooseberry, or in an organi- zed pulp as the orange and garcinia mangostona. Some are deposited in a lus- cious fluid at first, which ultimately becomes farinaceous, as the plaintain. 190 over the surface, and dipping their extremities into the substance of the placenta itself. That surface of the placenta which is attached to the uterus, is divided into lobes, with slight sulci between them, and is covered with a layer of the decidua like clotted blood. On the surface which is next die child, we see the eminent branches of the umbi- lical vessels, over which we find spread the chorion and amnion. If we inject from the umbilical vessels of the human foetus, we find that the placenta is rendered turgid, and vessels are to be found filled in every part of it; but always between their ramifications there remains an uninjected substance ; even the uterine surface of the placenta is not injected, for the foetal vessels do not pass all the way to that surface. If we inject from the uterine arteries, we, in like manner, ren- der the placenta turgid, but nothing passes into the umbilical vessels; and when we cut into the placenta, we find cells full of injection, and covered with a fibrous uninjected matter. Hence we may in- fer that the placenta consists uniformly of two portions. The one is furnished by the deciduous coat of the uterus, the other by the vessels of the chorion ; and these two portions may, during the first three months, be separated, by maceration, from each other. The structure of the foetal portion, so far as we know, appears to be similar to that of the pulmonary vessels, the artery terminat- ing in the vein. But the other portion is somewhat different; there is not a direct anastomosis, but the artery opens into a cell, and the vein begins from this cell; for, by throwing in wax by the uterine artery, we may frequently inject the veins. These cells communicate freely with each other in every part of the placenta, and may be compared to the corpora cavernosa penis. From the general principles of physiology, as well as from ex- periments on the chick in ovo, and from the fatal effects which in- stantly follow compression of the cord whilst the child is in utero, it is allowable to infer, that the placenta serves to produce a change on the blood of the foetus, analagous to that which the blood of the adult undergoes in the lungs ; and from considering, that the foetus itself cannot create materials for its own growth and support, 191 we may farther infer, that the placenta is the source of nutrition also. The placenta may be formed at any part of the uterus, but, in general, it is found attached near the fundus. Its structure is sometimes changed, part of it being ossified or indurated, or on the contrary, unusually soft. These changes may produce either hemorrhage, or retention of the placenta. Hyda- tids may form in the placenta ; or fleshy tumours may grow in its substance. In neither of these cases does the child necessarily die. § 10. MEMBRANES AND LIQUOR AMNII. The ovum when it descends into the uterus, consists of two membranes, one within the other, having very transparent jelly in- terposed between them. But in process of time the innermost, which is called the amnion, grows so much faster than the outer- most, called the chorion, that it comes in contact with it, or at least has only a thin layer of jelly interposed. The amnion is thin, pellucid, and totally without the appearance of either vessels or regular fibres ; yet, in the end of pregnancy, it is stronger than the chorion and its vascular covering: it lines the chorion, covers the placenta, and mounts up on the naval string, affording a coat to it all the way to the umbilicus, where it termi- nates. The sac, formed by the amnion, is filled with a fluid, which ap- pears to be composed chiefly of water, with a very little earth, al- bumen, and saline matter. As this water is contained within the amnion, it has received the name of liquor amnii. In this sac the foetus lies. The quantity of water, upon an average, which is contained within the amnion, at the full time, is about two English pints ; but sometimes it is much more, and at other times scarcely six ounces. In the early periods, the quantity is larger, in proportion to the size of the uterus, than afterwards. The chorion, like the amnion, is thin and transparent, adheres firmly to the placenta, and covers all the vessels which run on it* 192 surface; but it does not dip down with them into the substance of the placenta. The ovum, when it first descends, or at least very soon afterwards, has the chorion every where covered with vessels, which sprout out from it. These form a covering to it, which, from its appearance has been called the shaggy or spongy cho- rion. § 11. DECIDUA. The last coat to be described, is one yielded entirely by the uterus, and serves to connect the uterus with the foetal vessels of the chorion. This, as Harvey observes, is not a covering of the foetus, but a lining of the uterus, which falls off after delivery; and therefore it is called the caducous coat, or the membrana decidua. The illustrious Haller supposed, that this was formed by naked vessels shooting out from the uterus. Dr. Hunter imagined that the arteries of the uterus poured out coagulable lymph, which was afterwards changed into decidua. His brother, Mr. John Hunter, attributed its origin to coagulated blood, which formed a pulpy substance on the inner surface of the uterus. Having been so fortunate as to meet with three or four opportu- nities of investigating the state of the uterus, within a month after conception, I shall describe what appears to me to be the structure of the decidua. Very speedily after impregnation, and always be- fore the embryo enters into the womb, its size is increased, its fibres are softer and more separated from each other, and its ves- sels very much enlarged. On cutting it up, its cavity is found to be considerably broader and longer, and somewhat wider than in the unimpregnated state; and all the fundus and body have their sur- face covered with a dense coat, which adheres firmly to the ute- rus. If the vessels have been injected, this evidently is seen to consist of two different substances, namely, vessels, and a firm tough gelatine. It seldom happens that all the vessels can be equally filled, and therefore some spots are redder than others. The vessels do not pass on to the surface of this coat, but are seen 193 shining through it. They proceed directly from the surface of the womb, and project at right angles to the plane which yields them; they are intermixed with a little gelatine, and consist of both arte- ries and veins. Over their extremities is spread a layer of gelati- nous matter, which very early is observed to contain fibres, form- ing a kind of net-work. Thus the decidua consists of two layers, one highly vascular, proceeding directly from the uterus; the other, which is most probably formed by these vessels, is more fibrous and gelatinous; and when this is removed, the primary vessels, or outer layer, may be seen like a fine efflorescence, covering the surface of the uterus. In some cases the decidua extends a little into the fallopian tubes; in other instances it does not. In no case does the cervix form decidua. It is only produced by the fundus and body of the womb; and immediately above the cervix, the decidua stretches across, so as to form a circumscribed bag within the uterus. In some instances, however, 1 have observed this con- tinuation to be wanting, although the parts were opened with care. In all other circumstances, these uteri resembled those where the decidua was continued across; but, perhaps, notwithstanding this, there may have been a difference of two or three days in the pe- riod of impregnation, occasioning this variation. In every case, the decidua, consisting thus of two layers, is completely formed before the ovum descends. When the embryo passes down through the tube, it is stopped, when it reaches the uterus, by the inner layer, which goes across the aperture of the tube, and thus would be prevented from falling into the cavity of the uterus, even were it quite loose and unat- tached. By the growth of the embryo, and the enlargement of the membranes, this layer is distended, and made to encroach upon the cavity of the uterus, or, more correctly speaking, it grows with the ovum. This distention or growth gradually increases, until at last the whole of the cavity of the uterus is filled up, and the protruded portion of the inner layer of the decidua comes in contact with that portion of itself which remains attached to the outer layer. We find then, that the inner Jayer is turned down and covers the chorion; from which circumstances, it has been 2fi 194 called the reflected decidua.(s) In Sir E. Home's case, he says, the tubes were quite pervious, that is, no decidua was stretched across them, and the ovum lay at the cervix uteri. In such a case, the ovum instead of growing downwards would grow upwards, and carry still a reflected cast of decidua with it. Thus we see, that whenever the ovum descends, it is encircled by a vascular covering from the uterus, which unites, in every point, with those shaggy vessels which sprouted from the chorion, and which made what was called the spongy chorion. One part of these vessels forms placenta, and the rest gradually disappear, leaving the chorion covered by the decidua reflexa. This oblite- ration begins first at the under part of the chorion. CHAP. XVII. Of Sterility. Sterility depends either on malformation, or imperfect action of the organs of generation. In some instances the ovaria are wanting, or too small; or the tubes are imperforated; or the uterus very small. In these cases the menses generally do not appear, the breasts are flat, the external organs small, or they partake of the male structure, and the sexual desire is inconsiderable. In a great majority of instances, however, the organs of genera- (») By others it is thus explained, viz. That after the cavity of the uterus is completely lined with the secreted decidua, the ovum passes into it from the fallo- pian tube, and in passing along its parietes, involves and covers itself completely over every point of its surface with a coat of the decidua, which at that period may be compared to a coat of white paint; as the ovum increases in size, the decidua immediately covering it, (called decidua reflexa) ultimately comes into intimate contact with that portion of the decidua, which continues to line the cavity of the uterus, and forms apparently but one membrane- 195 tion seem to be well formed, but their action is imperfect or disor- dered. The menses are either obstructed or sparing, or they are profuse or too frequent, and the causes of these morbid conditions have been already noticed. It is extremely rare for a woman to conceive, who does not menstruate regularly; arid, on the contrary, correct menstruation generally indicates a capability of impregnation on the part of the woman. A state of weakness and exhaustion of the uterine system, occa- sioned by frequent and promiscuous intercourse with the other sex, is another very common cause of barrenness in women, and hence few prostitutes conceive. A morbid state of the uterus and ovaria, often accompanied with fluor albus, may likewise be ranked amongst the causes of sterility, and this is known by its proper characters. Women who are very corpulent, are often barren, for their cor- pulence either depends upon want of activity of the ovaria, spayed, or castrated animals generally becoming fat, or it exists as a mark of weakness of the system. When sterility'depends upon organic disease, we have it seldom in our power to remove it; but when there is no mark of the ex- istence of such a state, and we have ground to suppose that it is occasioned by debility, or imperfect action of the uterine system, we are to employ such means as are supposed capable of removing this, either by operating on it along with the general system of the body, or more directly on the uterus itself. Our first attention must be directed to menstruation, as the state of that function is our principal directory in the choice of the class of medicines to be employed. On this subject I must refer to what has been said in chap. xii. We will also, altogether independently of the state of menstruation, naturally consider the condition of the constitution and habit of body, with regard to plethora, irritability, torpor, or debility, and use varied and persevering means for rectifying those states; always, however, taking care that we do not injure the constitution in seeking for a remote good. In the majority of cases, weakness of uterine action is the cause, and the remedies are sea- bathing and tonics, in various forms; general stimulants, such as 196 Bath waters, mercury, essential oils, nitrous acid, he. when medi- cines of this description are not contraindicated by the state of menstruation; local stimulants, which act more directly on the uterus or its vicinity, as the semicupium, cantharides, balsam of copaiba, he. Of all these, the first class is the safest, and the most frequently useful. The ancients employed medicated pes- saries, which have long fallen into disrepute, rather, perhaps, from the absurdity of their ingredients, than from any argument re- specting the inefficacy of gentle stimulants acting on the vagina and womb. A temporary separation from the husband is of service, espe- cially when the menses are profuse, and, in most cases, frequent intercourse should be avoided. Should a woman, who has been for some years barren, con- ceive, she must be very careful during gestation, for abortion is readily excited. In some cases, the uterine system is capable of being acted on by the semen of one person, but not of another. CHAP. XVIIL Of Extra-uterine Pregnancy. § 1. SYMPTOMS, PROGRESS* AND SPECIES. It sometimes happens that the ovum does not pass down into the womb, but is retained in the ovarium, or stops in the tube, or is deposited among the bowels. Of all these species of extra-ute- rine pregnancy, the tubal is the most frequent. The symptoms of extra-uterine pregnancy are not, at first, very definite; but generally, the usual sympathetic effects of pregnancy, or the diseases of gestation, are more distressing than if the foetus 197 were contained in utero, nor do they cease so early. In some cases, they even increase in violence, as pregnancy advances.* The symptoms, though often more violent, are, however, simi- lar in kind to those of common pregnancy. The belly swells, the uterus itself enlarges, and may be felt to be heavy; but after some time, it does not correspond in its size, and in the state of its cer- vix, to the supposed period of gestation, or may return to the un- impregnated size.f The menses are often obstructed, though in some cases they have continued to appear for two or three months. The breasts enlarge, the morning sickness takes place about the usual period,J and the child quickens at the proper time, but it is felt chiefly upon one side. An obstruction to the free passage of urine is sometimes produced till the sac rise out of the pelvis. Occasionally in the early stage of pregnancy, painsfy resembling those of colic, are felt, and these are often so severe as to excite syncope, || or convulsions ;1T and it has happened, that during these pains, the tube or ovarium has burst, and the person died, owing * Vide Paper by Dr. Garthshore, Lond. Med. Journ. Vol. VIII. p. 344. f Vide Mr. Tucker's case, Med. and Phys. Journ. xxix. 448. i In Dr. Clark's case the morning sickness, and other signs of pregnancy, ap- peared very regularly. At the end of nine months, attempts were made to ex- pel the foetus. These were followed by inflammation and decline of health. Then suppuration took place, and the patient sunk. Transactions of a Society, &c. Vol. 11. p. 1. In Mr. Mainwaring's case, in the same work, p. 287, the pa- tient suffered much from morning sickness, and pain at the groins. § In the Journal de Scavans for 1756, we are told of a woman at Louvain, who at first had so dreadful pain when she went to stool, that she thought her bowels were coming out.—In Pouteau's case the woman suffered great pain till after the second month. Melanges, p. 333. || Bianchi mentions a case, in which, in the first months, the woman complain- ed of great pain in the lower belly, with nausea, and fainting fits. The motion of the child ceased in the fifth month, and then milk was secreted. De Nat. in Hum. Corp. Vitioso Morbosoque Gener. p. 166.—In Dr. Mounsey'scase, the pain, vomiting, and fainting fits, continued till the woman quickened. Phil. Trans. Vol XLV. p. 131.—In Dr. Fern's case, the person complained of great pain till the third month ; and from that period till the eighth month, was subject to convul- sions and syncope. Phil. Trans. Vol. XXI. p. 121. 1 Vide Dr. Fern's case, and a case by Mr. Jacob, in Lond. Med. Jour. Vol. VIII. p. 147. 198 to the internal hemorrhage.* When these pains either do not oc- cur, or are removed, or the patient survives the rupture of the sac, we generally find, that at the end of eight, nine, or ten months from the commencement of gestation, appearances of labourf take place; the woman suffers much from pain, and there may be a sanguine- ous discharge from the uterus. The pains go off more or less gradually,^ the motion of the child ceases, and milk is secreted.^ In a few instances, very little farther inconvenience is felt, the tumour of the belly remaining for many years, and the child being converted into a substance resembling the gras des cimetieresf whilst the sac which contains it becomes indurated. More fre- quently, however, considerable irritation is produced,|| with nau- sea, loss of appetite, frequent vomiting, chills, difficulty of breath- ing, and great debility; inflammatory symptoms supervene, and hectic takes place. The sac adheres to the peritoneum, or intes- tines ; and after an uncertain period, varying from a few weeks or months to several years, it either opens externally, or communi- * In Mr. Langstaff's case, the patient felt violent pains in the lower belly, sick- ness, and faintness, and died in seven hours after being taken ill. Two quarts of blood were found effused into the pelvis, and abdomen, and a foetus, with its membranes, was found, apparently about eight weeks old. The right fallopian tube was as large as a hen's egg, and had burst in two places. The uterus was very vascular, and contained jelly, but it is said had no decidua; and the cervix was not shut up by mucus. The tube was obliterated at the uterine extremity, which probably was the cause of the evil. Med. Chir. Trans. Vol. VII. p. 437. Sabatier mentions two instances of ovarian pregnancy, where the patient died quickly after pain and fainting. Med. Operat. Tom. I. p. 343. | In Dr. Perfect's case, no labour pains came on, but the motion of the child ceased at the end of nine months. The abdomen neither increased nor diminish- ed in size for two years and seven weeks ; but she was afflicted with constant pain in the hypogastric region, attended with fever, and finally sunk under maras- mus. Cases in Midwifery, Vol. II. p. 164. tin Mr. Bell's case, the pains continued, though gradually abating, for three weeks. Med. Comment. Vol. TT. p. 72. § In Mr. Bell's case, milk continued to be secreted for several years. In Mr. Turnbull's case, a fluid was secreted, rather like pus than milk. H In the case of a female mulatto, the outlines of which I was favoured with by Dr. Chisholm, the pain was so great that it coidd not be allayed by the strongest opiates. It ended fatally. 199 cates with the abdominal viscera. Very foetid matter, together with putrid flesh, bones, and coagula, are discharged through the abdominal integuments,* or by the rectum,f vagina,J or bladder.^ Sometimes, even an entire foetus has been brought away from the umbilicus, || or by the rectum .IT It is worthy of notice, that the * This termination is noticed so long ago as by Albucasis, lib. II. c. 76. In the Paduan Commentaries, there is related a case, where the abdominal parietes opened by gangrene, which is also said to have affected the uterus, and the child was then expelled, and the patient recovered. f Vide cases by Langius, in his Epistolx, Tom. II. p. 670. Tulpius, Opera, lib. IV. c. 39. p.358.—Pouteau in his Melanges, p.373.—Mr. Shiever, in Phil. Trans. No. 303. p. 172.—Wintlirop. Phil. Trans. Vol. XLIH. p. 304. and Simon, p. 529. —Lindestaple, Vol. XLIV. p. 617. Morley, Vol. XIX. p. 486. Gordon, in Med. Comment. Vol. XVIII. p. 323. Cammel, in Lond. Med. Jour. Vol. V. p. 96. Case by M.Bergeret, in the Recueil Periodique, Tom. XIV. p. 289. $ Vide Marcel. Donatus, De Med. Hist. Mirab. lib. IV. c. 22.—Horstii Opera, Tom. II. p. 536. In this case, the foetus was discharged both by the vagina and rectum.—Benevoli, in his Dissert, p. 104, gives an instance where the greater part of the child was expelled by the vagina, but the woman died before the pro- cess was completed.—Mr. Smith's case in Med. Comment. Vol. V. p. 314.—In Mr. Colman's case, pains came on, and the head was felt in the pelvis at the time of her reckoning, and long afterwards, but the os uteri could not be perceived. In some time, hectic fever, with diarrhoea and sore mouth, appeared. Six months after her attempts at labour, an opening was felt in the vagina, but very unlike the os uteri. The hand was introduced, and a putrid child was extracted. Some feces continued to come by the wound, but at last she got well. Med. and Phys. Jour. Vol. II. p. 262.—See also Camper's case, in his Demonst. Anat. Path. lib. II. p. 16. and Dr. Fothergill's case, in Mem. of Med. Society, Vol. VI. p. 107. § Vide Stalpart Van der Wiel, Opera, Tom. I. p. 305. In this case, bones came away with the urine.—In the case of Ronseus, the child was discharged partly by the bladder, but chiefly by the anus. Epist. Med.—A similar instance is related by Morlanne, the extraneous matter forming a nucleus for a calculus. By an operation similar to that of lithotomy, two stones and five portions of cranial bones were extracted. Recueil Period. Tom. XIII. p. 70.—In Prof. Josephi'js case, the child was found altogether in the bladder. Med. and Phys. Jour. Vol. XIV. p.519. U Vide case of Mrs. Stag, in Lond. Med. Obs. and Inquiries, Vol. II. p. 369 ; and cases by Mr. Jocob, Dr. Maclarty, and others. 1 In Mr. Gifford's case, the child was expelled entire by the anus, and even the cord was found hanging out of the intestine. Phil. Trans. Vol. XXXVI. p. 435.—See also Mr. Goodsir's case, in Annals of Medicine, Vol. VII. p. 412.—Dr. Albcrs has a similar case, 200 placenta, in this process, always is ultimately destroyed,* and dis- charged among the putrid fluid. Often time is not allowed for this process to be accomplished, but the person dies at an early period. Thus it appears, that there are different terminations of the ex- tra-uterine pregnancy. The sac may burst, and the person die speedily of hemorrhage ;f or the child may escape into the abdo- men, and be enclosed in a kind of cyst of lymph ;J or the sac may remain entire, the child being retained many years,^ and the parts become hard; notwithstanding this, the menses may return, and • In Dr. M'Knight's case, although the caesarean operation was performed be- fore any bad effects were produced on the health, no part of the placenta could be found. f In Dr. Clark's case, the tube burst in the second month, and the woman died from loss of blood. Transactions of a Society, Vol. I. p. 216.—Vide case by Duverney, in his works, Tom. II. p. 353. and by M. Littre in the Memoirs of the Acad, of Sciences, for 1702, and by Riolan, in his works. See also Med. Comment. Vol. I. p. 429.—In Mr. T. Blizard's case, rupture took place at a very early period, for the woman had miscarried only five weeks previous to this event. Vide Edin. Phil. Trans. Vol. V. p. 189.—Mr. Tucker's case, Med. and Phys. Jour- nal, XXIX. 448. i Vide a case by La Croix, in La Med. Eclaree, Tome IV. p. 349. § 1 have known the foetus retained for twenty years, and there are some instan- ces, where it has been retained for thirty, forty, or fifty years. Mrs. Ruff, whose case is related in the Med. and Phys. Jour, for May 1800, carried the child fifty years. Middleton's patient carried it sixteen years. Phil. Trans. Vol. XLIV. p. 617. Mounsey's thirteen years, Vol. XLV. p. 1-1. Steigertahl's forty-six years. Vol. XXXI. p. 126. Broomfield's nine years, Vol. XLI. p. 696. Sir P. Skippon's patient discharged it by suppuration at the groin, after retaining it twenty years, Vol. XXIV. p. 2070. See also cases by M. Grivel, in Edin. Med. Jour. Vol. II. p. 19, and Dr. Caldwell, p. 22. Sometimes no attempt is made to expel, but the foetus is converted into a substance, which Fourcroy finds to resemble the gras des cimetieres. System, Tom. X. p. 83. Sandifort relates a case, where, after attempts at labour, no further inconvenience was sustained, but the child was found after twenty-two years to be indurated. Observationes, lib. II. p. 36. He quotes Nebel for a case, where it was retained fifty-four years. Cheselden found it converted into earthy matter. The late Mr. Hamilton of this place had a preparation of a foetus, covered with calcareous matter, which was retained 32 years. This woman had pains at the end of nine months, after which the belly decreased in size.- 201 the woman conceive again.* But the most frequent termination is that of inflammation ending in abscess, attended with fever and pain, under which the patient either sinks, or the foetus is expelled in pieces, and the cure is slowly accomplished. From a review of cases it appears, that a majority ultimately recover, or get the bet- ter of the immediate injury : of the rest, some have sunk speedily, either from hemorrhage or inflammation, or exhaustion produced by ineffectual attempts to expel the child; or more slowly from hectic fever; or in consequence of some other disease being called into action, by the violence which the constitution has sus- tained. In some cases the sac soon rises quite out of the pelvis. In others, it remains longer, and falls down between the rectum and vagina, forming a tumour, accompanied with symptoms of retro- version of the uterus.f In such cases, the sac inflames, and bursts into the rectum or vagina. Dr. Merrimanf is of opinion, that all these cases are instances of retroverted uterus, and not of extra- uterine pregnancy; but, for the present, this must rest entirely on * In the 5th Vol. of the Edin. Med. Essays, there is related a case in which the patient seemed to have a second extra-uterine pregnancy before she got quit of the first.—See also Primrose de Morb. Mul. p. 326.—Mr. Hope, in the 6th Vol. of the Med. and Phys. Jour. p. 360, details a case, where the woman in the seventh month of pregnancy had pains, which continued for three weeks, and then went off, leaving a hard tumour on the left side, which was somewhat pain- ful ; she then had another pregnancy, and a fortnight after delivery, began, after taking a laxative, to vomit, and continued to do so, ultimately throwing up fecu- lent matter. The case ended fatally.—See also, Turk, in Haller, Disp. Chir. IV. 793. f Vide Mr. Mainwaring's case, in Trans, of a Society, &c. Vol. II. p. 287. In Mr. White's case, related in Med. Comment, Vol. XX. p. 254, the symptoms were very like those of retroversion, and the case was only distinguished by the result. In Mr. Cammel's case, there was not only a tumour betwixt the vagina and rectum, but the os uteri was turned upward and forward. Lond. Med. Jour. Vol. V. p. 96. Mr. Kelson's case very much resembled retroversion, for in the tenth week both the urine and stools were obstructed. In about a fortnight, the impediment was suddenly removed, and the uterus felt in situ. She conti- nued well to the ninth month, when labour ineffectually came on; but in pro- Cess of time the child was discharged by the anus. Med. and Phys. Jour. Vol. XI. p. 293. . Vide Dissert, on Retroversion, &c. 1810. 202 supposition. The mere circumstance of the pregnancy being com- plicated with suppression of urine, or tumour at the back part of the pelvis, is no proof; as both of these may arise from the pres- sure of the sac on the pelvis. Sometimes, when parturient efforts are made, the head descends into the pelvis, though it was not there before; but either no os uteri can be felt, or it is felt directed to the pubis, and it is not affected by the pains.(*) It is curious to observe, that generally the uterus enlarges some- what,* and, in most instances, I imagine, deciduaf is formed. In a remarkable case, related by the ingenious Mr. Hay,J of Leeds, the placenta was formed in the uterus, while the foetus lay in the tube. Tubal pregnancy sometimes does not proceed farther than the second month, the tube bursting at that time; or, to speak more correctly, I believe the tube slowly inflames, and sloughing takes place. In many instances, however, the tube goes on enlarging for nine months, and acquires a size nearly equal to that of the ;i; (t) It is very probable that some of these cases have in reality originated from retroversions of the uterus, which, as Merriman has proved, may even continue partially in that state until the full period of utero-gestation. 1'his subject shall be more fully explained, when retroversion of the uterus comes to be treated of. In the meantime the student is referred to a review of Dr. Merriman's Work, in the Eclectic Repertory, Vol. I p. 338. * Boehmer long ago observed this; and Dr. Baillie, in the 79th Vol. of the Phil. Trans, mentions, that Dr. Hunter had a preparation of tubal pregnancy, in which the uterus was found enlarged to double its natural size, and containing decidua. He also states, that in an ovarian case, the uterus was enlarged, thick, and spongy, and its vessels enlarged. Dr. Clarke found the uterus, in the second month of an extra-uterine pregnancy, exactly of the same size as if the embryo had been lodged within it. The decidua was formed, and the cervix filled with gelatinous matter. Transactions of a Society, Vol. I. p. 216. See also a case by Saviard, in Phil. Trans. No. 222. p. 314. A case similar to Dr. Clarke's is related by Mr. T. Blizard, in the Edin. Phil. Trans. Vol. V. p. 189. See also Annals of Med. Vol. III. p. 379. | In Mr. Houston's case, the cervix was so closed up that it would not admit a probe. Phil. Trans. Vol. XXXII. p. 387. The decidua would appear sometimes to enlarge, and form a mass like placenta, which in Mr. Turnbull's case was ex/ pelled with hemorrhage. Mem. of Med. Society, Vol. HI. p. ir6. * Vide Med. Obs. and Inq. Vol. III. p. 341. f 203 gravid uterus, at the same stage of gestation.* The placenta dif- fers from a uterine placenta in being much thinner and more ex- tended. External examination discovers little difference, at the full time, between this and common pregnancy. Ovarianf is much more rare than tubal pregnancy, and it is sel- dom that the ovarium acquires a great size. It either bursts ear- lyj, or inflammation and abscess take place; or the fcetus dies, and is converted into a confused mass ; or it excites dropsy of the ovarium.^ The ovarian pregnancy, until inflammation has taken place, produces a circumscribed moveable tumour, like dropsy of the ovarium. In ventral pregnancy, the most rare of the three species, the mo- tions of the child are felt more freely, and its shape is readily dis- tinguished through the abdominal integuments. The expulsive efforts come on as usual, and the head of the child is sometimes forced into the pelvis. It dies, and the usual process for its remo- val is carried on, if the woman do not sink immediately under the irritation. The placenta is found attached to the mesentery or in- * Among many other cases in proof of this, I may refer to one very accurately detailed by Dr. Clarke, in Trans, of a Society, &c. Vol. II. p. 1. f In a case related by Varocquier, the ovarium did not acquire a larger size than an egg. The woman died, after suffering violent pain in the left side, low down. The viscera were slightly inflamed. Mem. de l'Acad. de Sciences, Tom. CXIII. p. 76. In the case by L'Eveille, the foetus was apparently betwixt three and four months old. Rapport de la Societe Philomatique, Tom. I. p. 146. See also a case in the Recueil Period. Tom. XIII. p. 63; and in the Recueil des Actesde la Societe de Lyon. t Vide Chambon, Malad. de la Grossesse, Tom. II. p. 373. Case by St. Mau- rice, in Phil. Trans. No. 150, p. 285. In the case related by La Rocque, the ova- rium was found ruptured, and the abdomen full of blood. Journ. de Med. 1683. Boehmer found the ovarium ruptured, and the fcetus half expelled. Obs. Anat. fasc. prim. Dr. Forrester's patient, after violent colic pains, voided blood by the anus. The hemorrhage and fainting fits proved fatal. The foetus was found in the ovarium. Annals of Medicine, Vol. III. p. 379. § Vide Roederer, Elemens, c. 15. § 758. In Mr. Dumas's case, a fluid like chocolate was drawn off" by tapping, which was twice performed. The ovarium contained hair, bones, &c. La Med. Eclairee, Tom. IV. p. 65. Mr. Bell's tubal case excited ascites. 204 testine?.* It has been supposed, that the examples of this variety are all in reality instances of ruptured uteri; but this is not sup- ported by satisfactory proof. At the same time, I have no doubt that many of them are. § 2. TREATMENT. In the treatment of extra-uterine pregnancy, much must depend on the circumstances of the case. In the early stage, if the sac be lodged in the pelvis, we must procure stools, and have the bladder regularly emptied, as in cases of retroverted uterus. Attacks of pain, during the enlargement of the tube, require blood-letting and anodynes, laxatives, and fomentations. The same remedies are indicated when convulsions take place. Ovarian requires a simi- lar management with tubal pregnancy, except that if it be compli- cated with dropsy, relief may be obtained by tapping. When expulsive efforts are made, and the head is felt through the vagina, and the nature of the case distinctly ascertained, it may be supposed, and some recorded cases would seem to justify the supposition, that much suffering may be avoided, by making an incision through the vagina, and delivering the child ; but, as yet, experience has not fully ascertained the utility of this practice, f * Vide Dr. Kelly's "case, in Med. Obs. and Inquiries, Vol. III. p. 44. In Mr. Clarke's case, the placenta was attached to the kidneys and intestines, Mem. of Med. Society, Vol. III. p. 179. In the Mem. of the Acad, of Sciences, there is a case related, where the placenta adhered to the lumbar vertebra. In the his- tory by La Coste, it was placed under the stomach and colon. Vide CEuvres de Duverney, Tom. II. p. 363. In Mr. Turnbull's case, it was very thin, and adher- ed to the intestines. Mem. of Med. Society", Vol. HI. p. 176. A case of ventral pregnancy, complicated with hernia, is related by M. Martin in the Recueil des Actes de la Societe de Sante de Lyon. Courtial found it adhering to the sto- mach and colon. | In a case, probably of this kind, related by Lauverjat, and quoted by Sabatier, the child was extracted by an incision through the vagina, and the woman reco- vered. De la Med. Oper. Tome I. p. 136. A similar case is to be met with in the Journ. des. Spavans, 1722. A very interesting case is related by Delisle, in the Bulletin de la Societe" Med. d'Emulation, for May and June, 1818 ; where the child was extracted alive, by an incision through the vagina. The mother died in a quarter of an hour, and the child half an hour after her. It has, in one instance, however, been extracted thus, with success to both parties. 205 It has been proposed, in these and other circumstances, to perform the caesarean operation,* in the usual manner, upon the accession of labour; but there is not only great danger from the wound, but likewise from the management of the placenta, which, if removed, may cause hemorrhage, especially in ventral pregnancy, and, if left behind, may produce bad effects. The last, however, is the safest alternative. The result of the numerous cases upon record will certainly jus- tify, to the fullest extent, our trusting to the powers of nature, rather than to the knife of the surgeon. If any exception is to be made to this rule, it is in those cases where the child is distinctly felt through the vagina, and can be extracted by an incision made there. Allaying pain and irritation in the first instance, by blood- letting, anodynes, and fomentations; and avoiding, during £(11 the inflammatory stage, stimulants and motion, whilst, by suitable means, we palliate any particular symptom, constitute the sum of our practice. A tendency to suppuration is to be encouraged, by poultices; and the tumour, when it points externally, is either to be opened, or to be left to burst spontaneously, according to the sufferings of the patient, and the exigencies of the case.f The passage of the * M. Colomb. performed the cesarean operation, but it ended fatally. Recueil des Actes de la Societe de Lyon. Osiander has also failed. f Dr. Maclarty relates the case of a negress, where the breech of the child pro- truded through an ulcer, at the lower part of the abdominal tumour, and the arm at the upper part of the tumour. The intermediate portion of skin was divided, and the foetus extracted. The head of the child stuck firmly, but was brought out with the forceps. There was no placenta, but putrid matter was discharged with the child. The woman recovered. Med. Comment. Vol. XVII. p. 481. Another case is related by Duverney, where the child was extracted from the groin; and this is one of the rare instances where the placenta was not destroyed. It was extracted with the child. CEuvres, Tom. II. p. 357. Cyprianus gives an instance of the child being removed, after having been retained twenty-one months. Histor. Foetus Hum. Salva Matre ex Tuba Excisi. Mr. Brodie enlarged the navel with a lancet. Phil. Trans. Vol. XIX. p. 580. See also Mr. Baynham's case, in Med. Facts, Vol. I. p. 73. In Mr. Bell's case an incision, four inches in length, was made, and the bones of two children extracted. Med. Comment. Vol. II. p. 72. Dr. Haighton relates an interesting case, where some bones were discharged by the vagina, but the tumour also pointed above the pubis, and 206 bones, and different parts of the foetus, may often be assisted : and the strength is to be supported under the hectic which accom- panies the process. After the abscess closes, great care is still necessary, for, by fatigue or exertion, it may be renewed, and prove fatal.* When no process is begun for removing the foetus, but it is re- tained and indurated, our practice is confined to the palliation of such particular symptoms as occur. CHAP. XIX. Of the Signs of Pregnancy. Some women feel, immediately after conception, a particular sensation, which apprizes them of their situation; but such in- stances are not frequent; and, generally, the first circumstances which lead a woman to suppose herself pregnant, are the suppres- sion of the menses, and an irritable, or dyspeptic state of the through this one of the ribs appeared. The practitioner made an incision, but so great hemorrhage came on, that he was obliged to apply a bandage till next day, when he extracted the bones. The woman recovered. Med. Records, p. 260. Dr. M'Knight performed the operation in the twenty-second month, although the woman enjoyed tolerable health; very dangerous symptoms supervened, but the woman, who certainly was brought into a very hazardous state by the premature operation, did recover. No placenta was found. Mem. of Med. So- ciety, Vol. IV. p. 342. * In Dr. Morley's case, this happened two years after the original abscess had healed. Phil. Trans. Vol. XIX. p. 486. Mr. Moyle details a history, where the abscess first of all burst, in consequence of leaping over a hedge. Bones con- tinued to be discharged for a year, without much injury to the health. The ab- scess then healed, but three years afterwards a tumour again appeared, and, in consequence of exertion, burst; when about a yard of intestine protruded. Some days elapsed before Mr. Moyle saw her. The intestine was then gangrenous, but she lived 12 days longer, and the portion was thrown off before death. Med. Jour. Vol. VI. p. 52. 207 stomach. She is sick or vomits in the morning, and has returning qualms or fits of languor during the forenoon; is liable to heart- burn through the day or in the evening, and to that disturbed sleep through the night, which so frequently attends abdominal irritation. In some instances, the mind also is affected, becoming unusually irritable, changeable, or melancholy. The breasts often at first become smaller, but about the third month they enlarge, and oc- casionally become painful; the nipple is surrounded with a brown circle or areola; and often, even at an early period, a serous fluid begins to ooze from it. She looses her looks, becomes paler, and the under part of the lower eye-lid is of a leaden hue. The fea- tures become sharper, and sometimes the whole body begins to be emaciated, whilst the putee quickens. In many instances, particu- lar sympathies take place, causing salivation, tooth-ach, jaundice, he. In other cases, very little disturbance is produced, and the woman is not certain of her condition, until the period of quick- ening. Some females, at the time of conception, have a slight discharge of blood from the uterus, and in almost every case the menses are afterwards suppressed. It has, however, been disputed, how far this suppression is an invariable effect of pregnancy. That some have been regular during the whole time of gestation is attested by distinguished practitioners, whilst others, no less eminent, maintain, that although repeated sanguinous discharges, like menstruation, may take place, yet these are neither regular, as to the monthly period, nor exactly of the quantity of the menses. I have not known any instance where menstruation was perfect and regular during the whole of pregnancy. In the commencement of pregnancy, the abdomen does not be- come tumid, but, on the contrary, is often rather flatter than for- merly ; and, when it does first increase in size, it is rather from in- flation of the bowels, than from expansion of the uterus. As an in- crease of bulk, together with many of the other symptoms of ges- tation, may proceed from suppression of the menses, we cannot positively, from those signs, pronounce a woman to be with child. The enlargement of the belly is at first accompanied with tension 208 or uneasiness about the navel, Avhich becomes rather prominent, especially toward the sixth month. When women have any doubt with regard to their situation, they generally look forward to the end of the second quarter of preg- nancy, as a period which can ascertain their condition. For, about the end of the fourth month, or a little sooner or later, in different women, the uterus ascends out of the pelvis, and the motion of the child is first perceived, or it is said to quicken -,(u) and, in some cases, a few drops of blood flow from die uterus at this period. ("uj Professor Roederer kept a correct account of one hundred women, not- ing the time when it was presumed they were impregnated, the period at which they quickened, and again, the time when they were delivered. Out of this number we are informed, that eighty quickened at the fourth month, a por- tion of thfe remainder quickened at the the third month, and the rest went on to the fifth. Therefore, we may with great propriety consider four months as the general time of quickening; and upon finding that a woman has quickened, within a day or two, we may with great confidence calculate that she has five months to go. The term quickening, is certainly not the most accurate phrase that could be selected, to express the simple fact of the uterus rising above the brim or cavity of the pelvis. It is well known that the impregnated uterus generally remains in the pelvis, b as we have just observed, until the latter part of the fourth month; and that after this period, as it enlarges, it necessarily rises above that cavity into the abdomen; but it is to be remarked— 1. The ascent of the impregnated uterus from its position in the pelvis to its subsequent station, is sometimes gradual and unobserved; of course, the sensa- tion of quickening is not then felt. 2. The uterus is sometimes so impacted in the cavity of the pelvis, as not t» reach its final station within the abdomen without the assistance of art, produc- ing the disease called retroverted uterus, during which, quickening is never felt. 3. At other times, and those frequent, though not constant, there exists some slight impediment to the ascent of the uterus, which being suddenly overcome, tlds viscus rises at once into the abdominal cavity, constituting what has been referred to the fcetus, under the term quickening. The sudden intrusion, therefore, of the volume of the uterus among the abdo- minal viscera, accompanied by as sudden a removal of pressure from the iliac ves- sels, is supposed to be equal to produce the sensation we have above noticed. We may then state, " That the sensation of quickening is felt in transitu, at the moment when the uterus, removing from the pelvis, enters the abdominal cavi- ty/* Vide Eclectic Repertory, Vol. III. p. 3Q. October. No. IX. 209 Some quicken at the end of the third, and others not till the fifth month, which may depend on the size of the pelvis, the growth of the uterus, and quantity of fluid it contains. The motion is first felt in the hypogastrium, and is languid and indistinct, but by de- grees it becomes stronger. It is possible for women to mistake the effects of wind for the motion of a child, especially if 'they have never borne children, and be anxious for a family. But the sensa- tion produced by wind in the bowels is not confined to one spot, but very often is referred to a part of the abdomen, where the mo- tion of the child could not possibly be felt. It is not to be supposed, that the child is not alive till the period of quickening, though the code of criminal law is absurdly founded on that idea. The child * is alive from the first moment that it becomes visible, but the phenomena of life must vary much at different periods. The child is not felt to move till after the ascent of the uterus out of the pelvis. Does this arise from any change of the phenomena of life at that time in the child itself, or from the muscular power becom- ing stronger, or from the uterus now being in a situation, where, there being more sensibility, the motion is better felt.? All of these probably contribute to the sensation, which becomes stronger as the child acquires more vigour, and as the relative proportion of liquor amnii decreases. This foetal motion, however, is not to be confounded with the sensation felt by the mother from the ute- rus rising out of the pelvis, and which precedes the feeling of flut- tering. If this elevation shall take place suddenly, the sensation accompanying it is pretty strong, and the woman at the time often feels sick or faint, and, in irritable habits, even an hysterical fit may attend it. From the time when this is felt, Avomen are said to have quickened, and they afterwards expect to be conscious of the motion of the child. This motion in many, soon increases, and becomes very vigorous; in others, it is languid during the whole of pregnancy; and in a kw cases, scarcely any motion has been felt, although the child at birth is large and lively. The morning sickness, and many of the sympathetic effects of pregnancy, gene- rally abate after this, and the health improves during the two last quarters. 210 Many women suppose, that, by examining the blood drawn from the veins, their pregnancy may be ascertained. Very soon after impregnation, the blood becomes sizy; but it differs from the blood of a person affected with inflammation. In the latter case, the sur- face of the crassamentum is dense, firm, and of a buff colour, and more or less depressed in the centre. But in pregnancy the sur- face is not depressed, the coagulum is of a softer texture, of a yel- low, and more oily appearance. It is not possible, however, to de- termine positively, from inspecting the blood; for a pregnant wo- man may have some local disease, giving the blood a truly inflam- matory appearance; and, on the other hand, it is possible for the suppression of die menses, accompanied with a febrile state, to give the blood the appearance which it has in pregnancy. Examination of the uterus itself is a more certain mode of as- certaining pregnancy. About the second month of gestation, the uterus may be felt prolapsing lower in the vagina than formerly ; its mouth is not directed so much forward as before impregnation; it is shut up, and the cervix is felt to be thicker, or increased in circumference. When raised on the finger, it is found to be hea- vier, or more resisting. Some have advised, that the os uteri should be raised upward and forward, so as to retrovert the womb, in or- der that its body may be felt, but this is not expedient. Examina- tion, at this period, is liable to uncertainty, because the uterus of one woman is naturally different in magnitude from that of another. But, in the third month, we can arrive at tolerable certainty, the womb being then felt decidedly to be heavier, and more easily ba- lanced on the finger; during wThich something can be felt to be floating within the uterus. In the beginning of the fifth month, it is found to be higher than when unimpregnated : a kind of fluctua- tion may be perceived, and by placing the hand on the lower part of the belly, so as to press on the fundus of the womb, it can be made to give more resistance to the finger applied per vaginam, and may by it be rolled about. After quickening, if we pat with the finger on the cervix uteri, we can generally make the child strike gently, so as to be felt. About this time, and still more dis- tinctly afterwards, we can. if the abdominal muscles be relaxed, 211 feel the uterus extending up from the symphysis pubis, and, in proportion as pregnancy advances, can more readily distinguish the members of the child, and feel its jerks or motions. Exami- nation, per vaginam, informs us of those changes of the cervix and os uteri, which were noticed in a former chapter. A simple suppression of the menses is apt to be mistaken for pregnancy; nor is it easy to distinguish, for some time, between them; but the doubt is soon cleared up by the state of the womb, and the want of motion at the proper period. In pregnancy, the uterus early descends somewhat in the pelvis, and its mouth be- comes more circular, in place of being transverse, whilst the gene- ral bulk of the womb and its weight are increased. Simple infla- tion of the bowels, with suppression of the menses, cannot mislead, if the state of the uterus be attended to; and, at an advanced pe- riod, the lower belly is found soft or puffy. Not unfrequently, a diseased ovarium makes the patient suppose herself pregnant, even although she should have the counter evi- dence of menstruation. For the abdomen is large, and the ovari- um is felt through the parietes, sometimes pretty high, like the uterus, or like a prominent part of a child. The tumour is acted on so far by the aorta as to occasion, at times, a sense of pulsation, which is mistaken for the motion of the child. Per vaginam the uterus is felt high, and its cervix often apparently developed from being raised, and the vagina elongated, whilst the os uteri itself may have its lips shortened. No child, however, can be felt, nor any distinct expansion of the lower part of the uterus, whilst externally the round and circumscribed tumour of the ovarium may be dis- tinguished. 212 CHAP. XX. Of the Diseases of Pregnant Women. § 1. GENERAL EFFECTS. Pregnancy produces an effect on the general system, marked often by a degree of fever, and always by an altered state of the blood. This state is the consequence of local increased action, which irritates and excites the system, in the same way as when an organ is inflamed. There would appear to be, likewise, a ten- dency to the formation of more blood than formerly, and the ner- vous system is evidently rendered more irritable. The gravid uterus, also, has an effect by sympathy, on other organs or viscera; and likewise produces changes in them, mechanically, by its bulk and pressure. The effect of irritation, or changes in the condition of the ex- tremities of the abdominal nerves, on the sensorium commune, and whole nervous system, as well as on the arterial action, is so fully proved, that it is not necessary to enter minutely here into that subject. It is, however, of great importance, that it should be borne in mind, in our pathological reasoning; although we are not yet prepared to explain, or, what is worse, to detail, many facts of practical value. The origin and distribution of the par vagum, and great intercostal nerves, might lead to the expectation of very important and intricate sympathies. Temporary affection of cer- tain portions of the intestinal canal produces pain in one eye or side of the head; when another portion is affected, or perhaps the same portion, in a different degree, the opposite side suffers, or the whole forehead is pained, or the upper part of the spinal mar- row sympathizes, and a secondary but most marked train of symp- toms is thereby produced; cough, feeling of suffocation, numbness, or spasms. Another affection of the bowels gives rise to convul- sive agitation of the muscles; whilst, once more, we find irritation, particularly of the small intestines, sometimes occasions drowsi- 213 ness, or a feeling of fulness and giddiness in the head, sometimes occasioning even a temporary insensibility, or paralysis. Hence some varieties of apoplexy and palsy are originally dependent on affections of the bowels; and hence the distressing, and, in many cases, injurious, effects produced by inefficient doses of laxatives, which irritate partially, without exciting briskly and universally, or in speedy succession, the whole tract of the intestines. Hence the impropriety of employing certain mineral waters, in cephalic affections, more especially if not aided by exercise, or an addi- tional laxative to excite briskly. Hence the origin of sick head- ach, of many hysterical and anomalous affections, of chorea, and disorders of the sanguiferous system; and hence the most valuable, but too often disregarded, fact, that many excitements, arising clearly from the bowels, or state of the abdominal nerves, are, from this indirect influence on the vascular system, best relieved by resorting to the lancet, before acting on the original seat of the disease by purgatives, which would be too slow in their operation. The uterus may directly influence the system, producing much ir- ritation and many disordered actions, and so. doubtless may the stomach and liver; but I question whether these different organs do not more frequently cause sympathetic disorders through the medium of the intestines. Even in many cases of dyspepsia, per- haps in most not dependent on organic disease, the complaint is referrible to the intestines, secretion of bile, crudity in the stomach, sickness and headach ; depending more on the state of the bowels than on primary disorders of the stomach. Hence dyspeptic patients are sure to suffer, if they take much liquid, or soups, or acidifiable diet, or aliment which passes easily out of the stomach, and is possessed of a gently laxative quality; for thereby the in- testines are excited to a hurtful, but not to a sufficient degree; they are irritated, but not to efficient action. A diet too light is, therefore, equally bad, in such cases, with one which is heavy and indigestible ; and that diet is best which neither passes too readily through the changes to be produced on it in the stomach, nor re- sists too long, nor runs rapidly into acetous fermentation. Every invalid must, to a certain degree, regulate his diet by experience; but when an acute attack is brought on, he will find it still a desi- 214 deratura to obtain a medicine which will rapidly and briskly excite the intestinal action, widiout occasioning a long interval of sick- ness, or being succeeded by debility of the canal. Effects both powerful and varied are often produced by the uterus in a state of gravidity. These may be divided into those arising from sympathy between the uterus and other abdominal viscera, and confined to these; into those exhibited ir> more re- mote parts, whether occasioned by sympathy directly with the uterus, or indirectly through the medium of the sympathising in- testines ; and into those arising more purely from mechanical pres- sure. The effects of pregnancy vary much, both in degree, and in the nature and combination of the symptoms, according to the consti- tution of the woman, and the natural or acquired irritability of different organs. In a few cases, a very salutary change is pro- duced on the whole system, so that the person enjoys better health, during pregnancy, than at other times. But in most in- stances, troublesome or inconvenient symptoms are excited, which are called the diseases of pregnancy, and which, in some women, proceed so far, as not only to deprive them of all enjoy- ment and comfort, but even to produce considerable fear of their safety. As these proceed from the state of the uterus, it follows, that when they exist, in a moderate degree, they neither admit of, nor require any attempts to cure them; for their removal implies a stoppage of the action of gestation, which is their cause. But when any of the effects are carried to a troublesome extent, then we are applied to, and may palliate, though we cannot take them away. This we do by lessening plethora, if necessary, by blood-letting, and allaying the increased irritability of the system by the regular use of laxatives, which remove that particular state of the bowels, which is so apt to cause restlessness and nervous irritation. If these are not altogether successful, the camphorated julap is a use- ful medicine.* Besides this general plan, we must diminish the * Petit/and many after him, have been of opinion, that opium is hurtful dur- ing gestation; and there can be no doubt that it generally is so, when given fre- 215 febrile state of the system, where such exists, by regulation of the diet, and suitable remedies. Individual symptoms must be treated on general principles. There is a great diversity, both in the effects of pregnancy, and also in the period at which these manifest themselves; for whilst some begin to suffer very early from the irritation of the uterus, and are much relieved from the effects thereof, after the child quickens, others feel very little inconvenience till towards the end of pregnancy, or the last quarter, when die womb is greatly en- larged, and the abdominal viscera disturbed. In the dietetic part of our treatment, we must bear in mind that we ought neither to admit of such regimen as shall fill the vessels with too much fluid, nor throw the organs of digestion into disor- der. Much liquid, even of the mildest nature, ought to be avoided, and the aliment must neither be too rich nor too acescent. Re- gard, however, must be had, in our directions, to the state of the patient, and the risks to be apprehended, on the one hand, from plethora, and, on the other, from debility. Wherever fruit agrees with the patient, it may be freely allowed, and the same may be said of well-boiled vegetables; but when these occasion acid or flatulence, they must be refrained from. It is of much importance to preserve the bowels in a correct and active state. The exercise to be taken, or permitted, must be regulated by the probable chance of abortion resulting. § 2. FEBRILE STATE. In many cases, the pulse becomes somewhat quicker, soon aftei- impregnation, and the heat of the skin is at the same time a little increased, especially in the evenings. In the latter months of preg- nancy, the febrile symptoms in some instances are extremely trou- blesome; the pulse is permanently frequent, but in the evenings it is more accelerated, whilst the skin becomes hot, and the woman quently. It is detrimental, both by its effects upon the stomach and bowels, and on the system at large. In severe spasms, or great irritation, it may be necessarj', but it never ought to be often repeated, as it ultimately increases the irritabili' ty, and injures the bowels, as it would do in chorea. 216 restless; she cannot sleep, but tosses about till day-break, when she procures short unrefreshing slumber, occasionally accompanied with a partial perspiration. In the morning, the febrile symptoms are found to have subsided; but in the afternoon they return, and the following night is spent alike uncomfortably. This state is attended with more emaciation, and greater sharp- ness of features, than is met with in pregnancy under different cir- cumstances ; but it is wonderful how well the strength is kept up, in spite of the want of rest, and of the uneasiness which is pro- duced, from this disease being sometimes conjoined with intolera- ble heat about the parts of generation. In slight degrees of this febrile state, all that is necessary is se- dulously to keep the bowels open, and take away a little blood. But when it becomes urgent, towards the last months of gestation, we are under the necessity of taking away blood more frequendy, but not in great quantity at a time ; and always in doing so, having regard to the constitution of the patient. The saline julap is of con- siderable service, by producing a gentle moisture, but a copious perspiration is neither necessary nor useful. The julap may either be given in repeated doses, through the day, or merely one or two doses in the morning, or early part of the night, according to cir- cumstances. The bowels are to be kept open by a mild laxative, such as the aloetic pill, or rhubarb and magnesia. The sulphuric acid is a very good internal medicine. The restlessness is best al- layed by sleeping with few bed-clothes ; and sometimes great re- lief is obtained, by dipping the hands in water, or grasping a wet sponge. Opiates very seldom give relief, and ought not to be pushed far, as they make the patient more uncomfortable, and are supposed even to injure the child; at all events, if the occasional exhibition, on any emergency, of a moderate dose of opium or hy- oscyamus, fail to procure comfortable sleep, no benefit is to ex- pected from increasing the quantity. Frequently nothing does much good, the state continuing until the woman is delivered. I need scarcely add, that we must take care not to confound this, which may be called the fever of pregnancy, with that arising from local disease, as for instance in the lungs or liver. 217 There is a species of fever, which may affect women about the middle of pregnancy, and makes its attack suddenly, like a regular paroxysm of ague. It soon puts on an appearance rather of hectic, combined with hysterical symptoms. The head is generally at first pained, or the patient complains of much noise within it, sleeps little, has a loathing at food, with a foul dry tongue, and a consider- able thirst, whilst the bowels are constipated. Sometimes she talks incoherently, or moans much during her slumber, and has fright- ful dreams: occasionally a cough, or distressing vomiting super- venes. This disease is very obstinate, and often ends in abortion; after which, if the patient do not sink speedily under the effects of the process, she begins to recover, but remains long in a chlo- rotic state, which, if not removed, may terminate in phthisis. I strongly suspect that this disease originates from the bowels, and bears great analogy to the infantile remitting fever. It is usually preceded by costiveness, and is sometimes apparently excited by irregularities in diet. We ought, on the first attack of the cool fit, to check it by warm diluents, with the saline julap. If the proper opportunity be lost, or these means fail, we must lessen irritation, by detracting some blood; open the bowels freely, and afterwards prevent feculent accumulation, keep the surface moist, and palliate troublesome symptoms. If the tongue be early loaded, and the patient is sick or squeamish, a very gentle emetic will be proper. The strength is to be supported. In a state of convalescence, gentle exercise and pure air are useful, but every exertion must be avoided. § 3. VOMITING. Vomiting is a very frequent effect of pregnancy, and occasionally begins almost immediately after conception. Generally it takes place only in the morning, immediately after getting up, and hence it has been called the morning sickness; but, in a few instances, it does not come on till the afternoon. It usually continues until the period of quickening, after which it decreases or goes off, but 29 218 sometimes it remains during the whole of gestation. Some women do not vomit, and have very little if any sickness; others begin, after the fourth month, to feel an irritation about the stomach and other viscera; and some remain free from inconvenience till the conclusion of pregnancy, when the distention of the womh affects the stomach. The fluid thrown up is generally glairy or phlegm, and the mouth fills with water previous to vomiting; but if the vomiting be severe or repeated, bilious fluid is ejected. Generally there is no occasion to prescribe any remedies. Puzos, and others, even considered vomiting as salutary; but in some cases, it goes to a very great length, recurring whenever the woman eats, or sdmetimes even when she abstains from eating, and continues for days or even weeks so obstinate, that she is in danger of mis- carrying,* or of suffering from Want of food. It is a general rule, in such cases, to take away early a small quantity of blood, a quantity proportioned to the vigour and fulness of the habit and state of the pulse. Of the utility of this practice, the general tes- timony of practitioners, and my own observation, fully convince me. Narcotic substances, such as opium or hyoscyamus have been tried internally, either without blood-letting or subsequent to it, but uniformly with little advantage. In a few instances, a cloth wet with laudanum applied to the pit of the stomach, has done good. The greatest attention must be paid to the bowels, and most marked benefit is often derived from a gentle dose of Epsom or Cheltenham salts. The severity of the vomiting may also be greatly mitigated by effervescing draughts, or soda water: the last of which, if it do not check the vomiting, renders it much easier. Even cold water has been employed with advantage.' A light bitter infusion is sometimes of service. Obstinate vomiting, especially if accompanied with pain, or tension in the epigastric region, may be relieved by the application of leeches to that part, which have been much recommended by Dr. John Sims and M. Lorentz. I have so often found advantage from this remedy, that I speak of it with confidence. If these means fail in procuring * It is worthy of remark, that abortion is very seldom occasioned by this cause, though emetics are apt to produce it. 219 speedy relief, it is necessary to refrain for a time eating, and have recourse to nourishing clysters, or to give only a spoonful of milk, soup, he. at a time. When the vomiting is bilious, and accom- panied with pain in the right side and shoulder, cough, and other symptoms of hepatitis, a seton should be immediately introduced into the side, and a very gentle course of mercury given, with cir- cumspection ; for if the medicine be given freely, it produces much debility, or abortion, and sometimes accelerates the fate of the patient. When vomiting is troublesome in the conclusion of pregnabjcy, it is proper to detract blood, and confine the person to bed. Cloths, dipped in laudanum, should be applied to the pit of the stomach, and a grain of solid opium may be*given internally; but if this do not succeed, it js not proper to give larger and repeated doses. Gende laxatives must be employed. § 4. HEARTBURN. Heartburn often takes place very early after conception, but sometimes not till after the fourth month. This is a complaint so very common, and so generally mitigated by absorbents, such as magnesia, soda, or chalk, that we are seldom consulted respecting it. But when .it becomes very severe and intractable, it is requi- site to try the most powerful of these means, such as calcined magnesia, combined with pure ammonia.(,z) When these fail, (~xj The late much regretted Dr. Young, of Maryland, in his ingenious ex- periments on the digestive process, has almost reduced it to a certainty, that the acid which exists in the stomach is to be referred to the liquor gastricus; that it is the phosphoric acid, and that the acidity of dyspeptic and pregnant women, is owing to the morbid quantity of this acid. Hence, as he justly remarks, the superiority of lime water as a corrector, from its great affinity to phosphoric acid. The following formula is also recommended by experienced practitioners for the same purpose. I have used it with advantage. R. Magnesiae ustee gj. Aquae purae Jv*s. Sp. Cinnamon giij. Aquae Ammoniae purae 3j" m. Two or three spoonfuls to be taken either occasionally, or when the symp- toms are more continual, immediately after every meal.' 220 liquor potassae, or the chalk mixture, with a large proportion of mucilage, may give relief. Laxatives are always indispensable. In obstinate cases, venesection is useful. Emetics have been pro- posed by Dr. Denman. They are only allowable where there is a constant screatus of disagreeable phlegm. In every severe case the diet must be carefully attended to. Pyrosis is to be relieved chiefly by laxatives, such as the aloetic pill, with extract of colocynth, some light bitter, or rhubarb and magnesia. If these means fail, antispasmodics may be useful, and ruSbing the epigastric region with anodyne balsam. 4 5. FASTIDIOUS TASTE. Women, during gestation, are subject to many bizarreries in their appetite, and often have a desire to eat things they did not former- ly like. This desire is common in cases of abdominal irritation, as we see in those who are afflicted with worms, or have indurated or morbid faeces in the intestines. These longings it has been thought dangerous to deny; for as it was supposed, that they de- pend upon some peculiar state of the child affecting the mother, it was imagined, that if this was not removed, the infant would sus- tain an injury, or might even bear the mark of the thing longed for. Into this doctrine it is now unnecessary to enter; and it will be sufficient to add, that when the desire is placed upon any article of diet, it may be safely gratified, and, indeed, generally the inclina- tion leads to some light and cooling regimen. § 6. SPASM OF STOMACH AND DUODENUM. Spasm of the stomach, or duodenum, may often be attributed to gome irregularity of diet, to the action of cold, or to the influence of the mind. It is necessary to interfere promptly, not only be- cause the pain is severe, but also because it may excite abortion, or kill the child. A full dose of laudanum, with ether, followed im- mediately by a saline clyster, is almost always successful; but when the attacks are renewed, then we must endeavour to prevent 221 them by tonics, such as colomba, oxyde of bismuth, or prepara- tions of steel. It is at the same time, essential that the bowels be kept open, and for this purpose, asafoetida combined with aloes and colocynth is well adapted. Blood-letting is of service, if the at- tack be prolonged. When spasm of the stomach takes place in the end of pregnancy, or about the commencement of parturition, with a sense of fulness or uneasiness in the head, it is necessary to detract blood, lest the patient be seized with convulsions. This remedy is likewise pro- per, when the pain is accompanied with tenderness about the epi- gastric region, heat of the skin, full pulse, and ruddy face. When pain proceeds from the passage of a biliary calculus, it is to be treated more solito. § 7. COSTIVENESS. Costiveness is a general attendant on pregnancy, partly owing to the pressure of the uterus on the rectum, and partly owing to the increased activity of the womb producing a sluggish motion of the bowels. We must not, however, neglect this state, because it na- turally attends gestation, for it may occasion many and serious evils. It certainly increases the irritability of the system, as well as some of the stomachic ailments; and is apt to cause irritation of the bowels, which may either excite premature labour, or give rise to much inconvenience after delivery, and not unfrequently occasions convulsions. Magnesia is a very common remedy, because it at the same time, relieves heartburn; but, when it fails, or is not required for curing acidity in the stomach, the common aloetic pill, the com- pound rhubarb pill, compound extract of colocynth, or a combina- tion of aloes with extract of hyoscyamus, should the former gripe, may be employed. Castor oil is also given, either alone, or made into an emulsion with mucilage. It sometimes happens, that indurated faeces are accumulated in the rectum or colon, producing considerable irritation. This cau- ses not only pain, but also an increased secretion of the intestinal 222 mucus, which is passed either alone, or with blood, together with pieces of hard faeces. This state, like dysentery, is often accom- panied with great tenesmus; but it may be readily distinguished, by examining per vaginam, for the rectum is found to be filled with faeces. Our first object ought to be to remove the irritating cause, which might ultimately produce abortion. Clysters are of great efficacy, because they soften the faeces, and assist in emptying that part of the intestine which is most distended. These are to be, at first, of a very mild nature, and must be frequently repeated. It may even be requisite to break down the feculent mass, with the shank of a spoon, or scooip.fy) After the rectum is emptied, laxa- tives, such as castor oil, or small doses of sulphate of magnesia must be given to evacuate the colon; and when the faeces are brought into the rectum, clysters must be again employed. After the bowels are emptied, hyoscyamus should be given, to allay the irritation ; or if this be not sufficient, and the pain and secretion of mucus, with tenesmus, still continue, an opiate clyster must be ad- ministered, but next day it is to be followed by a mild laxative. And if there be fever, or considerable pain in the abdomen, blood- letting will be necessary. If this costive state be neglected near the time of delivery, the labour is often protracted; and after de- livery masses of indurated faeces come down from the colon, pro- ducing considerable pain and frequency of pulse. When there is much irritation and sensibility, upon pressing on the abdomen, either before or after delivery, it will be proper to detract blood, at the same time that we use the remedies already pointed out. § 8. DIARRHCEA. The bowels, instead of being bound, may be very open; or cos- tiveness and diarrhoea may alternate with each other. The diar- (~yj The reader is referred, for a very interesting case of alvine concretion, where it became necessary to introduce a long flexible catheter through the hardened and impacted faeces, occupying the superior part of the pelvis, for the purpose of injecting an enema, to Hey's Practical Observations on Surgery, chap. XVIII. case 3. 223 rhoea is of two kinds; a simple increase of the peristaltic motion, and increased serous secretion ; or a more obstinate disease, de- pending on debilitated and deranged action of the bowels. In the first kind, the discharge is not altered from the natural state, ex- cept in being thinner; the appetite is pretty good, and the tongue clean, or only slightly white. This is not to be checked, unless it go to a considerable extent, or continue long, or the patient be weakened by it, or be previously of a debilitated habit. Anodyne clysters, or the confectio catechu, will then be of service. Should the pulse be frequent, and any degree of heat or tension be felt in the abdomen, venesection will be useful. In the second, kind, the appetite is lost or diminished, the tongue is foul, and; the patient has a bitter or bad taste, and occasionally vomits ill tasted or bilious matter; the breath is offensive, and often the head aches. The stools are very offensive, and generally dark coloured. In this case, small doses of rhubarb give great relief, and one grain of ipecacu- anha may occasionally be added to each dose of rhubarb. A light bitter infusion is also a useful remedy. Attention must be paid to the diet, which is to be light, and the food taken in a small quan- tity at a time. Considerable benefit is derived from soda water, whioh generally abates the sickness. When the tongue becomes cleaner, and the stools more natural, anodyne clysters may be ad- ministered. In all cases of continued diarrhoea, it is useful to have the surface kept warm with flannel; and sometimes a flannel roller, bound gently round the abdomen, gives great relief. § 9. PILES. Pregnant women are very subject to piles. This may be partly owing to the pressure of the womb upon the vessels of the pelvis, but is chiefly to be attributed to a sluggish state of the intestinal canal, communicating a similar torpor to the hemorrhoidal veins. As this state is attended with costiveness, the disease has been con- sidered as dependent on the mechanical action of the faeces; but whatever truth may be in this opinion, in some cases, yet generally it is without foundation ; and it is no unusual thing for those who are subject to piles, to be able to foretell an attack, by the appear- 224 ance of peculiar symptoms, indicating diminished action of the ali- mentary canal. The treatment of this disease is two-fold. We are to remove the cause by such means as give a brisker action to the bowels, such as bitters and laxatives; which last are also of great service by removing the irritation of the faeces from the rectum, and rendering them softer, by which the expulsion gives less pain. For this purpose, cream of tartar alone, or combined with sulphur, has been generally employed; but we may, with equal advantage, give small doses of castor oil, or of any of the mild neutral salts, dis- solved in a large quantity of water. Besides removing the cause, we must likewise lessen the effect by such local means as abate ir- ritation and sensibility. When the pain, inflammation, and swelling, are great, it- is of service to detract blood topically, by the applica- tion of leeches, or, especially if there be considerable fever, blood- letting may be necessary, as in other cases of local inflammation. The diet should be spare; all stimulants and cordials must be avoided; cooling and anodyne applications to the tumour are also very proper, such as an ointment containing a small quantity of acetate of lead, or a weak solution of the acetate of lead in rose water, or a mixture of the acetum lithargyri and cream. Sometimes astringents are of service, such as the gall ointment; or narcotics, such as opium* or belladona. If these means fail, it will be proper to give an anodyne clyster, and apply fomentations or emollient poultices to the tumour, but every practitioner can tell how often all topical applications have disappointed him. In some cases, the tumour becomes slack, and subsides gradually ; in other instances it bursts, and more or less blood is discharged. If the hemorrhage be moderate, it gives relief; but if profuse, it causes weakness, and must be restrained by pressure and astringents. Great pain, or much hemorrhage, are both apt to excite abortion; as the former is apt to act by sympathy in the neighbouring parts. Even in the unimpregnated state, internal piles are apt to produce symptoms, supposed to arise from the womb or vagina. The rectum-bougie in such cases is useful. • Dr. Johnston advises the following ointment to be applied, and then a poul- tice to be laid over the tumour. R. 01. Amygd. %i. 01. Succini ss Tr. Opii. 5'ii: M. System, p. 125. 225 § 10. AFFECTIONS OF THE BLADDER. The bladder is often affected by pregnancy. In some instances, like the intestines, it becomes more torpid thati' formerly ; so that the woman retains her water long, and expels it with some difficul- ty, and in considerable quantity at a time. This state requires great attention, for retroversion of the uterus nlay, at a certain stage of gestation, be readily occasioned. There is not much to be done with medicines in this case ; for although soda, and similar reme- dies, sometimes give relief, yet more reliance must pe placed on the regular efforts of the patient. Should these be delayed too long, then the catheter must be employed. More frequently the bladder is rendered unusually irritable, es- pecially about its neck, and the uretha participates in this state. There is also, in many instances, an uneasiness felt in the region of the bladder itself. This state requires a very different treat- ment from the former, for here it is our object to avoid every sa- line medicine which might render the urine more stimulating. Re- lief is to be expected by taking away blood, giving small doses of castor oil, and, occasionally, the extract or tincture of hyoscyamus, and encouraging the patient to drink mucilaginous fluids, which, if they do not reach the bladder as mucilage, at least afford a bland addition to the blood, from which the urine is secreted. The state of the bladder is sometimes productive of a slight irritation about- the symphysis of the pubis, rendering the articulation less firm and more easily separated. In such circumstances, when the pubis is tender, blood-letting and rest are the two principal remedies. A very distressing affection, which is often conjoined with this state of the bladder and uretha, but which may also take place without it, is a tender and irritable state of the vulva, producing great itching about the pudendum, especially during the night, and generally the urine is felt very hot. This distressing condition js often alleviated by blood-letting and laxatives; and when the itch- ing is great, a sponge, dipped in cold water, or in cold solution of cerussa acetata, should be applied. If much fever exist the saline julap, combined with a little tincture of opium, is useful. 30 226 Incontinence of urine is not uncommon in the end of gestation, and is produced by the pressure of the uterus on the bladder, by which the urine is forced off involuntarily, whenever the woman coughs or moves quickly ; or at least she cannot retain much of it, being obliged to void it frequently, but without strangury. For this complaint there is no cure ; and many consider it as a favour- able omen, that the child's head is resting on the os uteri. When the uterus is very pendulous, some advantage may be obtained, by supporting the belly with a proper bandage attached to the shoul- ders. § 11. JAUNDICE. Connected with the state of the alimentary canal, is the jaun- dice of pregnant women. This disease appears at an early period, and is preceded by dyspeptic symptoms, which generally increase after the yellowness comes on. In some instances, the tinge is very slight, and soon disappears. In other cases, the yellow co- lour is deep and long continued, and the derangement of the sto- mach and bowels considerable. Emetics, and other violent reme- dies, which are sometimes used in the cure of the jaundice, are not allowable in this case ; and, in every instance, when young married women are seized with jaundice, we should be very cau- tious in our prescriptions. Gentle doses of calomel, or of other laxatives, with some light bitter infusion, are the most proper re- medies ; and generally the complaint soon goes off. Jaundice may also take place in the end of gestation; and in this case, it proceeds most frequently from pressure on the gall duct. Some- times, however, it is dependent on a disease of the liver itself, which may occur at any period of gestation, and is marked by the usual symptoms. In this case, the danger is very great, and can only be averted by taking cautious measures for removing the he- patic disease. § 12. COLOURED SPOTS. In some cases, the skin is partially coloured ; the mouth, for in- 227 stance, being surrounded with a yellow or brown circle, or irregu- lar patches of these colours appearing on different parts of the bo- dy. This is an affection quite independent of the state of the bile, and seems rather to be connected with certain conditions of the alimentary canal. It goes off after delivery, and does not require any peculiar treatment. § 13. PALPITATION. The thoracic viscera not unfrequently suffer during pregnancy. Palpitation of the heart is a very common affection, and extremely distressing. It is a disease so well known, that it is needless here to describe it; but it may not be improper to observe, that women themselves sometimes mistake for it a strong pulsation of the arte- ries, at the upper part of the abdomen. It may make its attack repeatedly in the course of the day ; or only at night before falling asleep; or at the interval of two or three days ; and is very readi- ly excited by the slightest agitation of the mind. It is generally void of danger ; but, in delicate women, and in those who are dis- posed to abortion, it sometimes occasions that event; and, if long continued, it may excite pulmonic disease in those who are pre- disposed to it. Absolute rest, with antispasmodics, are requisite during the paroxysm. Hartshorn, ether, and tincture of opium, may be given, separately or combined. Roderic a Castro pre- scribes a draught of hot water. The attacks are to be prevented by the administration of tonics, such as tincture of muriated iron; and of foetids, such as valerian and asafoetida. Fatigue and exer- tion must be avoided, and the mind kept tranquil. If the person be plethoric, head be pained, or the face flushed, it is useful to take away a little blood. The bowels are to be carefully kept open. The diet must be attended to ; for it is often produced by a disordered stomach. A tendency to nervous or hysterical diseases is to be prevented, in those who are liable to them, by occasional blood-letting, the use of laxatives, and camphor, or fcetids. Opiates are only to be given for the immediate relief of urgent symptoms. 228 § 14. SYNCOPE. Another distressing affection of the heart, attendant on pregnan- cy, is syncope. This may take place at any period of gestation, but is most frequent in the three first months, or about the time of quickening. It often occurs in those who are otherwise healthy, but it also may occur daily for some time in those who are weak- ened by a loose state of the bowels, alternating with costiveness, or by want of sleep occasioned by toothach. It may succeed some little exertion, or speedy motion, or exposure to heat; but it may also come on when the person is at perfect rest. The paroxysm is sometimes complete, and of long duration ; at other times, the person does not lose her knowledge of what is going on, and soon recovers. A recumbent posture, the admission of cold air, or ap- plication of cold wrater to the face, the use of volatile salt, and the cautious administration of cordials, constitute the practice during the attack. Should the fit remain long, we must preserve the heat of the body, otherwise a protracted syncope may end in death. Those who are subject to fainting fits, must avoid fatigue, crowded or warm rooms, fasting, quick motion, and agitation of the mind. Tonics are useful when the system is weak, and the bowels must be regulated. There is a species of syncope, that I have oftener than once found to prove fatal in the early stage of pregnancy, which is de- pendent, I apprehend, on organic affections of the heart, that vis- cus being enlarged, or otherwise diseased, though perhaps so slight- ly as not previously to give rise to any troublesome, far less any pathognomonic symptoms. Although I have met with this fatal termination most frequendy in the early stage, I have also seen it take place so late as the sixth month of pregnancy. i § 15. DYSPNC3A AND COUGH. Sudden attacks of dyspnoea in tjiose who were previously heal- thy, are generally to be considered as hysterical, and are readily re- moved by antispasmodics. There is, however, a more obstinate 229 and protracted symptom, not unfrequently connected with preg- nancy, namely cough. This may come in paroxysms, which are generally severe, or it may be almost constant, in which case it is short and teasing. Sometimes a viscid fluid is expectorated, but more frequently the cough is dry. During the attack, the head is generally painful, and the woman complains much of the shaking of her body, especially of the belly. All practical writers are agreed with respect to the danger of this disease, for it is extremely apt to induce abortion; and it is worthy of remark, that after the child is expelled, the cough often suddenly ceases. But exposure to cold frequently brings it back; and should there be a predisposition to phtliisis, that disease may be thus excited. Blood-letting must be early, and sometimes repeatedly employed ; the bowels kept open; and lozenges, containing opium or hyoscyamus, must be occasion- ally used, to allay die cough. A large Burgundy pitch plaster, ap- plied betwixt the shoulders, is of service ; or a small blister over the junction of the cervical and dorsal vertebrae. Should abortion take place, and the cough continue, tonics, such as myrrh and oxyde of zinc, ought to be administered. § 16. HAEMOPTYSIS AND HiEMATEMESIS. In some instances, haemoptysis or haematemesis take place in pregnancy, especially in the last months, and these are very dan- gerous affections. Blood-letting is the remedy chiefly to be de- pended on ; and afterwards purgatives should be given; acids and hyoscyamus may be employed to allay irritation. If these means do not succeed, the patient dies. Should the hemorrhage take place during labour, or should pains come on prematurely, and the os uteri dilate, as sometimes happens, it will be prudent to accele- rate the delivery. § 17. HEADACH AND CONVULSIONS. Headach is a very alarming symptom, when it is severe, con- stant, and accompanied with symptoms of plethora. If the^ye 230 be dull or suffused, and the head giddy, especially when the pa- tient stoops or lies down, with a sense of heaviness over the eyes, or within the skull, great danger is to be apprehended, particularly if she be far advanced in her pregnancy. This is still more the case, if she complain of ringing in the ears, and see flashes of fire; or have indistinct vision. In such circumstances she is seized either with apoplexy or convulsions. These diseases are to be prevented by having immediate recourse to blood-letting and purgatives; and the same remedies are useful, if either one or other of these dis- eases have already taken place. The quantity of blood which is to be detracted, must be determined by the severity of the symp- toms, the habit of the patient, and the effect of the evacuation; but, generally, moderate evacuation will prevent, whilst very co- pious depletion is requisite to cure these diseases. If the headach be accompanied with oedema, the digitalis is a useful addition to the practice. I shall not at present enter more minutely into the treatment of convulsions. I shall only remark, that the first thing to be done is to detract blood from a vein; next, the bowels are to be immediately opened by a clyster, and then a purgative is to be administered. If the patient be seized with apoplexy, there is seldom any at- tempt made to expel the child,* and, in my own practice, I have never known that event take place. In eclampsia, on the contrary, if the paroxysm be protracted, there is generally an effect pro- duced on the uterus; its mouth opens, and the child may be ex- pelled, if the patient be not early cut off by a fatal coma. When- ever expulsive effects come on, we must conduct the labour accord- ing to rules hereafter to be noticed. In some instances, palsy either succeeds an apoplectic attack, or follows headach and vertigo. This disease does not commonly go off until delivery have taken place; but it may be prevented from becoming severe, by mild laxatives and light diet; and, after the woman recovers from her labour, the disease gradually abates, or yields to appropriate re- medies. All headachy however, do not forebode these dismal events, for * Mr. Wilson's case is an exception to tliis. Vide Med. Facts, Vol. v. p. 96; 231 often they proceed from the stomach, and evidently depend on costiveness, dyspepsia, or nervous irritation. These are generally periodical, accompanied with a pale visage; they feel more ex- ternal than the former, and are often confined to one side of the head. They are attended with acidity in the stomach, eructations, and sometimes considerable giddiness, or slight sickness, with bitter taste in the mouth. They are relieved by the regular exhi- bition of laxatives, by sleep, the moderate use of volatiles, and the application of ether externally. Hysterical convulsions are not uncommon during gestation, and tnore especially during the first four months. They occur in irri- table habits, or in those who are naturally disposed to syncope, or who have been exhausted by any pain, depriving them of rest, or by alvine discharges. They are distinguished by the face usually being pale during the attack, the countenance is very little distorted, there is no foam issuing from the mouth, the patient for a time lies as in a faint, and then has convulsive motions, or screams and sobs, and the fit generally is terminated by shedding tears. The treatment, in the first instance, consists in adminis- tering antispasmodics, particularly opiates and volatile foetids. Af- terwards, the returns are to be prevented by bringing the bowels into a correct state, and keeping them ;so. The exercise is to be gentle, but taken regularly. The diet mild, but nourishing. Sleep is to be procured, if necessary, by opiates; and tonic medi- cines, with the assistance of ammoniated tincture of valerian, must complete the cure. If, however, there be a feeling of fulness about the head, or weight, or headach, it is, even in spare habits^ of service to take away a little blood. § 18. TOOTHACH. Toothach not unfrequently attends pregnancy, and, sometimes, is a very early symptom of that state. The tooth may be sound or diseased, but, in neither case, ought we to extract it in the early months, if it be possible to avoid the operation. I have known the extraction followed in a few minutes by abortion. Blood-letting 231 frequently gives relief, and, sometimes, a little cold water taken into the mouth abates the pain. In other cases, warm water gives more relief. § 19. SALIVATION. Salivation is, with some women, a mark of pregnancy. It has been supposed that there is a sympathy existing between the pan- creas and salivary glands, and that the phlegm ejected by vomiting proceeded from the former, whilst, in many instances, the latter yielded an increased quantity of viscid saliva. This is a symptom which scarcely demands any medicine, but, when it does, mild lax- atives are the most efficacious. § 20. MASTODYNIA. Pain and tension of the mammae frequently attend gestation, and these symptoms are often very distressing. If the woman have for- merly had a suppuration of one mamma, that breast is generally most painful, and she is afraid of abscess again forming. In other instances, the pain, being accompanied with increased hardness of the breast, produces apprehension of cancer. These fears are ge- nerally groundless; but if suppuration do take place, it is to be treated on general principles. Blood-letting often relieves the un- easy feeling in the breast, which is also mitigated by gentle friction with warm oil. Nature often gives relief, by the secretion of a se- rous fluid which runs out from the nipple; but if this be much en- couraged by suction, Chambon remarks, that the fcetus may be in- jured. This, however, is so far from being always the case, that many women, who conceive during lactation, continue to nurse for some months, without detriment to the foetus. The discharge is in some instances so great about the seventh month, or later, as to keep the woman very uncomfortable. The diet in this case should be dry. The sudden abatement of the tension, and fulness of the breasts, with a diminution of size, are unfavourable circumstances, indicat- ing either the death of the child, or a feeble action of the womb. 233 § 21. (EDEMA. In the course of gestation, the feet and legs very generally be- come oedematous; and sometimes the thighs and labia pudendi par- ticipate in the swelling. The swelling is by no means proportioned always to the size of the womb, for, as has been remarked by Pu- zos, those who have the womb unusually distended with water, and those who have twins, have frequently very little oedema of the feet. This disease is partly owing to the pressure of the uterus, but it also seems to be somewhat connected with the pregnant state, independent of pressure; for in some instances the oedema is not confined to the inferior extremities, but affects the whole body. A moderate degree of oedema, going off in a recumbent posture, is so far from being injurious, that it is occasionally remarked, that mahy uneasy feelings are removed by its accession; but a greater and more universal effusion indicates a dangerous degree of irrita- tion. In ordinary cases, no medicine is necessary except aperients; but, when the oedema is extensive or permanent, remaining even after the patient has been for several hours in bed, it may be at- tended with unpleasant or dangerous effects, such as convulsions; or, it may predispose to puerperal diseases; we must therefore les- sen it by means of those agents which alleviate the other diseases of pregnancy, namely blood-letting and purgatives. These means are always proper, and are never to be omitted, unless the strength be much reduced ; in which case, we only employ the purgatives and cbrdials prudently, with acetate of pbtash, or sweet spirit of nitre. Diuretics, generally, are not successful, and many of them, if given liberally, tend to excite abortion. Friction relieves the feeling of tension. which has less to do with the action of gestation than any other part of the uterus ; and this ac- tion is often attended with considerable pain or uneasiness. Some- times it is connected with convulsive agitation of several of the external muscles of the body. Even in this case, expulsion does not always immediately take place ; for by bleeding, and rest, and opiates, the motion may sometimes be checked; but regular and universal action of the muscular fibres never yet has been stopped. It may, like other muscular actions, be suspended by anodynes or artificial treatment; but it never has, and never can be stopped, otherwise than by the expulsion of the ovum, when a new train of actions commence. Whenever, then, at any period of pregnancy, we have paroxysms of pain in the back,* and region of the uterus, * It may not be improper to mention, that in some febrile affections we have pain in the back and loins, occasionally remitting or disappearing altogether for a short space, and then returning. Sometimes along with this we have, owing to the affection of the circulation, and in some instances, to previous exertion, a 273 more especially if these be attended with feeling of weight in that region, tenesmus, micturition, descent of the uterus in the pelvis, and opening of the os uteri, we may be sure that expulsion, though retarded, will soon take place. This fact is not always attended to in abortion, for many think that if by anodynes they can abate the pain, they shall make the woman go to the full time.—This is true, with regard to many painful sensations which may attend a threatened abortion, or which may be present, although there be no appearance of abortion; but it does not hold with regard to those regular pains proceeding from universal action of the uterine fibres; and we may save both ourselves and our patients some trouble, by keeping this in remembrance. Seeing, then, that contraction is brought on by stopping the ac- tion of gestation, and that when it is brought on it cannot be check- ed, nor the action of gestation restored, we must next inquire how this action may be stopped. I have already mentioned several circumstances affecting the uterus, and likely to injure its actions; and these I shall not repeat, but go on to notice some others, which are often more perceptible : and first I shall mention violence, such as falls, blows, and much fatigue, which may injure the child, and detach part of the ovum. If part of the ovum be detached, we have not only a discharge of blood, but also the uterus, at that part, suffers in its action, and may influence the whole organ, so as to stop the action universally. But the time required to do this is various, an opportunity is often given to prevent the mischief from spreading, and to stop any farther effusion—perhaps to accomplish a re-union. Violent exercise, as dancing, for instance, or much walking, or the fatiguing dissipations of fashionable life, more especially in the discharge from the vessels about the os uteri. The state is distinguished from uterine contraction, by our finding that the cervix is unaffected, that the pains are increased by motion or pressure, and are more irregular than those attending labour. This state may be prevented from inducing abortion, by rest, by keep- ing the bowels open, by anodynes preceded by venesection, if the pulse indicate it. Frictions, with camphorated spirits of wine, or laudanum, give relief. Any exertion, during the remaining period of gestation, will renew the pain in the hack. 36 274 earlier months, by affecting the circulation, may vary the distri- bution of blood in the uterus, so much as to produce rupture of the vessels, or otherwise to destroy the ovum. There is also ano- ther way in which fatigue acts, namely, by subducting action and energy from the uterus: for the more energy that is expended on the muscles of the inferior extremities, the less can be afforded or directed to the uterus; and hence abortion may be induced at an early stage of gestation.* Even at a more advanced period, in- convenience will be produced upon the principle formerly men- tioned; for the nerves of the loins conveying less energy, in many instances, though not always, to the muscles, they are really weak- er than formerly, and are sooner wearied, producing pain, and prolonged feeling x>f fatigue for many days, after an exertion which may be considered as moderate. This feeling must not be con- founded with a tendency to abortion, though it may sometimes be combined with it, for generally by rest the sensation goes off. Neither must we suppose that the child is dead, from its being usually quiet during that period, for as soon as the uterus, which has been a little impaired in its action, recovers, it moves as strong- ly as ever. In the next place I mention the death of the child, which may be produced by syphilis, or by diseases, perhaps, peculiar to itself, or by that state which produces too much liquor amnii, or by in- jury of the functions of the placenta, which may arise from an improper structure of the gland itself, or aneurism, or other dis- eases of the cord. But in whatever way it is produced, the effect is the same in checking the action of gestation, unless there be twins, in which case it has been known, that the uterus sometimes did not suffer universally, but the action went on, and the one child was born of the full size, the other small and injured.f The * The same effect is observable in the stomach and other organs. If a deli- cate person, after a hearty meal, use exercise to the extent of fatigue, he feels that the food is not digested, the stomach having been weakened or injured in its actions. f It has even been known, that, in consequence of the death of one child, the uterus has suffered partially, and expulsion taken place; but the other child con- tinuing to live, has preserved the action of gestation in that part of the uterus. 275 rength of time required for producing abortion from this cause is various; sometimes it is brought on in a few hours; at other times, not for a fortnight, or even longer.(c) In these and similar cases, when the muscular action is commencing, the discharge is trifling, like menstruation, until the contraction become greater, and more of the ovum be separated. When symptoms of abortion proceed from this cause, it is not possible to prevent its completion; and it would be hurtful even if it were possible. When, therefore, after great fatigue, profuse evacuations in delicate habits, violent colic, or other causes, the motion of the child ceases, the breasts become flaccid, and the signs of gestation disappear, we need not attempt to retard expulsion, but should direct our principal atten- tion to conduct the woman safely through the process. Another cause is, any strong passion of the mind. The influence of fear, joy, and other emotions, on the muscular system, is well known; and the uterus is not exempted from their power; any sudden shock, even of the body, has much effect on this organ. The pulling of a tooth, for instance, sometimes suddenly produces abortion. A thunder storm, or violent cannonade, has been sup- posed to cause abortion by the concussion of the air; but it is which, properly speaking, belonged to it, and pregnancy has still gone on. This, however, is an extremely rare occurrence; for, in almost every instance, the death of one child produces an affection of the action of gestation in the whole uterus, and the consequent expulsion of both children. (c) In one instance that fell under my notice, a lady who had suffered several previous abortions, but who had also borne two healthy living children, was over- turned in a carriage before the completion of the third month of gestation. She was extremely bruised, and was, in consequence, confined to her bed for several days; yet, upon getting about again, she fancied, after the period of quickening, that she felt the motion of the child, with all the other symptoms of favourable and healthy pregnancy. She thus went on to the full period of utero-gestation; and on the very day she calculated, was delivered of a foetus that certainly had lost the principle of vitality for several months, not appearing larger than an embryo of five months. The placenta was also almost exsangueous, and appear- ed as if it might have been detached from the uterine parietes for some time. Indeed, the whole appeared like a preparation that had been preserved in sp. vini, or sp. terebinth. The lady had a speedy recovery, and, at no distant pe- riod, bore a healthy living child. 276 more probable when they have that effect, that it is owing to men- tal trepidation. Emmenagogues, or acrid substances, such as savine and other irritating drugs, more especially those which tend to excite a con- siderable degree of vascular action, may produce abortion. Such medicines, likewise, as exert a violent action on the sto- mach or bowels, will, upon the principle formerly mentioned, fre- quently excite abortion; and very often are taken designedly for that purpose in such quantity as to produce fatal effects ;* hence emetics, strong purgatives, diuretics, or a full course of mercury, must be avoided during pregnancy. If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suf- fer, and abortion be produced. Hence the accession of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why small-pox often excites abortion, whilst the same degree of ever, unaccompanied with eruption, would not have had that ef- fect. Hence also increased secretory action in the vagina, if to a great degree, though it may have even originally been excited in consequence of sympathy with the uterus, may come to incapacitate * It is an old observation, that those purgatives which produce much tenes- mus, will excite abortion; and this is certainly true, if their operation be carried to a considerable extent, and continue long violent. Hence dysentery is also apt to bring on a miscarriage. Those strong purges which are sometimes taken to promote premature expulsion, not only act by exciting tenesmus, but likewise by inflaming the stomach and bowels, and thus affect the uterus in two ways. It cannot be too generally known, that when these medicines do produce abortion, the mother can seldom survive their effect. It is a mistaken notion, that abortion can be most readily excited by drastic purges, frequent and copious bleeding, &c. immediately after the woman discovers herself to be pregnant; on the con- trary, the action of the uterus is then more independent of that of other organs, and therefore not so easily injured by changes in their condition. 1 have already shown, that abortion more frequently happens when the pregnancy is farther advanced, because then not only the uterus is more easily affected, but the foetus seems to suffer more readily. It is apt, either from diseases directly affecting itself, or from changes in the uterine action, to die about the middle of the third month, in which case expulsion follows within a fortnight. 277 the uterus for going on with its actions, and therefore it ought to be moderated by means of an astringent injection. Mechanical irritation of the os uteri, or attempts to dilate it pre- maturely, will also be apt to bring on muscular contraction. At the same time, it is worthy of remark, that the effect of such irri- tation is generally at first confined to the spot on which it acts, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for some time, produced; and therefore slight uneasiness at the lower part of the belly, with or without a tendency in the os uteri to move or dilate, whether brought on by irritation at the upper part of the vagina or os uteri, or by the affec- tion of the neck of the bladder, he. may be often prevented from extending farther, by rest, anodynes, and having immediate re- course to such means as the nature of the irritation may require for its removal.* The irritation of a prolapsus ani, or of inflamed piles, with or without much sanguineous discharge, may excite the uterus to con- tract ; and if the bleeding from the anus have been profuse, and the woman weakly, it may destroy the child. The piles, ought, there- fore, never to be neglected. Tapping the ovum, by which the uterus collapses, and its fibres receive a stimulus to action, is another cause by which abortion may be produced; and this is sometimes, with great propriety, done at a particular period, in order to avoid a greater evil. It is now the general opinion, that contraction will unavoidably follow the evacuation of the waters. But we can suppose the action of gestation to be in some cases so strong as not, at least for a very considerable time, to stop in consequence of this violence, and, if it do not stop, contraction will not take place. I do not, however, mean to say, that all discharges of watery fluid from the uterus, not followed by abortion, are discharges of the liquor amnii. On the contrary, I know, that most of these are the consequence of mor- bid action about the os uteri, the glands yielding a serous, instead * Chronic inflammation of the heart is generally attended with pain at the bottom of the abdomen, which is sometimes mistaken for symptoms of calculus. Jn one case abortion seemed to proceed from this disease of the heart. 278 of a gelatinous fluid, and this action may continue for many months. In all these cases, the woman must be confined to bed, and have an anodyne every night at bed-time, for some time, premising ve- nesection if the pulse indicate it, and conjoining gentle laxatives. There is just so much probability of gestation going on, as to en- courage us to use endeavours to continue it. In those instances where the discharge is small, and the oozing pretty constant, we conclude that it is yielded chiefly by the glands about the os uteri, and may derive advantage from injecting three or four times a day a strong infusion of galls, or solution of alum. The woman ought to use no exertion, as the membranes are apt to give way. It is sometimes necessary to lay down rules for the management of pregnant women, even although they may not have been liable to abortion. These are to be drawn from the remarks already delivered, and it is only requisite to add, that in all cases it is pro- per to attend to the effects of utero-gestation, or the diseases of pregnancy, which are to be mitigated, when severe, by suitable remedies. The danger of abortion is to be estimated by considering the previous state of the health, by attending to the violence of the discharge, and the difficulty of checking it; to its duration, and the disposition to expulsion which accompanies it; to the effects which it has produced in weakening the system, and to its com- bination with hysterical or spasmodic affections. In general, we say that abortion is not dangerous, yet in some cases, even at a very early period of gestation, and under vigorous treatment, it does prove fatal very speedily, either from loss of blood, or spasm in the stomach, or convulsions. It is satisfactory, however, to know, that this termination is rare, that these dangerous attendants are seldom present, and that a great hemorrhage may be sustained, and yet the strength soon recover. But if there be any disposi- tion in a particular organ to disease, abortion may make it active, and thus, at a remote period, carry off the patient. Miscarriages, if frequently repeated, are also very apt to injure the health, and break up the- constitution. 279 When abortion is threatened, the process fs very apt to go on to completion; and it is only by interposing, before the expulsive efforts are begun, that we can be successful in preventing it; for whenever the muscular contraction is universally established, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the process. As this is often the case before we are called, or as in many instances abor- tion depends on the action of gestation being stopped by causes* whose action could not be ascertained until the effect be produced, we shall frequently fail in preventing expulsion. This is greatly owing to our not being called until abortion, that is to say, the expulsive process has begun; whereas, had we been applied to upon the first unusual feeling it might have been pre- vented. What I wish then particularly to inculcate is, that no time be lost in giving notice of any ground of alarm, and that the most prompt measures be had recourse to in the very beginning; for, when universal uterine contraction has commenced, then all that we can do is to conduct the patient safely through a confine- ment, which the power of medicine cannot prevent, The case of threatened abortion, in which we most frequently succeed, is that arising from slipping of the foot, or from causes exciting a temporary over-action of the vessels, producing a slight separation; because here the hemorrhage immediately gives alarm, and we are called before the action of gestation be much affected^ Could we impress upon our patients the necessity of equal atten- tion to other preceding symptoms and circumstances, we might succeed in many cases where we fail from a delay, occasioned by their not understanding that an expulsion can only be prevented, by interfering before that process begins; for when sensible signs of contraction appear, the mischief has proceeded too far to be checked. Prompt and decided means used upon the first ap- proach of symptoms indicating a hazardous state of the uterus, or on the earliest appearance of hemorrhage, may, provided the child be still alive, be attended with success. In considering the treatment, I shall, first of all, notice the most likely method of preventing abortion in those who are subject to i.t; next, the best means of checking it, when it is immediately 280 threatened ; and, lastly, the proper method of conducting the wo* man through it, when it cannot be avoided. The means to be followed in preventing what may be called habitual miscarriage, must depend on the cause supposed to give rise to it. It will, therefore, be necessary to attend to the history of former abortions; to the usual habitudes and constitution of the woman; and to her condition when she becomes pregnant. In many instances a plethoric disposition, indicated by a pretty full habit, and copious menstruation, will be found to give rise to it. In these cases, we shall find it of advantage to restrict the pa- tient almost entirely to a vegetable diet, and, at the same time, make her use considerable and regular exercise. The sleep should be abridged in quantity, and taken, not on a bed of down, but on a firm mattress, at the same time that we pre- vent the accumulation of too much heat about the body. The bowels ought to be kept open, or rather loose, which may be ef- fected by drinking Cheltenham water, or taking some other laxa- tive. We must not, however, carry this plan too far, nor make a sudden revolution in the constitution, as this may be productive of permanent mischief, and occasion the diseases which proceed from a broken habit. Whenever the strength is diminished, the appe- tite impaired, or any other bad effect is produced, we have gone too great length. There is, in plethoric habits, a weakness of many, if not all, of the functions; but this is not to be cured by tonics, but by conti- nued and very gradually increased exercise, laxatives, and light diet, consisting chiefly of vegetables. This plan, however, must not be carried to an imprudent length, nor established too suddenly; but regard is to be had to the previous habits. It is a general rule, that exercise should not be carried the length of fatigue, and that it should be taken, if possible, in the country; whilst late hours, and many of the modes of fashionable life, must be departed from. We may also derive so considerable advantage from conjoining with this plan, the shower-bath or sea-bathing, that they ought not to be omitted. There is, I believe, no remedy more powerful in preventing abortion than the cold bath, and the best time for using it is in the morning. By means of this, conjoined with attention 281 to the vascular system, and prudent conduct on the part of the pa- tient, I suppose that nine-tenths of those who are subject to abor- tion, may go on to the full time. If the shower-bath be employed, we must begin with a small quantity of water; and, in some instan- ces, may at first add so much warm water, as shall make it just feel cold, but not to give too great a shock. If the cold bath cause headach, this may often be prevented by premising one or two doses of physic. After conception, the exercise must be taken with circumspect tion : but the diet must still be sparing, and the use of the cold bath continued. If the pulse be at any time full, or inclined to throb, or if the patient be of a vigorous habit, a little blood should be taken away at a very early period. In some cases, where the action is great, we must bleed almost immediately after the sup- pression of the menses. It is not necessary to bleed copiously; it is much better to take away only a few ounces, and repeat the evacu- ation when required, and we should manage so as to avoid fainting. The cold bath should be conjoined, and we may derive advantage by using the digitalis* so as slightly to affect the pulse, keeping it at or below its natural frequency, and to diminish its throbbing. But it is not requisite to be given to the degree employed in some other complaints; and if it be pushed to an imprudent length, the child may suffer. Half a grain may be given, twice or thrice a-day. It may be continued for two days, and then omitted for a day; and in this way it may be continued till the danger is past. In those cases where the digitalis produces feebleness, it is evidently im- proper to continue it regularly. Indeed, when this effect takes place, its further exhibition is unnecessary. It is also improper where it acts powerfully on the kidneys. By attending to these cautions, it may, in some cases requiring it, be continued with oc- casional omissions of a day or two, even for some weeks, but it is very seldom necessary to persist in it above a fortnight at most. • The acetite of lead has been recommended by the ingenious and justly ce- lebrated Dr. Rush of Philadelphia, in doses of from one to three grains, given three times a-day. Of this practice I cannot speak from my own experience; but Dr. Rush informs me that in his hands it has been attended with great success, 37 282 - Injecting cold water into the vagina, twice or Uirice a-day, has often a good effect, at the same time that we continue the shower- bath every morning. When there is much aching pain in the back, it is of service to apply cloths to it, dipped in cold water, or gently to dash cold water on it; or employ a partial shower-bath, by means of a small watering-can. In this, as in all other cases of habitual abortion, we must ad- vise, that impregnation shall not take place until we have corrected the system; and after the woman has conceived, iris requisite that she live absque marito, at least until gestation be far advanced. I need hardly add, that when consulted respecting habitual abortion, the strictest prudence is required on our part, and that the situation of the patient, and many of our advices, should be concealed from the most intimate friends of the patient. In other cases, we find that the cause of abortion is connected with sparing menstruation. This is often the case with women whose appearance indicates good health, and who have a robust look. This is not often to be rectified by medicine, but it may by regimen, &c. Here, as in the former case, we find it useful to make die greatest part of the diet consist of vegetables; but it is not necessary to restrict the quantity. When, on the other hand, the patient has a weakly delicate ap- pearance, it will be proper to give a greater proportion of animal food, and two or three glasses of wine, in the afternoon, with some bitter laxative, twice a-day, so as to strengthen the stomach, and at the same time keep the bowels open. * We also derive in both cases, advantage from the daily use of the warm bath, made of a pleasant temperature; but this is to be Omitted after conception ; at least for the first ten or twelve weeks; after which, if there be symptoms of irritation, or feeling of tension: about the belly, or pain about the groins, or pubis, it may be em- ployed, and is both safe and advantageous. But when the patient is of a phlegmatic habit, or subject to profuse fluor albus, it is not indicated, and sometimes is pernicious. The internal use of the Bath waters, previous to conception, is often of service; or where the circumstances of the patient will not permit this, we may desire her to drink, morning and evening, a pint of tepid water, containing 283 half a drachm of sweet spirit of nitre. Throwing up into the vagina tepid salt-water twice or thrice a-day, seems also to have a good effect. I have already mentioned, that abortion is sometimes the con- sequence of too firm action, the different organs refusing to yield to the uterus, which is thus prevented from enjoying the due quan- tity of energy and action. These women have none of the dis- eases of pregnancy, or they have them in a slight degree. They have good health at all times, but they either miscarry, or have la- bour in the seventh or eighth month, the child being dead; or if they go to the full time, I have often observed the child to be sickly, and of a constitution unfitting it for living. Blood-letting is useful by making the organs more irritable. The tepid bath is in gene- ral of advantage, and may be employed every second evening for some time. There is another case in which all the functions are healthy and firm, except the circulation, which is accelerated by the uterine ir- ritation. This is more or less the case in every pregnancy; but here it is a prominent symptom. The woman is very resdess, and even feverish, and apt to miscarry, especially if she be of a full habit. Immediate relief is given by venesection; and afterwards we may, for some time, give every night half a grain or a grain of digitalis, with two grains of the extract of hyoscyamus. When, on the contrary, abortion arises from too easy yielding of some organ, we must keep down uterine action, by avoiding ve- nery, and injecting cold water often into the vagina, or pouring cold water every morning from a watering-can, upon the loins and ilia; at the same time we must attend to the organ sympathizing with the uterus. Sometimes it is the stomach which is irritable, and the person is often very sick, takes little food, and digests ill. A small blister, or leeches, applied to the pit of the stomach often relieve this; a little of the compound tincture of bark, taken three or four limes a-day, is serviceable ; or a few drops of the tincture of muiiated iron, in a tumbler glassful of aerated water. At other times the bowels yield, and the patient is obstinately costive. This is cured 284 by aloetic pills, or manna, with the tartarite of potash. When the muscular system yields, producing a feeling of languor and gene- ral weakness, the use of the cold bath, with a grain of opium at bed-time, will be of most service. It is evident, that it is only by attending minutely to the history of former miscarriages, that we can detect these causes ; and we shall generally find, that in each individual case, it is the same organ in every pregnancy which has yielded or suffered. Previ- ous to future conception, we may with propriety, endeavour to render it less easily affected. General weakness is another condition giving rise to abortion ; and upon this I have already made some remarks. I have here only to add, that the use of the cold bath, the exhibition of the Pe- ruvian bark, and wearing flannel next the skin, constitute the most successful practice. Syphilis is likewise a cause of abortion. When it occurs in the mother, it often unfits the uterus for going on with its actions. At other times, more especially when the father labours under venereal hectic, or has not been completely cured, the child is evidently affected, and often dies before the process of gestation can be completed. In these cases, a course of mercury alone can effect a cure. But we are not to suppose that every child, born without the cuticle in an early stage of pregnancy, has suffered from this cause ; on the contrary, as some of these instances de- pend on causes already mentioned, and which cannot be cured by mercury, 1 wish to caution the student against too hastily conclud- ing that one of the parents has been diseased, because the child is born dead or putrid at an early period. It is not always easy to form a correct judgment; but we may be assisted by finding that the other causes which I have mentioned are absent; that we have appearances of ulceration on the child, and that, there are some suspicious circumstances in the former history and present health of the parents. A child may be born dead, and even putrid, not only in consequence of syphilis, but also of some malformation of the foetus itself, or of its appendages ; or of a general imperfection of the ovum, usually combined with an increased quantity of li- quor amnii; or of original debility of constitution, unfitting the 265 child for coming to maturity ; or of fatal derangement of structure or action, taking place in utero, from causes not very obvious ; or from weakness or imperfect action of the uterus itself, or such a condition of it as sometimes produces epilepsy ; or it is in certain cases occasioned by a convulsion. Most of these causes are not under our control; and indeed, with the exception of the case of syphilis, we can only propose to prevent the death of the child, by the use of such general means as invigorate the constitution of the parent, or as obviate palpable predisposing causes of injury to the uterine functions. Advancement in life, before marriage, is another cause of fre- quent abortion, the uterus being then somewhat imperfect in its action. In general we cannot do much in this case, except avoid- ing carefully the exciting causes of abortion ; and by attending minutely to the condition of other organs, during menstruation or pregnancy, we may, from the principles formerly laid down, do some good. It is satisfactory to know, that although we may fail once ox twice, yet, by great care, the uterus comes at last to act more per- fectly, and the woman bears children at the full time. After these observations, it is only necessary to add, that in every instance of habitual abortion, whatever the condition may be which gives rise to it, we find it is essential that the greatest attention be paid to the avoiding of the more evident and immediate exciting causes of miscarriage, such as fatigue, dancing, he. In some cases, it may even be necessary to confine the patient to her room, until the period at which she usually miscarries is past. When abortion is threatened, we come to consider whether, and by what means, it can be stopped. I have already stated my opinion, that when the action of gestation ceases, it cannot be renewed, and that general contraction of the uterine fibres is a criterion of this cessation. Still, as some of the means which may be supposed useful in preventing a threatened abortion, are also useful in moderating the symptoms attending its progress, we may properly have recourse to them. Some causes giving rise to abortion, do not immediately produce it, but give warning of their operation, producing uneasi- 286 ness in the vicinity of the uterus, before the action of that organ be materially affected. The detraction of a little blood at this time, if the pulse be in any measure full or frequent, or if the patient be not of a habit forbidding evacuations, and the subsequent exhibition of an anodyne clyster, or a full dose of opium,* together with a state of absolute rest in a recumbent posture for some days, will often be sufficient to prevent further mischief, and constitute the most efficacious practice. The patient should be strictly confined to bed, sleeping with few bed-clothes, and without a fire in her apartment. Indeed the very first thing to be done on entering the room, is to order the patient to bed. The diet should, in general, be low, -consisting of dry toast, biscuit, and fruit; and much fluid, especially warm fluid, should be avoided. This is the time at which we can interfere with the most certain prospect of success; and the greatest attention should be paid to the state of the rest of the system; removing uneasiness, wherever it is present, and preventing any organ from continuing in a state of undue action. It is difficult to persuade the patient to comply with that strict attention which is necessary at this period; but being persuaded that if this period be allowed to pass over with neglect, and contraction begins, nothing can afterwards prevent abortion, I wish particularly to impress the mind of the student with a due sense of its importance; and I must add, that as after every appear- ance of morbid uterine action is over, the slightest cause will re- new our alarm, it is necessary great attention be paid for some time to the patient. Often, instead of an uneasy feeling about the loins, or lower belly, we have, before the action of gestation stops, a discharge of blood, generally in a moderate, sometimes in a trifling degree. This is more especially the case when abortion is threatened, owing to an external cause; and, if immediately checked, we may prevent con- traction from beginning. Even in those cases where we do not expect to ward off expul- sion, it is useful to prevent, as far as we can, the loss of blood; for * Opiates are of signal benefit in this situation, and should seldom be omitted after venesection. 287 as I cannot see that the hemorrhage is necessary for its accomplish- ment, although it always attend it, I conclude that our attempts to prevent bleeding can never do harm ; if they succeed in check- ing abortion, we gain our object; if they fail, they do not increase, but diminish the danger. It should be carefully remembered, that the more we can save blood, the more do we serve our patient. As the means for check- ing the discharge will be immediately pointed out, it is unnecessary here to enter into any detail. Sometimes the vessels about the cervix and os uteri yield, post cvitum, a little blood; and this may occur either in those who have the uterus in a high state of activity, or more frequently where it is feeble in its functions. The same discharge may sometimes appear in rather greater quantity after impregnation, passing perhaps for the menses, and making the woman uncertain as to her situation; but it is generally, though not always, irregular in its appearance, and seldom returns above once or twice. In some instances, how- ever, it becomes greater and more frequent in proportion as the vessels increase in size. It is now apt to pass for menorrhagia*- If it be allowed to continue, it tends to injure the action of the Viterus, and produces expulsion, which sometimes is die first thing which shows the woman her situation. The discharge is best ma- naged by rest, the frequent injection of saturated solution of the sulphate of alumine, or decoction of oak bark, and the internal use ef tincture of kino. When a slight discharge takes placej in consequence of a slip of the foot, or some other external cause, we may also derive advan- tage from the use of the injection; but if the discharge be con- siderable, it will often fail. It is better, in such a case, to trust to the formation of a coagulum. When in a plethoric habit abortion is threatened, from a fright, or mental agitation, we have often palpitation, rapidity of the pulse, headach, flushed face, and pain about the back or pubis ; blood-letting relieves immediately the uneasiness in the head, and often the pain in the back; afterwards, the patient is to be kept cpol and quiet, and an anodyne administered. 288 In those cases, where regular uterine pain precedes or accom- panies the discharge, expulsion cannot be prevented; but when the discharge precedes the pain, it sometimes may; nay, if the child be still alive, it frequently may. Rest is absolutely necessary, if we wish the person to go to the full time : and it is occasionally necessary to confine her to bed for several weeks, prescribe the prudent and occasional use of digitalis,* and give an anodyne at bed-time, taking care also to keep the bowels in a proper state by gentle medicine. Blood ought also, unless the pulse and habit of the patient forbid it, to be detracted. A table spoonful of tincture of kino may be given three times daily. Styptic injections into the vagina, two or three times a-day, are of great benefit. This is a very critical situation: much depends on the vigour and promptitude of our practice ; and much, very much, upon the prudence of the patient. It is teazing to find, that sometimes after all our care and exertions, one rash act destroys in a single day the effect of the whole. When we cannot prevent abortion, the next thing is to conduct the patient safely through the process, by lessening the effects of separation or detachment of the ovum, and accelerating the con- traction. The first point which naturally claims our attention is the hemorrhage. Many practitioners, upon a general principle, bleed in order to check this, and prevent miscarriage; but mis- carriage cannot be prevented, if the uterine contraction have uni- versally commenced; and the discharge cannot be prudently moderated by venesection, unless there be undue or strong action in the vessels, or much blood in die system; and if so, a vein may be opened with advantage. This is not always the case, and * I have in a preceding note, advised some caution in the use of digitalis in uterine floodings. I would here, ajteo, recommend the same degree of circum- spection. When given in sufficient quantity to make any very sensible impres- sion on the system generally, it seems, in a very peculiar manner, to relax and debilitate the vessels of the uterus, disposing them, thereby, to passive hemor- rhage. When, however, it is administered with proper restrictions, I have no doubt it may prove both a safe and a useful medicine. But still,'I would greatly prefer to bleed in the aboye cases. C. 289 therefore, unless the vessels be at or above the natural force or strength of action, the lancet is not at this stage necessary. The fulness and strengdi of the pulse are lost much sooner in abortion than can be explained, by the mere loss of blood. This depends on an affection of the stomach, which has much influence on the pulse; and the proper time for bleeding is before this has taken place. When abortion has made so much progress before we are called, as to have rendered the pulse small and feeble; or when this is the case from the first, bleeding evidently can do no good. Instead of this, we may rather use the digitalis, but in ordinary cases, where the contraction is brisk, and the process quick, it is not at this stage absolutely necessary ; and I shall afterwards men- tion that, when the stomachic affection is urgent, and the pulse much affected by it, the use of this medicine is improper. When, however, the case is tedious, and the discharge long continued, at the same time that the sickness is not considerable, the digitalis will be of essential service, and it may be very properly com- bined with the sulphuric acid. Nauseating doses of emetic medi- cines act in the same way with the digitalis, but are much less effectual, and more disagreeable, as well as uncertain in their operation. Internal astringents have been proposed, but they have no effect in copious hemorrhage, unless they excite sickness, which is a different operation from that which is expected from them. They are more useful in protracted, but moderate hemor- rhage. The application of cloths, dipped in cold water, to the back and external parts ought always to be had recourse to. If the digitalis have been exhibited, it assists that medicine in moderating the circulation. Even when trusted to alone, it lessens the action of the sanguiferous system, particularly of the uterine vessels. The introduction of a small piece of smooth ice into the vagina has been recommended, and has often a very speedy effect in retard- ing the hemorrhage, whilst it never, if properly managed, does any harm. A small snow-ball, wrapped in a bit of linen, will have the same effect; but neither of these must be continued so long as to produce pain, or much and prolonged shivering. The heat of 38 290 the surface is also to be moderated, by having few bed-clothes, 4* and a free circulation of cool air. But the most effectual local method of stopping the hemor- rhage is by plugging the vagina. This is best done by taking a pretty large piece of soft cloth, and dipping it in oil, and then wringing it gently. It is to be introduced with the finger, portion after portion, until the lower part of the vagina be well filled. The remainder is then to be pressed firmly on the orifice. This acts by giving the effused blood time to coagulate. It gives no pain; it produces no irritation ; and those who condemn it, surely must ■ either not have tried it or have misapplied it. If we believe that abortion requires for its completion a continued flow of blood, we ought not, in those cases where the process must go on, to have recourse to cold, or other means of restraining hemorrhage. If we do not believe this, then surely the most effectual method of moderating it is the best. Plugging can never retard the process, nor prevent the expulsion of the ovum; for when the uterus con- tracts, it sends it down into the clotted blood in the upper part of the vagina, and the flooding ceases. Faintness operates also in many cases, by allowing coagula to form, in consequence of the blood flowing more slowly; and when the faintness goes off, the coagula still restrain the hemorrhage in the same way as when the plug has been used. This naturally points out the advantage of using the plug, together with the digi- talis, as we thus produce coagulation at the mouth of the vessels, and also diminish the vascular action. It will likewise show the impropriety of using injections at this time; for by washing out the coagula, we do more harm than can be compensated by any astringent effect produced on the vessels. The principal means, then, which we employ for restraining the hemorrhage, are bleeding, if the pulse be full and sharp; if not, we trust to the digitalis, combined with sulphuric acid, except in those cases already specified, as forbidding its use, in which we may substitute kino: to stuffing the vagina: to the application of cold to the external parts, keeping the heat of the body in general at a low temperature; and enforcing a state of absolute rest, which 29\ must be continued during the whole process, however long it may, in some cases, be. The drink should be cold, and the food, if the patient desire any, light, and taken in small portions. Opiates have been advised, in order to abate the discharge, and are, by many, used in every case of abortion, and in every stage. But, as we cannot finish the process without muscular contraction, and, as they tend to suspend that, I do not see that their constant exhibition can be defended on rational principles. If given in small quantity, they do no good in the present point of view; if in larger doses, they only postpone the evil, for they cannot check abortion after contraction has begun. But I will not argue against the use of opiates from their abuse. They are very useful in cases of threatened abortion, more especially in accidental separation of the membranes and consequent discharge. They do not directly preserve the action of gestation, but they prevent the tendency to muscular contraction, and thus do good. In weakly or emaciated habits, opiates alone, if given upon the first appearance of mis- chief, are often sufficient to prevent abortion; and, in opposite conditions, when preceded by venesection, they are of great ser- vice. Opiates are likewise useful for allaying those sympathetic pains about the bowels, and many of the nervous affections which precede or accompany abortion. They are also of much benefit in cases where we have considerable and protracted discharge, with trifling pains, as the uterus is not contracting sufficiently to expel the ovum, but merely to separate vessels, and excite hemor- rhage. By suspending for a time its action, it returns afterwards with more vigour and perfection, and finishes the process. But when the process is going on regularly, opiates will only tend to interfere with it, and prolong the complaint. It was at one time, a very frequent practice to endeavour, with the finger or small forceps, to extract the fcetus and placenta, in or- der to stop the discharge. Puzos strongly opposed this practice, and it is now very properly given up as a general rule. I do not wish, however, to-be understood as altogether forbidding manual assistance; but I am much inclined to consider it a useful precept, not to be hasty in attempting to extract the ovum. If the discharge be protracted, and the membranes entire, we may, if the situation 292 of the patient require it, sometimes accelerate expulsion, by eva- cuating the liquor amnii. But if the pregnancy be not advanced beyond die fourth month, it will be better to trust to smart clys- ters, and restrain the hemorrhage by means of the plug. We thus have a greater likelihood of getting all the ovum off at once, and may excite the action by gently dilating the os uteri, and moving the finger round it. If the membranes have given way, and the fcetus be still retained, we may, by insinuating a finger within the uterus cautiously, hook it out; or, in many cases, it will be found partly expelled through the os uteri, and may easily be helped away. But the most tedious and troublesome case generally is tiiat in which the foetus has been expelled, but the secundines are still retained, under one of two circumstances, namely, either they are only partially detached, and still adherent to a certain extent, or there is a circular and spasmodic contraction of the uterine fibres around a portion of them; a state which may occur even before the foetus itself be expelled. Now, we never can consider the pa- tient as secure from hemorrhage until these be thrown off, and therefore she must be carefully watched, especially when gestation is considerably advanced. In a great majority of instances, the uterus, within a few hours, contracts and expels them. But in some cases, the hemorrhage does become profuse, and there is little disposition to throw them off. By stuffing the vagina, we shall often find that the discharge is safely stopped, and the womb excited to act in a short time; or a warm saline clyster is to be given, of such strength as shall briskly stimulate the rectum, and excite sympathetically the uterus. But if we be disappointed, or the symptoms urgent, the finger must be introduced within the uterus,* and the remains of the ovum slowly detached by very gentle motion; and we must be very careful not to endeavour to pull away the secundines until they be fully loosened, for we thus leave part behind, which sometimes gives a great deal of trouble; and further, if we rashly endeavour to extract, we irritate the ute- rus, and are apt to excite inflammation, or a train of hysterical, * In some instances the half of the secundines will be found in the vagina, and the other half still in the uterus. In this case, all that is necessary is gently to bring them out. 293 and sometimes fatal symptoms. It is these two circumstances which make me cautious in advising manual assistance; and, for- tunately, the proportion of cases requiring it is not great in abor- tion at an early period. When there is retention of the secundines, with repeated or continued discharge, and frequent but useless pains, with feeling of sickness or sinking, we may suspect that part of the uterus is contracting spasmodically round the upper portion of the placenta, whilst all the rest is detached. This state of the womb, known under the name of the hour-glass contraction, is fre- quent after delivery at the full time; but it is perhaps scarcely less so after abortion, and may be met with even at a very early pe- riod, and most probably is the cause of every obstinate, and espe- cially every fatal, case. If a smart clyster do not excite re- gular and efficient contraction, it is necessary to introduce the hand into the vagina, and with one or more fingers remove the secundines, and excite the womb to proper action. The part of the placenta retained in the upper division by the constriction, is sometimes not larger than a walnut, although the patient be three or four months pregnant. When part of the ovum is left, or the whole of the secundines are retained, for a considerable time, we have another danger be- sides hemorrhage; for, within a few days, putrefaction comes on, and much irritation is given to the system, until the foetid sub- stance be expelled. Sometimes, if gestation have not been far ad- vanced, or the piece which is left be not very large, it continues to come away in small bits for many months; and during the whole time, the woman is languid, hysterical, and subject to irre- gularities of the menstrua, very often to obstruction. But more frequendy the symptoms are very acute ; we have loss of appetite, prostration of strength, tumid or tender belly, frequent, small, and sharp pulse, hot and parched state of the skin of the hands and feet, nocturnal sweats, and various hysterical symptoms. The discharge from the vagina is abominably foetid, and hemorrhage sometimes occurs to a violent degree. The treatment of this will hereafter be pointed out. From these observations we may see, upon the one hand, the 294 impropriety of allowing the secundines to remain too long in the uterus; and, on the other, the danger of making rash or unnecessa- ry attempts to extract, by which we irritate the uterus, and tear the placenta, which is almost always productive of troublesome conse- quences. The mechanical removal of the placenta is effected with least trouble and smallest irritation, in those cases in which it is most required, namely, where it is entirely or nearly detached, but still retained by a spasmodic contraction round the upper part, whilst in those where there is adhesion, there is generally less oc- casion to interfere, in the way of extraction, on account of the se- verity of the hemorrhage. I now return to the consideration of the usual progress of abortion. The stomach very soon suffers, and becomes debilitated, producing a general languor and feeble- ness, with a disposition to faint, which seems in abortion, to de- pend more upon this cause than directly upon loss of blood. In- deed, the hemorrhage produces both slighter and less permanent effects in abortion than at the full time, although less blood may have been lost in the latter, than in the former case, for the ves- sels are smallar and the discharge is not so sudden. There is still another cause for this ; namely, that the action of the uterus is less in the early than in the late months. Now, we know that the ef- fect of hemorrhage from any organ is, cceteris paribus, in propor- tion to its degree of action. Hence the discharge is less dangerous than at the full time, and still less in menorrhagia than in abortion. The effect of abortion on the stomach seems to be in propor- tion to the period at which it takes place, being greater when it occurs before the fourth month than after it. The effect, though distressing, and often productive of alarm, is nevertheless benefi- cial, lessening the action of the vessels in the same way with digi- talis, the use of which is improper when this condition is present. The strength of the pulse is much abated ; sometimes it becomes slower; but in general it remains much as formerly, in point of frequency; we are therefore not to be too anxious in removing this condition, which restrains hemorrhage ; yet as it may go be- yond due bounds and produce dangerous syncope, we must check it in time. We must likewise be very attentive to the state of the 295 discharge when this affection is considerable, for if, notwithstand- ing this, the hemorrhage should continue, it will produce greater and more immediately hurtful effects than if this were absent. The best method of abating this sinking and feebleness, is to keep the body perfectly at rest, and the head low. If necessary, we give small quantities of stomachic cordials, such as a little tinc- ture of cinnamon, or a few drops of ether in a glass of aerated wa- ter ; or we may give a little peppermint water, with fifteen drops of tincture of opium. In urgent cases, Madeira wine or undiluted brandy may be given ; but these are not to be frequently repeated, and are very rarely necessary. Large doses of opitim are also useful. Sometimes, instead of a feeling of sinking and faintness, the fibres of the stomach are thrown into a spasmodic contraction, pro- ducing sudden and violent pain. This is a most alarming symp- tom, and may kill the patient very unexpectedly. It is to be in- stantly attacked by a mixture of sulphuric ether and tincture of opium, in a full dose, whilst a sinapism is applied to the epigastric region; but if, when this pain occurs, there be symptoms of ap- proaching convulsions, then bleeding should precede the anodyne, and no ether should be given. Spasms about the intestines are more frequent, and much less dangerous. They are very readily relieved by thirty drops of tincture of opium, in a dessert-spoonful of aromatic tincture, or forty drops of the tincture of hyoscyamus in two tea-spoonfuls of the compound tincture of lavender. These disagreeable symptoms which I have described, fortu- nately do not often attend abortion; but the process goes on safely, and without disturbance. In this case, after it is over, we only find it necessary to confine the person to bed for a few days, as getting up too soon is apt to produce debilitating discharge. We must also, by proper treatment, remove any morbid symptoms which may be present, but which, depending on the peculiarities of individuals, or their previous state of health, cannot here be specified. When the patient continues weakly, the use of the cold bath, and sometimes of bark, will be of much service in restoring 296 die strength; and, in future pregnancies, great care must be taken that abortion may not happen again at the same period. § 37. UTERINE HEMORRHAGE. Of all the incidents to which a pregnant woman is exposed, none is more alarming or troublesome than uterine hemorrhage, when it occurs in the advanced stages of gestation, or after the delivery of the child. This, from its extent and impetuosity, has aptly been called a flooding; and, from the frequency of its occur- rence, it must be extremely interesting to every practitioner. The ovum is connected to the uterus by means of a vast multi- tude of delicate vessels, which pass almost at every point from the one to the other. These vessels are large where the placenta is attached; smaller where they pass into the decidua. As the ovum corresponds exactly to the inner surface of the ute- rus, and is in close and intimate contact with it, we find that as long as this union subsists, the vessels, notwithstanding their delicacy, are enabled to transmit blood without effusion. But whenever a separation of the one from the other takes place, then these vessels are either directly torn ; or, even supposing them to extend a little, they must be ruptured by their own action, or by the force of the blood which they receive and circulate. When this happens, an extravasation or discharge must be the consequence, which will be greater or smaller in proportion to the number and magnitude of the vessels which have given way, and the strength of the action, which exists in the sanguiferous system. The membranes are never so full of water as to be put upon the stretch, and therefore they cannot forcibly distend the womb, and make pressure on its inner surface. The womb again, during ges- tation, does not embrace the membranes tightly, so as to compress them. Hence it is evident, that when rupture first takes place, no resistance can, by the action of the one upon the other, be afforded to the flow of the blood. The consequence of uterine hemorrhage when considerable, is, that the force of the circulation is diminish- ed ; faintness, or absolute syncope, being induced. The blood in 297 this state flows more feebly; coagulation is allowed to take place* and the paroxysm is, for the present, ended. This coagulation, in slight cases, may take place even without the intervention of faintness. Re-union, however, when the separation is extensive, and the coagulum considerable, cannot be expected to take place; and, therefore, when the clot loosens, a return of the hemorrhage ^ is in general to be looked for. One or more copious discharges of blood must injure the functions of the uterus, and ultimately destroy, altogether, tne ac- tion of gestation. This tends to excite the muscular action of the uterine fibres; and, by their contraction, two effects will be pro- duced. The uterine vessels will be diminished in their diameter or capacity, and the whole surface of the womb pressing more strongly upon the ovum, a greater resistance will be given to the flow of the blood. Thus it appears, that nature attempts to save the patient in two ways. First, by die induction of a state of faintness, or sometimes of complete syncope, which tends to check the present attack. Secondly, when the hemorrhage is so great or obstinate as to pre- vent any possibility of the woman going safely to the full time, such effects are produced as tend to establish muscular contraction, and accelerate expulsion. This double process ought, in all our reasonings, to be held in view. Uterine contraction is of two kinds, which may be called per- manent and temporary. The permanent, is that continued action of the individual fibres by which the uterus is rendered tense, so that it feels hard if the hand be introduced into its cavity. The temporary, is that greater contraction which is excited at intervals for die expulsion of the foetus, producing what are called the pains 9 of labour. In those cases where nature effects a cure by expulsion, or the production of labour, it is chiefly to the permanent or tonic con- traction that we are indebted for the stoppage of hemorrhage ; be- cause this contraction lessens the size of the vessels, and keeps up a firm pressure of the uterine surface upon the ovum, until the pains have accomplished the expulsion or delivery of the child. The pains alone could not do this good ; for coming only at inter- 39 29'6 Vals, their effect would be fugacious. On the other hand, the permanent contraction would not be adequate to the purpose, with- out the pains, for these temporary paroxysms excite this action to a stronger degree, and by ultimately forcing down the child, ac- complish delivery before the powers of the uterus be worn out. Such are the steps by which the patient is naturally saved. But we are not to expect that these shall, in every instance, or in a majority of instances, take place at the proper time, or in the due degree. The debility and syncope may go too far; or the clots may not form in proper time, or may come away too soon, or too easily. The action of gestation may continue, notwithstanding die violence of the hemorrhage, thus preventing the accession of muscular contraction; or before this contraction be established and the child expelled, the discharge may have been so great and constant as to render the efforts of the womb weak and inefficient, and by still continuing, may destroy them altogether. These circumstances being considered, it will be evident, that although when the injury is small, and the discharge trifling, nature may permanently check it; or in more serious cases, may preserve the woman by the expulsion of the child; yet we cannot, with prudence, place our whole reliance on her unassisted opera- tions. There is also another circumstance relating to a particular spe- cies of flooding, which renders the accomplishment of a natural cure or escape still more doubtful. * This is, that the placenta is sometimes attached to the os uteri, which necessarily must pro- duce a hemorrhage whenever the cervix comes to be fully de- veloped, and the mouth to open. The vessels going to the placenta are much larger than those which enter the decidua; and therefore if part of the placenta be f detached, the quantity and velocity of the discharge must be greater, and the effects more to be dreaded, than when a part of the decidua alone is separated. If the placenta be fixed near the cervix uteri, and a part of it be detached, then the blood which is effused will separate the membranes down to the os uteri, and a profuse hemorrhage will appear. But sometimes, if it be fixed to the fundus uteri, the blood may be confined, especially if the sepa- 299 lion have been trifling, and a coagulum will be formed exterior to the membranes, the lower part of which will still adhere to the uterus; or if the central portion of the placenta have been de- tached, a collection of blood may be formed behind it, but may not extend beyond its circular margin. But if the placenta be placed over the os uteri, then the case is different; profuse dis- charge will take place, sinking the whole system, and very much enfeebling the uterus itself, so that when uterine contraction does come on, it will be weak, and incapable of speedily effecting ex- pulsion ; even although the contraction should be brisk and pow- erful, it cannot, owing to the structure of the placenta, do the same good as in other cases of flooding; and therefore, in every in- stance, much blood will be lost, and in many, in very many, the patient, if we trust to this contraction alone, will perish. Contrac- tion can only be expected in this case to do good, when it is pow- erful, and the pains come on so briskly as speedily to empty the uterus, at the same time that coagula shut the mouths of the pla- cental vessels at the unsupported part. It has been a common opinion, that flooding proceeded always from the detachment of a part of the placenta; but this point is not established.* In several cases of uterine hemorrhage, the placenta will be found attached to the fundus uteri; and we cannot suppose that in all of diese, the whole extent of the membranes, from the placenta to the os uteri, has been separated: yet this must happen before the discharge can in these circumstances appear. We can often account for the hemorrhage, by supposing a portion of the de- cidua to be detached; and we know that the vessels about the cer- vix are sufficiently able to throw out a considerable quantity of blood, if their mouths be open. But in most cases of profuse he- • Long ago, Andrea Pasta questioned the opinion, that flooding was always produced by separation of the placenta.—Vide Discorso del flusso di sangue, &c. We are not, however, to suppose, that hemorrhage does not proceed from de- tachment of the placenta in any instance when it is placed high up, but only that it is a rare occurrence. When the stream is rapid and profuse, we have every reason to suppose that part of the placenta is separated; but if we have occasion to deliver, it will generally be found, that it is placed close by the cervix uteri, or at least not very far from it. 300 tnorrhage, we shall find, that the placenta is attached near the os uteri, and more or less of it separated. It is possible for blood to be effused in consequence of detach- ment of part of the ovum, and yet it may not be discharged by the. os uteri * This detachment may be produced by fatigue, falls, blows, he. and the effusion is accompanied with dull internal pain at the spot where it takes place. This pain is something like colic, or like pain attending the approach of the menses. The part of the womb where the extravasation takes place, swells gradually, and the uterus in a short time feels larger. If the quantity be consider- able, the size increases, the uterus is firmer and tenser, as well as larger, the strength diminishes, and even faintings may come on. In course of time, weak slow pains are felt, but if the injury be great, these decline as the weakness increases. They may or may not be attended with the discharge of coagula from the os uteri. In such a case, it is evident, that nothing but delivery can save the mother. But if no bad effect be produced, and the separation is not extensive, the accident may not be discerned or suspected, at least till after the child is born, when often a great quantity of blood is evacuated without affecting the pulse or strength, which it would do, did it come recently from the vessels of the uterus. Let us next consider the causes giving rise to hemorrhage in va- rious degrees; and the first that I shall mention is external violence, producing a separation of part of the ovum. As the ovum and ute- rus correspond exactly to each other, and are, in the advanced stages of gestation, composed of pretty pliable materials, falls or blows do not produce laceration so frequently as might be sup- posed. In a majority of instances, the effect is produced chiefly by the operation on the vessels, their action being violently and suddenly excited, and rupture of their eoats thus produced. When the ovum is mechanically detached, the injury must have been con- siderable, and in general the foetus is destroyed. Fatigue or much exertion may injure the action of the uterus, and give rise to premature expulsion, which in this case is gene- * Vide Albinus Acad. Annot. lib. I. p. 58. Recueil Periodique, torn. ii. g, l£. and torn. iii. p.l. 301 rally attended with considerable discharge. Such exertions are likewise apt, by their effect on the circulation, to operate on the vessels passing to the ovum, and produce in them a greater degree of activity than they are capable of sustaining without rupture. It is, therefore, very properly laid down as a rule of practice, to forbid pregnant women to undergo much fatigue, or exert any great mus- cular action; and wherever this rule has been departed from, es- pecially by a patient of an irritable or of a plethoric habit, it be- hooves the practitioner to attend carefully to the first appearances of injury, or to the first symptoms of decay in the uterine action. Rest, and an opiate, will upon general principles be indicated, and when the circulation is affected, or we apprehend increased action about the uterine vessels, venesection must be premised, and the patient kept cool and tranquil. Violent straining at stool, or strong exertions of the abdominal muscles, made in lifting heavy bodies, or in stretching to a height, ©r frequent and continued stooping, may all, by compressing the womb, cause separation. For the greatest effect will be produced where the resistance is least, or the support smallest, which is at the under part of the uterus, and there rupture will be apt to take place. A preternatural degree of action in the vessels going to the pla- centa or decidua, must be dangerous, and likely to produce rupture and extravasation. This may either be connected with a general state of the vascular system, marked by plethora, or by arterial ir- ritation ; or it may be more immediately dependent on the state of the uterus itself. When the patient is plethoric, or when the action of the vascular system is increased, it is natural to suppose, that the effect will be greatest on those parts of the womb which are in the highest state of activity. These are chiefly two; the part to which the placen- ta is attached,for there the vessels are large and numerous; and the cervix and os uteri, because there the greatest changes are going forward. At one or other of these two places, rupture is most likely to take place, and it will happen still more readily if the placenta be attached at or near to the cervix. It may be excited either by too much blood circulating permanentiy in die system, or by a temporary increase of die strength and velocity of the circu- 302 lation, produced by passion, agitation, stimulants, he. A plethoric state is a frequent cause of hemorrhage in the young, the vigorous, and the active; the decidua is separated, and a considerable quan- tity of blood flows; perhaps the placenta is detached, and the he- morrhage is more alarming. In some cases, the rupture is preceded by spitting of blood, or*bleeding at the nose, and in these cases the lancet may be of much service. We sometimes find that extravasation is produced by an increas- ed action of the uterine vessels themselves, existing as a local dis- ease. In this case, the patient, for some time before the attack, feels a weight and uneasy sensation about the hypogastric region, with slight darting pains about the belly or back. These precur- sors have generally been ascribed to a different cause; namely, ri- gidity of the ligaments of the womb or of the fibres of the uterus itself. Spasmodic action about the os uteri, must produce a separation of the connecting vessels. The causes giving rise to this in the advanced period of gestation, are not always obvious, neither can we readily determine the precise cases in which this action excites flooding. We should expect that the discharge ought always to be preceded by pain, but we know that motion may take place in some instances about the os uteri without much sensation ; and, on the other hand, many cases of flooding, not dependent on mo- tion of the uterine fibres, are attended with uneasiness or irregu- lar pain about the abdomen. This spasmodic action is not unfre- quently produced by hanging pregnant animals. Whatever stops prematurely the action of gestation, may give rise to a greater or less degree of hemorrhage. For in this case, the development of the cervix takes place quickly, and the ovum must be separated. The quantity of the discharge* will depend upon the state of the circulation—the magnitude of the vessels which are torn—the contraction of the uterus—and the care which is taken of the patient. Hence it follows as a rule in every pre- * In those cases where the contraction becomes universal and effective, we have little discharge, and the patient is merely said to have a premature labour; but if the contraction be partial, and do not soon become effective, then we have considerable discharge, and the patient is said to have a flooding. 303 mature labour, more especially in its first stage, that we prevent all exertion, refrain from the use of stimulants, and confine the pa- tient to a recumbent posture. It sometimes happens, that effective contraction does not take place speedily after the action of gestation ceases, but a discharge appears. T.his may stop by the induction of syncope, or die for- mation of clots. The blood which is retained about the cervix and os uteri putrefying, produces a very offensive smell. Milk is se- creted as if delivery had taken place, and sometimes fever is ex- cited. In this state the patient may remain for some days, when the hemorrhage is renewed, and the patient may be lost if we do not interfere. Some undue state of action about the os uteri, removing or ceas- ing to form that jelly which naturally ought to be secreted there, rs another cause. This is generally productive of a discharge of watery fluid, tinged with blood ; and if the patient be not careful, pure blood may be thrown out in considerable quantity. It may even happen, that the hemorrhage, under certain circumstances, may prove fatal; and yet, upon dissection, no separation of the ovum be discover- ed, the discharge taking place from the vessels about the os uteri itself* In some instances where a portion of the placenta has been de- tached, I have observed, that near the separated part, die struc- ture of the placenta was morbid, being hard and gristly. In these cases, I could not detect any other cause of separation, and sup- pose diat by the accidental pressure of the child upon the indurat- ed part, the uterus may have been irritated. The insertion of the placenta over the os uteri,f may give rise to flooding in different ways. * Vide a case in point, by M. Hcinigke, in the first volume of Brewer's Bib- lioth. Germ. | So far as I have observed, uterine hemorrhage, when profuse, is produced most frequently by this cause; at least two-thirds of those cases requiring delive- ry, proceed, I think, from the presentation of the placenta ; and in the majority of the remaining third, it will be found attached near to the cervix. Most of those hemorrhages, which are.cured without delivery, proceed from the detachment of 304 The uterus and placenta may remain in contact until the term of natural labour, the one adapting itself to the other; but when- ever the os uteri begins to dilate, separation and consequent he- morrhage must take place. It is rare, however, for the accident to be postponed so long. In general, at an earlier period, in the eighth, or by the middle of the ninth month, we find that either the uterus and placenta no longer grow equally, in consequence of which the fibres about the os uteri are irritated to act; or so much blood as must necessarily, in this situation, circulate about the cer- vix uteri, interferes with its regular actions, and induces premature contraction of its fibres, with a consequent separation of the con- necting vessels. In order to ascertain whether the hemorrhage proceed from this cause, we ought, in every case to which we are called, carefully to examine our patient. The introduction of the finger is sometimes sufficient for this purpose, but frequently it may be necessary to carry the whole hand into the vagina. If the placenta present, we shall feel the lower part of the uterus thicker than usual, and the child cannot be so distincdy perceived to rest upon it. This is ascertained by pressing with the finger on the fore part of the cervix, betwixt the os uteri and bladder, and also a little to either side.* If the os uteri be a little open, then, by insinuating the finger, and carrying it through the small clots, we may readily ascertain whether the placenta or membranes present, by attending to the difference which exists betwixt them. But in diis examination, we must recollect, that only a small portion of the edge of the pla- centa may present, and this may not readily be felt at first. To conclude this part of the subject, I remark, in general, that hemorrhage from the uterus is not merely arterial, but also vein- the decidua alone, or of a very small portion of the placenta, which has been se- parated under circumstances favourable for firm coagulation. * When a large coagulum occupies the lower part of the uterus, we may be deceived if we trust to external feeling alone, without introducing the finger with- in the os uteri. If the uterus have its usual feel, and the child be felt distinctly through it, then we are sure that, however near the placenta may be to the os uteri, it'is not fixed exactly over it. 305 ous, and the orifices of these latter vessels are extremely large* Almost immediately after conception, the veins enlarge and dilate, contributing greatly to give to the uterus the doughy feel which it possesses. In the end of gestation the sinuses are of immense size, and their extremities so large that in many places they will admit the point of the finger. Now, as all the veins communicate more freely than the arteries, and, as they have in the uterus no valves, we can easily conceive the rapidity with which discharge will take place, and the necessity of encouraging coagulation, which checks veinous still more readily than arterial hemorrhage. In whatever way flooding is produced, it has a tendency to in- jure or disturb gestation, and to excite expulsion ; but these effects may be very slowly accomplished, and in a great many instances may not take place in time to save the patient or her child. Having already noticed those changes produced on the womb it- self by hemorrhage, and the danger of trusting to them for the re- covery of the patient, I will not recapitulate, but proceed very shortly to mention the effects produced on the system at large. During the continuance of the hemorrhage, or by the repetition of the paroxysms, if this be allowed to take place, certain altera- tions highly important are taking place. There is much less blood circulating than formerly; and this blood, when the hemorrhage has been frequently renewed, is less stimulating in its properties, and less capable of affording energy to the brain and nerves. The consequence of this is, that all the actions of the system must be performed more languidly, and with less strength. The body is much more irritable than formerly, and slight impressions produce greater effects. This gives rise to many hysterical, and sometimes even to convulsive affections. The stomach cannot so readily di- gest the food—the intestines become more, sluggish—the heart beats more feebly—the arteries act with little force—the muscular fibres contract weakly—the whole system descends in the scale of action, and must, if the expression be allowable, move in an infe- rior sphere. In this state, very slight additional injury will sink the system irreparably—very trifling causes will unhinge its ac- tions, and render them irregular. If the debility be carried to a degree farther, no care can recruit the system—no means can ie- 40 306 new the vigour of the uterus. We may stop the hemorrhage, but recovery will not take place. We may deliver the child, but the womb will not contract. If when the system is debilitated by he- morrhage, some irritation be conjoined, then the muscular action becomes more or less irregular, and an approximation is made to a state of fever. The pulse is feeble, but sharp; the skin rather warm; and the tongue more or less parched. This state of the vascular system is dangerous, both as it exhausts still more a frame already very feeble, and also as it tends to renew the hemorrhage. It will often be found to depend upon slight uterine irritation, upon accumulation in the bowels, upon pulmonic affections, upon mus- cular pain, or upon the injudicious application of stimuli. Such.,organs as have been previously disposed to disease, or have been direcdy or indirectly injured during the continuance of protracted flooding, may come to excite irritation, and give consi- derable trouble. An acute attack of hemorrhage generally leaves the patient in a state of simple weakness; but if the discharge be allowed to be frequently conjoined, and the case thus protracted, some irritation often comes to be produced, which adds to the danger, and excites, if the patient be not delivered, more speedy returns. A woman seldom suffers much in a first attack of hemorrhage. If she be stout and plethoric, she may lose a great quantity of blood, and yet, to appearance, not be greatly injured. The hemor- rhage may come on in every different situation; in bed she may awake suddenly from a dream, and feel herself swimming in blood; or it may attack her when walking; or may be pre- ceded by a desire to make water, and she is surprised to find the chamber-pot half filled with blood. She recovers from her consternation; perhaps in spite of every injunction, she walks about as usual, and finds no bad effect from motion; the feel- ing of heaviness which may have preceded the accident, is gone, she is lighter and better than she was before it, and hopes all is well; but in a few days the hemorrhage is repeated, and again stops; at last, after one or two attacks, for the time is uncertain, the os uteri become soft, and opens a little, perhaps without pain, or she feels dull slight pains, which, however, give her very little uneasiness. This state may take place early, and 307 Without dangerous debility; it may take place in the second or third attack; or, possibly, the hemorrhage may never have entirely ceased, continuing for a day or two like a flow of the menses, and then being suddenly increased, or flowing in a torrent. But, al- though this state may take place without alarming debility, it may also, and that very suddenly, be attended with the utmost danger, or may be accompanied with so much hemorrhage as to prove ab- solutely fatal. The patient is found without a drop of blood in her face, the extremities cold, the pulse almost gone, the stomach una- ble to retain drink. She is in the last stage of weakness, but it is not the weakness produced by fever or disease, for we find her voice good, and, generally, the intellect clear. The hemorrhage has, perhaps, stopped, and a young man would suppose it still possible for her to recover. But, although not a drop of blood is afterwards lost, the debility increases, the pulse is quite gone, she breathes with difficulty, and gives long sighs, wavers in her speech, and in a short time expires. We may lay it down as a general observation, that few cases of profuse hemorrhage, occurring in an advanced stage of gestation, can be cured without delivery or the expulsion of the child. For when the discharge is copious or obstinate, the placenta is gene- rally separated, sometimes to a very considerable extent, and a re- union, without which the woman can never be secure against another attack, can rarely be expected. If the placenta present, the hemorrhage, although suspended, will yet to a certainty return, and few shall survive if the child be not delivered. But in those cases where only a portion of the decidua, or a little bit of the margin of the placenta* has been detached, and the communicating vessels opened, either by a state of over-action in the vascular system, or by too much blood in the vessels, or by some mechanical exertion, if proper care be taken, the hemor- rhage may be completely and permanently, checked; or if it should return, it may be kept so much under, or may consist so much of the watery discharge from the glands about the os uteri, * In this case, after labour is over, we may discover the separated portion by the difference of colour ; it is generally browner and softer than the rest. 308. as neither to interfere with gestation, nor injure the constitution? yet it is to be recollected, that even these cases of flooding may sometimes proceed to a dangerous degree, requiring very active and decided means to be used; and in no case can the patient be considered as safe, unless the utmost care and attention be paid to her conduct. It would thus appear, that some hemorrhages almost inevitably end either in the delivery of the child, or the death of the parent; whilst others may be checked or moderated without an operation. A precise diagnostic line, liable to no exceptions, cannot be drawn betwixt these cases; and therefore, whilst we believe that rapid and profuse hemorrhages, which indicate the rupture of large ves- sels, can seldom be permanently checked, we still, provided the placenta do not present, are not altogether without hopes of that termination, which is more desirable for the mother, and safer for the child, than premature delivery. In slighter cases, our hope is joined with some degree of confidence. A second attack, especially if it follow soon after the first, and from a slight cause, or without any apparent cause, greatly dimin- ishes the chance of carrying the woman to a happy conclusion without manual interference. In forming our opinion respecting the immediate danger of the patient, we must consider her habit of body, and the previous state of her constitution. We must attend to the state of the pulse, con- necting that in our mind with the quantity and rapidity of the dis- charge. A feeble pulse, with a hemorrhage, moderate in regard to quantity and velocity, will, if the patient have been previously in good health, generally be found to depend on some cause, the con- tinuance of which is only temporary. But when the weakness of the pulse proceeds from profuse or repeated1 hemorrhage, then al- though it may sometimes be rendered still more feeble by oppres- sion, or feeling of sinking at the stomach; yet, when this is reliev- ed, it does not become firm. It is easily compressed, and easily affected by motion ; or, sometimes, even by raising the head. If the paroxysm is to prove fatal, the debility increases—the pulse flutters and becomes imperceptible—the extremities first, and then the whole body, become cold and clammy—the breath- 309 ing is performed with a sigh—she calls to be raised and bave die windows opened—is in constant motion, with great anxiety, per- haps vomits—and syncope closes the scene. If irritation be conjoined with hemorrhage, then the pulse is sharper, and, although death be near, it is felt more distinctly than when irritation is absent. The termination in this case is often more sudden than a person, unacquainted with the effect of pain and irritation on the pulse, would suppose. For when the pulsation is distinct, and even ap- parently somewhat firm, a slight increase of the discharge, or some- times an exertion without discharge, speedily stops it, the heat de- parts, and the patient never gets the better of the attack. We must likewise remember, that a discharge, which takes place gradually, can be better sustained than a smaller quantity, which flows more rapidly. For the vessels in the former case come to be accustomed to the change, and are able more easily to accom- modate themselves to the decreased quantity. But when blood is lost rapidly, then very speedy and universal contraction is required in the vascular system, in order that it may adjust itself to its contents, and diis is always a debilitating process. The difference too be- twixt the former and the present condition of the body, is rapidly produced, and has the same bad effect as if we were instantly to put a free liver upon a very low and abstemious diet. In all cases of flooding, we find, that during the paroxysm, the pulse flags, and the person becomes faint. Complete syncope may even take place ; but this in many cases is more dependent on sick- ness or oppression at the stomach, than on direct loss of blood. In delicate and irritable habits, the number of fainting fits may be great, but unless the patient be much exhausted, we generally find that the pulse returns* and the strength recruits. The prognosis here must depend greatly on the quantity and velocity of the dis- charge ; for it may happen, that the first attack of hemorrhage may produce a syncope, from which the patient is never to re- cover. When we are called to a patient recently attacked with flooding, our most obvious duty is immediately to restrain the violence of the discharge; after which we can take such measures as the 310 nature of die case may demand, either for preserving gestation, or for hastening the expulsion of the child. A state of absolute rest, in a horizontal posture, is to be enforced with great perseverance, as the first rule of practice. By rest alone, without any other assistance, some hemorrhages may be cured; but without it, no woman can be safe. Even after the immediate alarm of the attack is over, the woman must still recol- lect her danger. She should be confined to bed, upon a firm mattress for several days, and ought not to leave her apartment for a much longer period. In general, the patient has gone to bed before we are called ; and, perhaps, by the time that we arrive, the bleeding has in a great measure ceased. The partial unloading of the vessels, pro- duced by the rupture, the induction of a state approaching to syn- cope in consequence of the discharge, the fear of the patient, and a horizontal posture, may all have conspired to stop the hemor- rhage. The immediate alarm from the flooding having subsided, the pa- tient often expresses herself as more apprehensive of premature la- bour, than of the hemorrhage, which she considers as over. If the attack have been accompanied with slight abdominal pain, her fears are confirmed. But we are not to enter into these views of the case ; we are to consider the discharge as the prominent symptom, as the chief source of danger. We are to look upon the present abatement as an uncertain calm; and whatever advice we may give, whatever remedies we may employ, we are not to leave our patient until we have strongly enforced on her attendants the dan- ger of negligence, and the necessity of giving early intimation should the hemorrhage be renewed. There is no disease to which the practitioner can be called, in which he has greater responsibi- lity than in uterine hemorrhage. The most prompt and decided means must be used; the most patient attention must be bestowed; and, whenever he undertakes the management of a case of this kind, whatever be the situation of the patient, he must watch her with constancy, and forget all considerations of gain and trouble. His own reputation, his peace of mind, the life of his patient, and that of her child, are all at stake. I am doing the student the most 311 essential service, when I earnesdy press upon his attention these considerations. And when 1 intreat, implore him to weigh well the proper practice to be pursued, the necessary care to be be- stowed, I am pleading for the existence of his patient, and of his own honour and happiness. Procrastination, irresolution, or timi- dity, have hurried innumerable victims to the grave; whilst the rash precipitation of unfeeling men has only been less fatal, because negligence is more common than activity. I shall endeavour to point out the proper treatment in the com- mencement of uterine hemorrhage, and the best method of termi- nating the case when the patient cannot be conducted with safety to the full time. After the patient is laid in bed, it is next to be considered how the hemorrhage is to be directly restrained, and whether we may be able to prevent a return. It is at all times pro- per to ascertain exactly the situation of the patient by examination, as we thus learn the state of the cervix and os uteri, and whether there be any tendency to labour; whether the discharge be stopped by a coagulum in the mouths of the vessels,* or by a large clot in the upper part of the vagina; whether the placenta be attached to the os uteri, or whether the membranes present. We likewise en- deavour to ascertain the quantity of blood which has been lost— the rapidity with which it flowed—the effect which it has produced upon the mother or child—and the cause which appeared to excite the hemorrhage. The first remedy which, upon a general principle, offers itself to our attention, is blood-letting. In those cases, where the attack has been produced by over-action of the vessels, or a plethoric condi- tion ; or where it seems to be kept up by these causes, this remedy employed early, and followed by other means, may be effectual not only in checking the present paroxysm, but also in preventing a re- turn. By the timely and decided use of the lancet, much distress may be avoided, and both the mother and the child may be saved from * We may conjecture that this is the case, if we find no clot in the vagina plugging the os uteri. We are not warranted to thrust the finger forcibly within the os uteri, in this examination ; or to rub away the small coagula which mav be formed within it, and which may be restraining the.hemorrhage. 312 danger. But we are not to apply the remedy for one state to eveiy condition; we must have regard to the cause, and consider how far the hemorrhage is kept up by plenitude or morbid activity of the vessels. In those cases where the attack is not excited by, or con- nected with, plethora, or undue action in the vascular system, ve- nesection is not indicated. We have in these cases, which are, I believe, by far the most numerous, other means of safely, and pow- erfully moderating vascular action, without the detraction of blood, which, in this disease, it ought to be a leading principle to save as much as possible; and it must be impressed on the student,"that venesection is rarely required in the disease in question. Whatever lessens materially or suddenly the quantity of blood, must directly enfeeble, and call for a new supply, otherwise the system suffers for a long time. We shall find, that except under those particular circumstances which I have specified, and where we have ground to believe that the rupture of vessels has been dependent on their plenitude or over-action, the circulation may be speedily moderated by other means, and especially by the application of cold. This is to be made not only by applying cloths dipped in cold water to the back and vulva, but also by sponging over the legs, arms, and even the trunk, with any cold fluid; covering the patient only very lightly with clothes, and promoting a free circulation of cold air, until the effect upon the vessels be produced. After this we shall find no advantage, but rather harm from the further application of cold. All that is now necessary, is strictly and constantly to watch against the application of heat, that is, raising the temperature above the natural standard. The extent to which this cooling plan is to be carried, must de- pend upon circumstances. In a first attack, it is in general to be used in all its vigour; but where the discharge, either towards the end of this attack, or in a subsequent paroxysm, has gone so far as to reduce the heat much below the natural standard, the vigorous application of cold might sink the system too much. In some urgent cases it may even be necessary to depart from our general rule, and apply warm cloths to the hands, feet, and stomach. This is the case where the discharge has been excessive, and been suf- 313 fered to continue profuse or for a long time, and where we are afraid that the system is sinking fast, and the powers of life giving way. There are cases in which some nicety is required in deter- mining this point, and in these circumstances we must never leave our patient, but must watch the effects of our practice. This is a general rule in all hemorrhages, whatever their cause may have been, or from whatever vessel the blood may come. A cold skin and a feeble pulse never can require the positive and vigorous ap- plication of cold; but on the other hand, they do not indicate the application of heat, unless they be increasing, and the strength de- clining. Then we cautiously use heat to preserve what remains, not rashly and speedily to increase action beyond the present state of power. When an artery is divided, it is now the practice to trust for a cure of the hemorrhage to compression, applied by a ligature. We cannot, however, apply pressure directly and mechanically to the uterine vessels, but we can promote coagulation, which has the same immediate effect. Rest and cold are favourable to this process, but ought only in slight cases to be trusted to alone. In this country it has been the practice to depend very much upon the application to the back or vulva, of cloths dipped in a cold fluid, generally water, or vinegar and water; but these are not always effectual, and sometimes, from the state of the patient, are not admissible. Astringent injections are seldom of benefit in any discharge which deserves the name of hemorrhage. They com- monly do good in a stillicidium, rather troublesome from its du- ration, than hazardous from its extent. In urgent cases they are hurtful, by washing away coagula. Plugging the vagina with a soft handkerchief,* answers every * The insertion of a small piece of ice in the first fold of the napkin, is attend. ed with great advantage, and has often a very powerful effect. Dr. Hoffman employed the introduction of lint, dipped in solution of vitriol, but this was rather as an astringent than a plug, and he does not propose it as a general prac- | tice. He considers, that he was obliged to have recourse ad anceps et extremum \ auxilium.—Vide Opera Omnia, T. IV. Leroux employed the plug more freely. —Vide Observations sur les Pertes, 1776. Some modern writers hold it in httle » estimation; and Gardien says, that when the placenta is attached over the os uteri it is injurious, by exciting the uterus to dilate the mouth. T. II. p. 404. 4L 314 purpose which can be expected from them ; and whenever a dis- charge takes place to such a degree as to be called a flooding, or lasts beyond a very short time, this ought to be resorted to. The advantage is so great and speedy, that I am surprised that it ever should be neglected. I grant that some women may, from deli- cacy or other motives, be averse from it; but every consideration must yield to that of safety : and it should be impressed deeply on the mind of the patient, as well as of the practitioner, that blood is most precious, and not a drop should be spilled which can be preserved. Unless the flooding shall in the first attack be perma- nently checked, which, when the separated vessels are large or numerous, is rarely accomplished, we may expect one or more re- turns before expulsion can be accomplished. The more blood, then, that we allow to be lost at first, the less able shall the patient be to support the course of the disease, and the more unfavourable Shall delivery, when it comes to be performed, prove to her and to the child. It is of consequence to shorten the paroxysm as much as possible; and therefore, when circumstances will permit, we should make it a rule to have from the first a careful nurse, who may be instructed in our absence to use the napkin without delay, should the hemorrhage return. But whilst I so highly commend, and so strongly urge the use of the plug, I do not wish to recommend it to the neglect of other means, or in every situation. In the early attacks of he- morrhage, when the os uteri is firm, and manual interference is improper, I know of no method more safe or more effectual for re- straining the hemorrhage and preserving the patient. But when the hemorrhage has been profuse, or frequently repeated, and the cir- cumstances of the patient demand more active practice, and point out the necessity of delivery, then the use of the plug cannot be proper. If trusted to, it may be attended with fatal and deceitful effects. We can indeed restrain the hemorrhage from appearing outwardly ; but there have been instances, and these instances ought to be constantly remembered, where the blood has collect- ed within the uterus, which, having lost all power, has become re- laxed, and been slowly enlarged with coagula; the strength has 315 decreased—the bowels become inflated—the belly swelled beyond its size in the ninth month, although the patient may not have been near that period ; and in these circumstances, whilst an inattentive practitioner has perhaps concluded that all was well with regard to the hemorrhage, the patient has expired, or only lived long enough to permit the child to be extracted. All practical writers warn us against internal flooding; hay, so far do some carry their apprehension, that they advise us to raise the head of the child, and observe whether Mood or liquor amnii be discharged ;* an ad- vice, however, to which I cannot subscribe, because in those cases where the membranes have given way, or been opened, the head cannot be thus moveable, nor these trials made, unless we have waited until a dangerous relaxation has taken place in the uterine fibres ; and if, on the other hand, we have delivery in contempla- tion, it is our object to confine the liquor amnii as much as possi- ble, until we turn the child. Blood may also collect in the upper part of the vagina, to a dangerous quantity, when the plug has been trusted to, too late. Besides using these means, it will also, especially in a first at- tack, and where we hive it not in contemplation to deliver the wo- man, be proper to exhibit an op\ate,(d) in order to allay irritation; and this is often attended with a very happy effect. On this subject long experience enables me to speak with decision, and to recom- mend, in every instance where the hemorrhage does not depend on plethora, the exhibition of a full dose of laudanum, which tran- quilises the patient, allays irritation, and checks, for the time, the discharge. Such are the most effectual methods of speedily or immediately stopping the violence of the hemorrhage. The next points for consideration are, whether we can expect to carry the patient • Vide Dr. Johnson's System of Midwifery, p. 157. and Dr. Leake's Diseases of Women, Vol. 11. p. 280. (rf) In the exhibition of opiates in uterine hemorrhagies generally, we would advise their combination with ipecacuanha, in the proportion of half a grain of the^ latter to about two grains of opium ; to be repeated more or less frequently, according to the circumstances of the case. Vide Barton's Edit, of Cullen's Mat. Med. Vol. ii. p. 334, and Chapman's Edit, of Burns. 316 safely to the full time, and by what means we are to prevent a re- newal of the discharge. It may, I believe, be laid down as a general rule, that when b considerable portion of the decidua has in the seventh month, or later, been separated, the hemorrhage, although it may be checked, is apt to return. When a part of the placenta has been detached, and more especially if that organ be fixed over the os uteri, ges- tation cannot continue long; for either such injury is done to the nterus as produces expulsion and a natural cure, or the woman bleeds to death, or we must deliver, in order to prevent that dread- ful termination. If the discharge be in small quantity, and have not flowed with much rapidity—if it stop soon or easily—if no large clots are formed in the vagina—if the under part of the uterus has its usual feel, showing that the placenta is not attached there, and that no large coagula are retained within the os uteri—if the child be still alive—if there be no indication of the accession of labour—and if the slight discharge which is still coming away be chiefly watery, we may, in these circumstances, conclude, that the vessels which have given way are not very large, and have some reason to ex- pect, that by care and prudent conduct, the full period of gestation may be accomplished. It is difficult to say, whether, in this event the uterus forms new vessels to supply the place of those which have been torn, and whether re-union be effected by the incorpo- ration of those with corresponding vessels from the chorion. In the early months we know that re-union may take place; but when, in the advanced period of pregnancy, the decidua has be- come very thin, soft, and almost gelatinous, it is not established that the circulation may be renewed. At all events, we know that the power of recovery or reparation is very limited, and can only be exerted when the injury is not extensive. The means for pro- moting re-union of the uterus and decidua, are the same with those which we employ for preventing a return of the hemorrhage; and these we advise, even when we have little hope of effecting re- union, and making the patient go to the full time, because it is our .object to prevent, as much as possible, the loss of blood. B17 Wben the placenta is partly separated, all the facts of which wc are in possession, are against the opinion that re-union can take place. If the spot be very trifling, and the vessels not large, we may have no return of the bleeding; a small coagulum may per- manently restrain it; but if the separation be greater, and the pla- centa attached low down, or over the os uteri, the patient cannot go to the full time, unless that be very near its completion. We judge of the case by the profusion and violence of the discharge; for all great hemorrhages proceed from the separation of the pla- centa; and by the feel of the lower part of the uterus,—by.the quantity of clots, and the obstinacy of the discharge, which may perhaps require even actual syncope to stop the paroxysm; a cir- cumstance indicating great danger. The best way by which we can prevent a return, is to moderate the circulation, and keep down die actions of the system to a pro- per level with the power. The propriety of attending to this rule will appear, if we consider, among other circumstances, that when a patient has had an attack of flooding, a surprise, or any agitation which can give a temporary acceleration to the circulation, will often renew the discharge. The action of the arteries depends very much upon that of the heart; and the action of this organ again is dependent on the blood. When much blood is lost, the heart is feebly excited to contraction, and in some cases it beats with no more force than is barely sufficient to empty itself. This evidently lessens the risk of a renewal of the bleeding; and in several cases, as, for example, in hemoptysis, we, by suddenly detracting a quantity of blood, speedily excite this state of the heart. Whatever tends to rouse the action of the heart, tends to renew hemorrhage; and if the proposition be established, that the rapidity with which the strength and action of the vessels are di- minished is much influenced by the rapidity with which a stimulus is withdrawn, the converse is also true; and we should find, were it practicable to restore the quantity of blood as quickly as it has been taken away, that the same effect would be produced on the action of the heart, as if a person had taken a liberal dose of wine. It has been the practice to give nourishing diet to restore the quantity of blood; but until the rup- 318 lured vessels be closed, or the tendency to hemorrhage stopped, this must be hurtful. It is our anxious wish to prevent the loss of blood; but it does not thence follow, that, when it is lost, we should wish rapidly to restore it. This is against every principle of sound pathology; but it is supported by die prejudices of those who do not reflect, or who are ignorant of the matter. When a person is reduced by flooding, even to a slight degree, taking much food into the stomach, gives considerable irritation; and if much blood be made, vascular action must be increased. What is it which stops the flow of blood, or prevents for a time its repe- tition ? Is it not diminished force of the circulation which cannot overcome the resistance given by the coagula ? Does not motion displace these coagula, and renew the bleeding? Does not wine increase for a time the force of the circulation, and again excite hemorrhage? Is it not conformable to every just reasoning, and to the experience of ages, that full diet is dangerous when vessels are opened? Do we not prohibit nourishing food and much speaking in hemorrhage from the lungs? And can nourishing diet and motion be proper in hemorrhage from the uterus? If it were possible to restore in one hour the blood which has been lost in a paroxysm of flooding, it is evident, that, unless the local condition of the parts were altered, the flooding would, at the end of that hour, be renewed. The diet should be light, mild, given in small quantity at a time, so as to produce little irritation;* and much fluid, which would soon fill the vessels, should be avoided. We shall do more good by avoiding every thing which can stimulate and raise action,-]- than * Such as animal jellies, sago, toasted bread, hard biscuit, 8tc. These articles, given at proper intervals, are sufficient to support the system without raising the action too much. f The system, with its power of action, may, for illustration, be compared to a man with his income. He who had formerly two hundred pounds per annum, but has now only one, must, in order to avoid bankruptcy, spend only one half of what he did before; and if he do so, although he has been obliged to live lower, yet his accounts will be square at the end of the year.—The same applies to the system. When its power is reduced, the degree of its action must also be re- duced ; and, by carefully proportioning the one to the other, we may often con- 319 by replenishing the system rapidly, and throwing rich nutriment into the stomach. It is, however, by no means my intention to say, that we must, during the whole remaining course of gestation, (provided that that go on, the attack having been permanendy cured) keep down the quantity of blood. I only mean that we are not rapidly to increase it. Even where the strength has been much impaired by the pro- fusion of the discharge, or the previous state of the system, it is rather by giving food so as to prevent further sinking, than by cram- ming the patient, that we promote recovery; and I beg it to be re- membered, that although I talk of the management of those who are much reduced, yet I am not to be understood as in any degree encouraging the practice of delay, and allowing the patient to come into this situation of debility; but when we find her already in this state, it is not by pouring cordials and nutriment profusely into the stomach, that we are to save her; it is by giving mild food, so as gradually to restore the quantity of blood and the strength; it is by avoiding the stimulating plan on the one hand, and the starving system on the other, that we are to carry her safely through the danger. Some medicines possess a great power over the blood vessels, and enable us, in hemorrhage, to cure our patient with less ex- pense of blood than we could otherwise do. Digitalis is of this class, and may be given for a short time, with advantage, in flood- ing, where the pulse indicates increased vascular action, and when we do not mean to proceed directly to delivery. But when the discharge has been trifling, and the pulse is slow, and perhaps fee- ble, digitalis is unnecessary even from the first, or may be hurtful; and if, in the progress of the disease, the stomach have become duct a paUent through a very great and continued degree of feebleness. At the same time, it must be observed, that as there is an income so small as not to be sufficient to procure the necessaries of life, so also may the vital energy be so much reduced, as to be inadequate to the performance of those actions which are essential to our existence, and death is the result. But surely he who should at- tempt to prevent this by stimulating the system, would only hasten the fatal ter- mination. Does not heat overpower and destroy those parts which have been frostbit ? 320 affected, and the patient is sick, inclined to vomit, or faintish, ol the pulse feeble and small, it is likewise improper. In those cases which demand it, when the pulse is sharp, and throbbing, and frequent, it may be given in the form of tincture. Two drachms may be added to a four-ounce mixture, and a table- spoonful given every two hours, watching the effect, and diminish- ing the dose when necessary. It ought seldom to be continued above two days, and sometimes all the benefit to be expected from it is derived in twenty-four hours.(e) At the same time that we thus endeavour to diminish the action of the vascular system, we must also be careful to remove, as far as we can, every irritation. I have already said all that is neces- sary with regard to heat, motion, and diet. The intestinal canal must also be attended to, and accumulation within it should be carefully prevented by the regular exhibition of laxatives. A cos- tive state is generally attended with a slow circulation in the veins belonging to the hepatic system, and of these the uterine sinuses form a part. If the arterial system be not proportionally checked, (e) Our author has here omitted to mention, the powerful effects of the ace- tate of lead in restraining uterine hemorrhage. The dose must depend upon the circumstances of the case, and the judgment of the practitioner. In a general way we may say, that two or three grains may be given at a time, and repeated more or less frequently according to the ur- gency of the symptoms. It should be combined with a portion of opium. Professor Barton, who has called the attention of American practitioners to this powerful article of the materia medica in restraining internal hemorrhage, recommends the combining with it a portion of ipecacuanha. For his opinion on this subject, we must refer the student to the Professor's edition of Cullen's Materia Medica, vol. ii. p. 20, 21, and 334. Other practitioners, among whom is Dr. Chapman, in these cases place considerable confidence in a combination of opium and ipecacuanha, in the proportion of two grains of the former to half a grain of the latter, to be repeated every two hours. From my own experience, I should be induced to decide in favour of the ace- tate of lead, when combined as above directed. Dr. Kuhn informed me that the late Dr. Glentworth of this city, placed the greatest reliance on yarrow-tea, or a strong decoction of yarrow (Achillea Mille- folium, L.) in uterine hemorrhage, and said that he never was disappointed in his expectations of a cure after the proper use of this article of the materia medica. Instances of its good effects in hemorrhagies are mentioned by several of the German physicians, particularly by Stahl and Hoffman. 321 this sluggish motion is apt, by retarding the free transmission along the ineseraic veins, to excite the hemorrhage again. Uneasiness about the bladder or rectum, or even in more distant parts, should be immediately checked ; for in many cases hemor-* rhage is renewed by these irritations. In those cases, or where the patient is troubled with cough, or affected with palpitation, or an hysterical state, much advantage may be derived from the exhibi- tion of opiates. In many instances, where an attack of flooding is brought on by some irritation affecting the lower part of die uterus in particular, or die system in general, or where the bowels are pained, and the pulse not full nor strong, rest, cool air, and an ade- quate dose of tincture of opium will terminate the paroxysm, and perhaps prevent a return. This is especially the case, if only a part of the decidua have been separated, and the discharge have not been profuse. When the vascular system is full, venesection is ne- cessary before the anodyne be administered, and die digitalis may either succeed the opiate or be omitted, according to the state eft the pulse and of the stomach. It may happen that we have not been called early in a first at- tack, and that some urgent symptom has appeared. The most fre- quent of these, is a feeling of faintness or complete syncope. This feeling often arises rather from an affection of the stomach than* from absolute loss of blood; and in this case it is less alarming than when it follows copious hemorrhage. In either case, however, we must not be too hasty in exhibiting cordials. When the faintish- ness depends chiefly upon sickness at the stomach, or feeling of failure, circumstances which may accompany even a small discharge, it will be sufficient to give a few drops of hartshorn in cold water, and sprinkle the face with cold water: a return is prevented by an anodyne draught, or opium pill. When it is more dependent on absolute loss of blood, we may find it necessary to give a full dose of opium or laudanum, with the addition of small quantities of wine warmed with aromatics; but the latter, even in this case, must not be given with a liberal hand, nor too frequently repeated.* It is * As syncope and loss of blood have both the effect of relaxing the muscular fibre, as re well known to surgeons, it ma\ be supposed that they should increase 42 322 scarcely necessary for me to add, that we are also to take immediate steps, by the use of the plug, he. for restraining the discharge. This I may observe once for a\\.(f) Complete syncope is extremely alarming to the bye-standers : and, if there have been a great loss of blood, it is indeed a most dangerous symptom. It must at all times be relieved, for although faintness be a natural mean of checking hemorrhage, yet absolute and prolonged syncope is hazardous. We must keep the patient at perfect rest, in a horizontal posture, with the head low, open the windows, sprinkle the face smartly with cold vinegar, apply volatile salts to the nostrils, and give sixty or eighty drops of laudanum in- ternally, and occasionally a spoonful of warm wine. Universal coldness is also a symptom which must not be allowed to go beyond a certain degree, and this degree must be greatly de- termined by the strength of the patient, and the quantity and rapi- dity of the discharge. When the strength is not previously much reduced, a moderate degree of coldness is, if the hemorrhage threaten to continue, of service; but when there has been a great loss of blood, then universal coldness, with pale lips, sunk eyes, and approaching deliquium, may too often be considered as a fore- runner of death. When we judge it necessary to interfere, we should apply warm cloths to the hands and feet, a bladder half filled with tepid water to the stomach, and give some hot wine and water inwardly. Vomiting is another symptom which sometimes appears. It proceeds very generally from the attendants having given more the flooding by diminishing the contraction of the uterus, if that have already taken place. But the contrary is the case, for by allowing coagula to form, syn- cope restrains hemorrhage, and therefore ought not to be too rapidly remov- ed, in a first attack, and before the os uteri has become dilatable. CfJ In restraining uterine hemorrhage, we should not forget that injections thrown up the vagina, and if possible into the uterus, may have a considerable effect in repressing the discharge. In this way 1 have known solutions of the ace- tate of lead, of the sulphate of alumine, and a strong decoction or infusion of galls, produce salutary effects. A solution of the acetate of lead in cold water, combined with laudanum, may also be thrown up by enema, as recommended by JJr. Dewees. 323 nourishment or fluid than the stomach can bear, or from a gush of blood taking place soon after the patient has had a drink. It in this case is commonly preceded by sickness and oppression, which are most distressing, and threaten syncope, until relief is obtained by vomiting. Sometimes it is rather connected with an hysterical state, or with uterine irritation. If frequently repeated, it is a de- bilitating operation, and by displacing clots may renew hemorrhage; but sometimes it seems fortunately to excite the contraction of the uterus, and gives it a disposition to empty itself. For abating vomiting, we may apply a cloth dipped in laudanum, and cam- phorated spirits of wine, to the whole epigastric region; or give two grains of solid opium, or even more, if the weakness be great. Sometimes a little infusion of capsicum is of service. It should just be gently pungent. In flooding it .is of importance to pay much attention to the state of the stomach, and prevent it from being loaded; on the other hand, we must not let it remain too empty, nor allow its action to sink. Small quantities of pleasant nourishment should be given frequently. We thus prevent it from losing its tone, without oppressing it, or filling the system too fast. Hysterical affections often accompany protracted floodings, such as globus, pain in the head, feeling of suffocation, palpitation,* retching, in which nothing but wind is got up, &,c. These are best relieved by some foetid or carminative substance conjoined with opium. The retching sometimes requires an anodyne clys- ter, or the application of a camphorated plasterf to the region of the stomach. After having made these observations on the management of flooding, and the best means of moderating its violence, of pre- venting a return, and of relieving those dangerous symptoms which * The quantity of brood lost is sometimes so great as to do irreparable injury to the heart, and ever after to impede its action. One well marked instance of this is related by Van Swieten, in his commentary on Aph. 1304, where for twelve years the woman, after a severe flooding, could not sit up in bed without violent palpitation and anxiety. ■j- This may be made by melting a little adhesive plaster, and then adding to it a large proportion of camphor, previously made into a thick liniment by rub- bing it with olive oil. 324 sometimes attend it, I next proceed to speak of the method of de- livering the patient when that is necessary. I have separated the detail of the medical treatment of a paroxysm from the considera- tion of the manual assistance, which may be required; because, however intimately connected the different parts of our plan may be, in actual practice, it is useful, in a work of this kind, in order. to avoid confusion, that I lay them down apart. As some peculiarities of practice arise from the implantation of the placenta over the os uteri, I shall confine my present remarks to those cases in which the membranes are found at the mouth of the womb, desiring it to be remembered, however, that this cir- cumstance does not necessarily indicate that the hemorrhage does not proceed from separation of the placenta, which may be fixed very near the cervix, although it cannot be felt. The operation of delivering the child is not difficult to describe or to perform. I am generally in the practice of giving, a quarter of an hour before I begin, fifty drops of tincture of opium, or if the patient be much reduced, I give even eighty. The hand, pre- viously lubricated, is then to be slowly and gently introduced com- pletely into the vagina. The finger is to be introduced into the Os uteri, and Cautiously moved so as to dilate it: or if it has al- ready dilated a little more, two fingers may be inserted, and very slow and gentle attempts made at short intervals to distend it; and the practitioner will do well to remember, that he will succeed best when he rather acts so as to stimulate the uterus and make it dilate its mouth, than forcibly to distend it. On the part of the Operator, is demanded much tenderness, caution, firmness, and composure; on the part of the patient is to be desired patience and resolution. The operator is to keep in mind, that painfjul di- lation is dangerous, it irritates and inflames the parts, and that the woman should complain rather of the uterine pains which are ex- Cited, than of the fingers of the practitioner. More or less time will be required fully to dilate the os uteri, according to the state in which the uterus was when the operation was begun. If the os uteri is soft and pliable, and has already, by slight pains, been m part distended, a quarter of an hour, or perhaps only a few minutes, will often be sufficient for this purpose; but if it has 325 scarcely been affected before by pains, and is pretty firm,-though not unyielding, then half an hour may be required. 1 speak in general terms, for no rule can be given applicable to every case. Not unfrequendy, although the patient have felt scarcely any pains, and certainly no regular pains, the os uteri will be found as large as a penny piece, and its margin soft and thin. The os uteri being sufficiently dilated, the membranes are to be ruptured, the hand introduced, the child slowly turned and delivered, as in foot- ling cases; endeavouring rather to have the child expelled by uterine contraction than brought away by the hand. Hasty ex- traction is dangerous, for the uterus will not contract after it. And, therefore, if when we are turning, we do not feel the uterus acting, we must move the hand a little, and not begin to deliver until we perceive that the womb is contracting. The delivery must be but slow until die breech is passing ; then we must be careful that the cord be not too long compressed before the rest of the child be born. The child being removed, and the belly properly sup- ported, and gently pressed on by an assistant, the hand should again be cautiously introduced into the womb, and the two knuckles placed on the surface of the placenta, so as to press it a little, and excite the uterus to separate it. The hand may also be gently moved in a little time, and the motion repeated at intervals, so as to excite the uterus to expel its contents; but upon no ac- count are we to separate the placenta and extract it. This must be done by the uterus: for we have no other sign that the con- traction will be sufficient to save the woman from future hemor- rhage. The whole process, from first to last, must be slow and deliberate, and we are never to lose sight of our object, which is to excite the expulsive power of the uterus. It is not merely to empty the uterus—it is not merely to deliver the child, that we introduce our hand: all this we may do, and leave the woman worse than if we had done nothing. The fibres must contract and press upon the vessels; and as nothing else can save the patient, it is essential that the practitioner have clear ideas of his object, and be convinced on what the security of the patient depends. But to teach the method of delivery, and say nothing of the cir- cumstances under which it is to be performed, would be a most 326 dangerous error. I have, in the beginning of this section, pointed out the effect of hemorrhage, both on the constitution and on the uterus; and I have stated, that the action of gestation is always im- paired by a certain loss of blood, and a tendency to expulsion brought on. But before the uterine contraction can be fully ex- cited, or become effective, the woman may perish, or the uterus be so enfeebled as to render expulsion impossible. Whilst then we look upon the one hand to the induction of contraction, we must not on the other delay too long. We must not witness many and repeated attacks of hemorrhage, sinking the strength, bleach- ing the lips and tongue, producing repeated fainting fits, and bring- ing life itself into immediate danger. Such delay is most inexcu- sable and dangerous ; it may end in the sudden loss of mother and child; it may enfeeble the uterus, and render it unable afterwards to contract; or it may so ruin the constitution, as to bring the pa- tient, after a long train of sufferings, to the grave. Are we then uniformly to deliver upon the first attack of flood- ing, and forcibly open the os uteri ? By no means : safety is not to be found either in rashness or procrastination. The treatment which I have pointed out, will always secure the patient until the delivery can be safely accomplished. As'long as the os uteri is firm and unyielding—as long as there is no tenden- cy to open, no attempt to establish contraction, it is perfectly safe to trust to the plug, rest, and cold. But I must particularly state to the reader, that the os uteri may dilate without regular pains ; and in almost every instance it does,' whetiier there be or be not pains, become dilatable. Did I not know the danger of establish- ing positive rules, I would say, that as long as the os uteri is firm, and has no disposition to open, the patient can be in little risk, if we understand the use of the plug; we may even plug the os uteri itself, which will excite contraction. But if the patient be neglected,-then I grant that long before a tendency to labour or contraction be induced, she may perish. I am not, however, con- sidering what may happen in the hands of a negligent practitioner, for of this there would be no end, but what ought to be the result of diligence and care. 327 It is evident, that when the uterus has a disposition to contract, and the os uteri to open, delivery must be much safer and easier than when it is still inert, and the os uteri hard. We may, with confidence, trust to the plug, until these desirable effects be produced; and in some instances, we shall find, that by the plug alone we may secure the patient: the contraction may become brisk, if we have prevented much loss of blood, and ex- pulsion may naturally take place. Who would, in those circum- stances, propose to turn die child, and deliver it ? Who would not prefer the operation of nature to that of the accoucheur ? To de- termine in any individual case whether this shall take place, or whether delivery must be resorted to, will require deliberation on the part of the practitioner. If he have used the plug early and effectually, and the pains have become brisk, he has good reason to expect natural expulsion ; and the labour must be conducted on the general principles of midwifery. But if the uterus have been enfeebled by loss of blood—if the pains are indefinite—if they have done little more than just open the os uteri, and have no dis- position to increase, then he is not justified in expecting that ex- pulsion shall be naturally and safely accomplished, and he ought to deliver. When he dilates the os uteri, he excites the uterine ac- tion, and feels the membranes become tense. But he must not trust to this, he must finish what he has begun. Thus it appears, that by the early and effective use of the plug, by filling the vagina with a soft napkin, or with tow, we may safely and readily restrain the hemorrhage, until such changes have taken place on the os uteri as to render delivery easy ; and then we ei- ther interfere or trust to natural expulsion, according to the brisk- ness and force of the contraction, and state of the patient. By this treatment, we obtain all the advantage that can be de- rived from the operations of nature; and, where these fail, are enabled to look with confidence to the aid of artificial delivery. But it may happen that we have not had an opportunity of re- straining the hemorrhage early ; we may not have seen the patient until she has suffered much from the bleeding.* In this case, wTe shall * We are not to confine our attention to the quantity which has been lost, but 328 generally be obliged to deliver, and must, upon no account, delay too long ; yet, if the os uteri be very firm, without disposition to open, and require hazardous force to dilate it, we shall generally find that the sinking is temporary: wTe may still trust for some time to the plug, and give opiates to support strength. Hemorrhage is naturally restrained by faintness. A repetition is checked in the same way; and faintness takes place sooner than formerly. In one or two attacks, the uterus suffers, and the os uteri becomes dilatable. Slight pains come on, or are readily ex- cited by attempts to distend the os uteri. Syncope then will, in general, even when the plug has not been used, and the patient has been neglected, restrain hemorrhage, and prevent it from prov- ing fatal until the os uteri has relaxed; but a little delay beyond that period will destroy the patient; and it is possible, by giving wine, and otherwise treating her injudiciously, to make hemor- rhage prove fatal, even before this takes place. But although I have considered it as a general rule, that where the os uteri is firm and' unyielding, we may, notwithstanding present alarm, trust some time to the plug, yet I beg it to be remembered, that there may be exceptions to this rule; for the constitution may be so delicate, and the hemorrhage so sudden, or so much increased by stimu- lants, as to induce a permanent effect, and make it highly desira- ble that delivery should be accomplished: but such instances are rare; and although I have spoken of the effects of syncope in re- straining hemorrhage, I hope it will not be imagined by the stu- dent that I wish to make him familiar with this symptom. It is very seldom safe, when we have our choice, to wait till syncope be induced ; and if it have occurred, it is not usually prudent ta run the risk of a second attack. The old practitioners, not aware of the value of the plug, nor acquainted with the sound principles of physiology, had no fixed rule relating to delivery, but endeavoured to empty the uterus ear- ly ; but it was uniformly a remark, that those women died who to the effect it has produced; and this will ceteris paribus be great in proportion as the hemorrhage has been sudden. 529 had the os uteri firm and hard.* What is this but to declare, that the rash and premature operation is fatal ? It is an axiom which should be deeply engraved on the memory of the accoucheur, and which should constandy influence his conduct. Pain and suffering are the immediate consequence of the practice; whilst a repetition of the flooding after delivery, or the accession of inflammation, are the messengers of death. It was the fatal consequence of this blind practice that suggested to M. Puzos the propriety of puncturing the membranes, and thus endeavouring to excite labour. His reasoning was ingenious; his proposal was a material improvement on the practice which then prevailed. The ease of the operation, and its occasional success, recommend it to our notice; but experience has now determined that it cannot be relied on, and that it may be dispensed with. If we use it early, and on the first attack, we do not know when the contraction may be established; for, even in a healthy uterus, when we use it on account of a deformed pelvis, it is sometimes several days before labour be produced. We cannot say what may take place in the interval. The uterus being slacker, the hemor- rhage is more apt to return, and we may be obliged, after all, to have recourse to other means, particularly to the plug. Now, we know that the plug will, without any other operation, safely re- strain hemorrhage, until the os uteri be in a proper state for deli- very .f The proposal of M. Puzos then is, I apprehend, inadmis- sible before this time. If, after this, there be occasion to interfere, it is evident that we must desire some interference which can be depended on, both with respect to time and degree. This method can be relied on in neither; for we know not how long it may be * Vide the Works of Mauriceau, Peu, &c. f The ingenious M. Alphonse Le Koy seems much inclined to trust almost entirely to the plug, and supposes that the blood will act as a foreign body, and excite contraction; but this, as a general doctrine, must be greatly qualified. Respecting the proposal of M. Puzos, he observes, " Puzos, en conseillant assez hardiment de Percer les eaux, n'avoit d'autres vues que la contraction de la ma- trice, qui est la suite de cette operation et la cessation de la perte, et il la con- seilla meme dans les cas des pertes qu'arrivent avant terme. Mais un grand nom- bre de femmes sont peries par l'effect de cette meme pratique." I.econs su? les pertes de sang, p. 45. 330 of exciting contraction, nor whether it may be able to excite effec- tive contraction after any lapse of time. If it fail, we render deli- very more painful, and consequently more dangerous to the mo- ther, and bring the child into hazard. It has been observed, in objection to this, by Dr. Denman,* that if turning be difficult, the flooding will be stopped by the contraction of the womb. But we know that the uterus, emptied of its water, may embrace die child so closely as to render turning, if not difficult, at least painful; and yet not be acting so briskly as to restrain flooding: nothing but brisk contraction can save a patient in flooding, if the vessels be large or numerous. Spasmodic action may also take place. The only case then which remains to be considered, is tiiat in which pains come on, and expulsion is going forward. Now, in this case, the flooding is stopped either by the contraction or by the plug, and the membranes burst in the natural course of labour; after which it is speedily concluded. Here, then, in- terference is not required; but if, after going on in a brisk way for some time, the pains abate a little, which often happens even in a natural labour, it will be proper to rupture the membranes, if we have reason to think that a slight stimulus to the uterus would renew its action : and in determining this, the practitioner must be influ- enced by the previous discharge; for if the uterus have been much reduced by it in its vigour, it will be less under the influence of a stimulus; and if, upon the present diminution of the pains, the flooding is disposed to return, I should think that we surely ought to trust rather to the hand, which can stimulate in the necessary degree, and finish the process with safety, than to a method which is much more uncertain and less under our command.^ The proposal of M. Puzos then will, if this reasoning be just, be * Introduction to the Practice of Midwifery, Vol. II. p. 310. •f In those cases where the placenta presents, few practitioners would think of trusting to the evacuation of the liquor amnii; they would deliver. If then de- livery be considered as safe and proper in one species of flooding, it cannot be dangerous in the other; and whenever interference in the way of operation is necessary, the security afforded by the introduction of the hand will much more than compensate for any additional pain. But even in this respect, the two ope rations are little different, if properly performed. 331 very limited in its utility. Its simplicity gave me at first a strong partiality in its favour ; but I soon found cause to alter my opinion. There still remains a most important question to be answered. In those cases where the patient has been allowed to lose a great deal of blood frequently and suddenly, when the strength is gone, the pulse scarcely to be felt, the extremities cold, the lips and tongue without blood, and the eye ghastly, shall we venture to de- liver the woman ? Shall we, by plugging, endeavour to prevent farther loss, and by nourishment and care recruit the strength ; or empty the uterus, and then endeavour to restore the loss ? We have only a choice of two dangers. The situation of the patient is most perilous, and I have in practice weighed the argument with that attention which the awful circumstances of the case required. I think myself justified in saying, that we give both mother and child the best chance of surviving by a cautious delivery. For in these cases the uterus is almost torpid, it possesses no tonic «.on- traction;* the very continuance of the ovum within it is more than it can bear. The general system is completely exhausted, and cannot support its condition long. I have never known a woman live twenty-four hours in these circumstances. On the other hand, I grant, that it is possible the woman may die in the act of delivery, or very soon after it; but if she can be sup- ported for two days, we may have hopes of recovery. By a very slow and cautious delivery, and by endeavouring thereafter, by re- taining the hand for some time in the womb, to excite its action, so as to prevent discharge afterwards, we not only remove the irri- tation of the distended womb, but we likewise take away a recep- tacle of blood. During the contraction of the uterus, the blood in its sinuses will be thrown into the system, and tend to support it. Part, no doubt, will escape; but by keeping the hand in the uterus, by supporting the abdomen with a compress, and exciting the ute- rine action by cold applications to the belly, we may prevent a great loss. When to these considerations we add the additional * The use of the plug cannot here certainly prevent the farther loss of blood, for the uterus affords no resistence, the hemorrhage continues, and after death large coagula will be found within the womb. 332 chance which the child has for life, our practice, I apprehend, will, in this \tery hazardous case, be decided. When the pulse becomes firmer and fuller upon the contraction of the uterus, the risk from debility is diminished. ANfulI dose of laudanum ought uniformly to be given previous to delivery, as I have formerly advised; and afterwards, forty drops of the same medicine are to be given at stated intervals, in order to support the strength. In the course of two days, several hundred drops may be given, without affecting the head, or producing stupor. If the stomach be irritable, solid opium may be given, or an opiate-clyster is to be administered. This practice does not rest on my own experience alone, but is corroborated also by that of Dr. Hamilton, the justly celebrated Professor of Midwifery in Edinburgh. Small quantities of light nourishment must also be given frequently, and a state of rest strictly enforced, in so much, that the patient, for some time after delivery, ought not even to be shifted, but only a firm bandage applied over the abdomen, in order to support the muscles and contained viscera; and this is a precaution which never ought to be omitted. At one time it was supposed that the placenta was, in every in- stance, attached originally to the fundus uteri, and that it could only be found presenting in consequence of having been loosened and falling down. This accident was supposed to retard the birth of the child, by stopping up the passage, and also was considered as dangerous on account of the flooding which attended it. On this account Daventer endeavoured to accelerate the delivery by tearing the placenta, or rupturing the membranes when they could be found. This was a dangerous practice, and very few survived when it was employed. Mr. Gifford and M. Levret* were among the first who established it as a rule that the placenta did not fall » Je m'engagfc a prouver lmo. que le placenta s'implante quelquefois sur la circonference de l'orifice de la matrice; c'est-a-dire, sur celui qui du col va join- dre l'interieur de ce viscere, et non sur celui qui regarde de la vagin. 2do. Qu'en ce cas la perte de sang est inevitable dans les dernier tems de la grossesse. Et 3tio. Qu'il n'y a pas de voye plus sure pour remedier a cet accident urgent que de fair l'accouchement force.—L'art des Accouchemens, p. 343. 333 down, but was, from the first, implanted over the os uteri: and the latter gentleman published a very concise and accurate view of the treatment to be pursued. We know, that, during the eighth month of gestation, very con- siderable changes take place about the cervix uteri. It is com- pletely developed and expanded; and in the ninth month, very little distance intervenes betwixt the ovum and the lips of the os uteri. These changes cannot easily take place without a rupture of some of the connecting vessels; for either the placenta does not adapt itself to the changes in the shape of the cervix, or, which happens more frequently, some slight mechanical cause, or action of the fibres about the os uteri, produces a rupture. This rupture may doubtless take place at any period of preg- nancy,* but it is much more frequent in the end of the eighth and beginning of the ninth month, than at any other time. But whe- ther the separation happens in the seventh, eighth, or ninth month, the consequent hemorrhage is always profuse, and the effects most alarming. The quantity, but especially the rapidity, of the dis- charge, very frequently produce a tendency to faint, or even com- plete syncope, during which the hemorrhage ceases, and the wo- man may continue for several days without experiencing a renew- al of it. In some instances she is able to sustain many and repeated attacks, which may take place daily for some weeks. These, however, it is evident, cannot be very severe, and the strength must originally have been great. In other instances, the woman never gets the better of the first attack. It, indeed, dimi- nishes, but does not altogether leave her, and a slight exertion re- news it in its former violence. But whether the patient suffer much or little in the first attack—whether she be feeble or robust, the practice must be prompt, and the most solemn call is made upon the practitioner for activity. The moment that a discharge of blood takes place, he ought to ascertain, by careful examina- tion, the precise nature of the case, and must take instant steps * In some cases, hemorrhage has taken place so early as the third month. By proper means this has been stopped, and the patient has continued well for some months, when the flooding has returned, and the placenta been discovered to present. 334 for checking it, if nature have not already accomplished that event. If the os uteri be firm and close in a first attack, we ought to use the plug, which will restrain the hemorrhage, and insure the pre- sent safety of the patient. If this practice have been immediately followed, she shall in general soon recover, and the length of time for which she shall remain free from a second attack will depend very much upon the care which is taken of her; but sooner or later the attack must and will return. If the uterus have been in- jured in its action by the first attack, this will generally be attended with very slight dull pains, and we shall feel the os uteri more open and laxer than usual; but if the first and second discharges have been prompdy checked, it may be later before these effects be per- ceived ; but the moment that they are produced, we ought to de- liver ; and it should even be a rule, that where they are not likely soon to take place, and the discharge has been profuse and rapid, and produced those effects on the system which I have already pointed out, as the consequence of dangerous hemorrhage, we must not delay until pains begin to open the os uteri. Fortunately, we are not often obliged to interfere thus early; for by careful manage- ment, and the use of the plug, we can secure our patient. Although I have said that we may wait safely until the os uteri begins to open, and asserted, that no woman can die from mere hemorrhage, before the state of the os uteri admit of delivery, I must yet add, on this important subject, that this state does not con- sist merely in dilatation, for it may be very little dilated, but in dilatability;(g) we may safely deliver whenever the hand can be introduced without much force. A forcible introduction of the hand fgj Rigby, a respectable surgeon of Norwich, in England, is entitled, as we believe, to the credit of first promulgating this distinction, which is of great im- portance to be attended to in practice; his words are, " We should be as much influenced (as respects the period of introducing the hand) by the os uteri being in a state capable of dilatation without violence, as by its being really open ; when this is the case, therefore, if the woman's situation demand speedy assistance, we should not hesitate to attempt delivery." His Essay on this subject, was published in the year 1777, and is in every respect a valuable work, rendered more so by the number of interesting cases appended to it. It has been repub- lished in this city, and is highly worthy of the perusal of every student and prac- 335 on the first attack of hemorrhage, would, in many cases, be attend- ed with the greatest danger, and in almost every case is improper and unnecessary. I have never yet seen an instance, where delivery was required during the first paroxysm, if the proper treatment was followed. Whether it may be required in a second or third attack, or even later, must depend upon the quantity and rapidity of the discharge, its effects, and the strength of the woman. But when- ever we find the os uteri softer, and in any degree more open than in its usual state before labour, admitting the finger to be intro- duced easily within it, we may deliver safely; and if the hemor- rhage be continuing, ought not to delay. This state will generally be found accompanied with obscure pains ; but we attend less to the degree of pain than of discharge, in determining on delivery. The pains gradually increase for a certain period, and then go off. During their continuance, the os uteri dilates more; but if the he- morrhage have been, or continues to be considerable, we must not wait until the os uteri be much dilated, as we thus reduce the wo- man to great danger, and diminish the chance of her recovery. A prudent practitioner will not, on the one hand, violently open up the os uteri at an early period, but will use the plug,* until the os uteri become soft and dilatable; and if the hemorrhage be not con- siderable, he will even, if the state of the patient allow him, wait until slight pains have appeared, or the os uteri begin sensibly to open without them; for he will recollect that the more violence that is done to the os uteri, the greater is the risk of bad symptoms supervening. It is an error into which some have fallen, who look upon debility from discharge as the only barrier to recovery. Vio- lent delivery may produce inflammation, or a very troublesome fever. On the other hand, he will not allow his patient to lose much blood, or have many attacks; he will deliver her immediately, for titioner of midwifery. Its title is, "An Essay on the Uterine Hemorrhage, which precedes the delivery of the full grown Fcetus : illustrated with cases by Edward Rigby, member of the Corporation of Surgeons in London." * Gardien thinks, that in such cases, the plug will do harm by exciting the ute- rus to detach more of the placenta, and thus increase the hemorrhage, T. ii. p. 404. 336 he knows that whenever this is necessary, it is easy, the os uteri yielding to his cautious endeavours. But very frequently we are not called until the patient have had one or two attacks; and been reduced to great danger. We find her with feeble pulse, ghastly countenance, frequent vomiting, and complaining occasionally of slight pains. On examination, the va- gina is so filled with clotted blood, adhering firmly by the lymph to the uterus, that at first we find some difficulty in discovering the os uteri. We cannot here hesitate a moment what course to follow. If the patient is to be saved, it is by delivery. The os uteri will be in part dilated; it may easily be fully opened. We perhaps find an edge of*the placenta projecting into the vagina, perhaps the centre of the placenta presenting or protruding like a cup into the vagina; but in those cases the rule is the same. We pass by the placenta to the membranes, rupture them,* and turn the child, de- livering according to the directions which I have already given, and treating the patient in all other respects in the exhibition of opiates and cordials and nourishment, and exciting the subsequent contrac- tion of the womb, as in the case formerly considered. It may be supposed, that as the treatment is so nearly the same, it is not material that we distinguish wrhether the placenta or mem- branes present. But it is convenient to make a distinction, be- cause in those cases where the placenta does not present, it is pos- sible, in certain circumstances, to cure the flooding, and carry the patient to the full time ; and in those cases, which are indeed the most numerous, where this cannot be done, we always look to ute- rine contraction as a very great assistance, and expect that where that is greatest, the danger will be least. But when the placenta presents, we have no hope of conducting the woman safely to the full time. We have no ground to look to contraction or labour pains as a mean of safety; for, on the contrary, every effort to di- late the os uteri separates still more the placenta, and increases the hemorrhage.! The very circumstance which in some other cases * This is much safer for the child than pushing the hand through the placenta; and it is equally advantageous for the mother, and easy to the operator. ■J-The greatest number of profuse or alarming hemorrhages proceed from the .presentation of the placenta, or the implantation of its margin over the os uteri ; 337 would save the patient, will here, in general, increase the danger. I say in general, for there are doubtless examples where the pati- ent has by labour been safely, and without assistance, delivered of the child, when part of the placenta has presented. Nay, there ha,ve been instances where the placenta has been expelled first, and the child after it.* These examples are to be met with in col- lections of cases by practical writers ; and some solitary instances are likewise to be found in different journals. It would be much to be lamented if these should ever appear without having, at the same time, a most solemn warning sent along with them to the ac- coucheur, to pay no attention to them in his practice-! I am con- vinced that they may do inexpressible mischief, by affording argu- ment for delay, and excusing the practitioner to himself for pro- crastination. There is scarcely any malady so very dreadful as not to afford some examples of a cure effected by the powers of nature alone; but ought we thence to tamper with the safety of those whose lives are committed to our charge ? Ought we to ne- glect the early and vigorous use of an approved remedy, because the patient has not in every instance perished from the negligence of the attendant ? It is highly proper to publish the case of a pati- ent who, from hernia, has had an anus formed at his groin, because it adds to our stock of knowledge : But what should we think of a surgeon who should put such a case into the hands of a young man without, at the same time, saying, " Sir, if such a case ever hap- pen in your practice, either you or your patient will be very much to blame.'7 I do not mean from this to say that we are to blame, in every instance, the accoucheur who has attended a case where the placenta has presented, and the patient been delivered by na- ture : far from it, for by the use of the plug, he may have restrain- ed the hemorrhage, pains may have come on, and the child, de- and consequently, the greatest number of cases requiring delivery are of this kind. • Even in those cases where the placenta is expelled first, the flooding may re- cur, and the woman die, if she be not assisted. Vide La Motte. Obs. ccxxxviii. and ccxxxix. f Most of those who have met with such cases, do not seem to count much upon them. 44 338 scending may have carried the plug before it: or when he was call- ed to his patient, he may have found her alrealy in labour, and the process going on so well and so safely, that all interference would have been injudicious. But these instances are not to be convert- ed into general rules, nor allowed to furnish any pretext for pro- crastination. They happen very seldom, and never ought to be related to a young man without an express intimation that he is not to neglect delivery, when it is required, upon any pretence whatsoever. % 38. FALSE PAINS. Many women are subject, in the end of gestation, to pains about the back or bowels, somewhat resembling those of labour, but which, in reality, are not connected with it. These, therefore, are called false pains. They sometimes only precede labour a few hours; but in many cases, they come on several days, or even some weeks, before the end of pregnancy, and may be very fre- quently repeated, especially during the night, depriving the woman of sleep. They are often confined altogether to the belly, shifting their place, and being very irregular both in their attacks and con- tinuance. In some cases they affect the side, particularly the right side, in the region of the liver, and are exceedingly severe, espe- cially in the evening ; they are accompanied with acidity or wa- ter-brash, or retching, and generally the child is at that time very resdess. These pains may doubtless occur in any habit, but they most frequently harass those who are addicted to the use of cor- dials. On other occasions, the false pains occupy chiefly the back or hips, or upper part of the thighs. They even sometimes re- semble still more nearly parturient pains, in being attended with an involuntary effort on the part of the abdominal muscles, to press down, so as to make the woman suppose that she is about to be delivered ; and this is occasionally accompanied with tenesmus or with protrusion of the bladder from the vagina, very like the membranes of the ovum. In other cases, they are attended with a discharge of watery fluid from the vagina. False pains may be occasioned by many cause's: the most frequent are flatulence • a 339 spasmodic state of the bowels, resembling slight colic; or irrita8- tion, connected with costiveness or diarrhoea; or nephritic affec- tions, often accompanied with strangury. A sudden motion of the back, or unusual degree of fatigue, may cause a remitting pain in the back and loins ; or getting suddenly out of bed when warm, and placing the feet on the cold floor, may have the same effect. A slight degree of lumbago may also resemble the parturient pains. Agitation of mind, or a febrile state of the body, or some irri- tation in the neighbourhood of the uterus, or some unusual motion of the child, may produce an uneasy sensation in the uterus ; and sometimes this is accompanied by a discharge of watery fluid from the vagina. Other uterine irritations may excite painful action in the uterus itself, or sympathetically in other parts, as the intestines or muscles of the abdomen. Amongst these irritations may be mentioned that which sometimes attends the full development of the cervix in the last weeks of gestation, or the expansion of the portion immediately adjoining the os uteri. False pains may often be distinguished by their situation; as for instance, when they affect the bowels or kidneys; by their shifting their situation; by their duration; by their irregularities ; and by the symptoms with which they are attended. But the best criterion is, that they are not attended with any alteration in the uterine fibres, which, during true or efficient labour pains, contract so as to render the uterus more compact, and make it feel harder when the hand is placed over it on the abdomen. They also sel- dom affect the os uteri, that part not being dilated during their con- tinuance. It is necessary however, to observe, that a dilated state of the os uteri does not always prove that the pains are those of la- bour ; for it may be found prematurely dilated, to a slight degree, before the proper term of labour, without any pain. In this case, if the pains proceed from affections of the bowels, no effect is pro- duced during the pain, in rendering the os uteri tense, or making it larger. On the other hand, it sometimes happens, that the fibres about the os uteri are prematurely irritated ; and this state may be accompanied with pain, and with a perceptible change on the os uturi during a pain. This is a very ambiguous case; but we may "be assisted in our judgment, by discovering, that the term of utero- 340 gestation is not completed, that the os uteri is hard or thick, and the pains irregular, both in severity and duration, coming on at long intervals, or being frequently repeated for some hours, and then going altogether off for so many more, and thus perhaps con- tinuing even for several days. This seems sometimes to depend on preternatural sympathy of the neighbouring parts with the os uteri, so that when it begins to dilate, the abdominal or perineal muscles, &c. are excited to painful action, which, on the principle of the sympathy of equilibrium, which I have elsewhere explain- ed, immediately calls off the uterine action, which for a long time rather excites those other parts to unprofitable pain, than establish- es itself into regular labour. In all such cases, it is best to proceed on the supposition, that the woman is not actually in labour. By letting her alone, she most likely will have a continuance of pain, terminating, it is true, in labour, but the process will be tedious and fatiguing; whereas, by suspending the action by an opiate, and if necessary by venesection, she may go on for some time lon- ger, and shall at all events have an easier delivery. When the false pains are accompanied with a febrile state, or are very distressing during the night, it will be proper to detract blood, and afterwards give an anodyne. In all other cases, it is generally sufficient to keep the woman in a state of rest; open the bowels by means of a clyster, if there be no diarrhoea, and after- wards give -an opiate to be succeeded by a laxative. Rubbing with anodyne balsam is also useful, or gentle friction with the flesh brush. Motion also often relieves the muscular pain, whilst a quiescent state increases it, and hence it is in many cases worst during the night. In other instances, the erect posture or walking, probably from irritation of the cervix and os uteri, by pressure of the child's head, excite* pain. Shivering and tremor occur in some cases, in the end of preg- nancy; and as they also occasionally precede labour, they often give rise to an unfounded expectation, that delivery is approach- ing. They appear to be connected sometimes with the state of the stomach, or alimentary canal; in other instances with some change in the os uteri itself, which even without pain, may be so far opened or relaxed as to allow the finger very easily to touch 341 the child's head through the membranes. It is usually in the evening, or through the night, that the shivering is felt; and it is occasionally pretty severe, and may be several times repeated. Nothing, however, is required, except a little warm gruel, or a moderate dose of laudanum, which is always effectual. THE PRINCIPLES OF BOOK H. OF PARTURITION. CHAP. I. Of the Classification of Labours. LABOUR may be defined to be the expulsive effort made by the uterus for the birth of the child, after it has acquired such a de- gree of maturity, as to give it a chance of living independently of its uterine appendages. I propose to divide labours into seven classes; but I do not con- sider the classification to be of great importance, nor one mode of arrangement much better than another, for the purposes of practice, provided proper definitions be given, and plain rules delivered, ap- plicable to the different cases. The classes which I propose to explain are, Class I. Natural Labour; which I define to be labour taking place at the end of the ninth month of pregnancy; the child pre- senting the central portion of the sagittal suture, and the fore- head being directed at first toward the sacro-iliac symphysis; a due proportion existing betwixt the size of the head, and the capacity of the pelvis: the pains being regular and effective; 344 the process not continuing beyond twenty-four hours, seldom above twelve, and very often not for six. No morbid affection supervening, capable of preventing delivery, or endangering the life of the woman. This comprehends only one order.f aj (~aj Our author might, perhaps with propriety, have divided this class into two orders, viz. Order 1. The posterior fontanelle of the child presenting towards the left ace- tabulum, and the anterior fontanelle, or forehead, towards the right sacro- iliac symphysis. This is by far the most common presentation. Order 2. The posterior fontanelle presenting towards the right acetabulum, and the anterior fontanelle, or forehead, towards the left sacro-iliac sym- physis. This position or presentation, according to Baudelocque, occurs but in the proportion of 1 to 7 or 8 of the first. In an accurate register kept by Baudelocque, it appears, that of 12,183 presen- tations of the head, 10,003 were of the first position, or with the posterior fonta- nelle towards the left acetabulum, and 2,113 in the second position, or with the posterior fontanelle towards the right acetabulum. Classification and systematic arrangement generally, are most frequently purely artificial and arbitrary; and that of our author, as laid down above, is not such as we can cordially approve, but as his division of the subject in the following sec- tions is founded upon it, we have not deemed it proper to propose any essential alteration. The great and deserved celebrity of Baudelocque as a practical writer, seems, notwithstanding, to demand that we should here briefly state his division of the presentations of the vertex, which he considers as natural. There are then, according to him, six positions in which the vertex presents at the superior strait, viz. 1. The posterior fontanelle is situated behind the left acetabulum, and the ante- rior before the right sacro-iliac symphysis. 2. The posterior fontanelle is situated behind the right acetabulum, and the an- terior before the left sacro-iliac symphysis. 3. The posterior fontanelle answers to the symphysis of the pubis, the anterior to the sacrum. 4. The anterior fontanelle answers to the left acetabulum, and the posterior to the right sacro-iUac symphysis. 5. The anterior fontanelle is situated behind the right acetabulum, and the pos- terior before the left sacro-iliac symphysis. 6. The anterior fontanelle is behind the symphysis of the pubis, and the posterior before the sacrum. The more frequent occurrence of the 1st. and 2d. than of the 4th. and 5th. is calculated to be in the proportion of 80 or 100 to 1. The 3d. and 6th. presenta- * tions are extremely rare, and indeed may be almost considered as preternatural, or pre-supposing some deformity of the pelvis or foetal head. 345 Class II. Premature Labour, or labour taking place considerably before the completion of die usual period of utero-gestation, but yet not so early as necessarily to prevent the child from surviving. This comprehends only one order. Class III. Preternatural Labours, or those in which the presenta- tion, or position of the child is different from that which occurs in natural labour ; or in which the uterus contains a plurality pf children, or monsters. This comprehends seven orders. Order 1. Presentation of the breech. Order 2. Presentation of the inferior extremities. Order 3. Presentation of the superior extremities. Order 4. Presentation of the back, belly, or sides of the child. Order 5. Malposition of the head. Order 6. Presentation of the funis. Order 7. Plurality of children, or monsters. Class IV. Tedious Labour, or labour protracted beyond the usual duration; the delay not caused by the malposition of the child, and the process capable of being finished safely, with- out the use of extracting instruments. This comprehends two orders. Order 1. Where the delay proceeds from some imperfection or irregularity of muscular action. Order 2. Where it is dependent principally on some mecha- nical impediment. Class V. Laborious or Instrumental Labour; labour which cannot be completed without the use of extracting instruments ; or altering die proportion betwixt the size of the child, and the capacity of the pelvis. This comprehends two orders. Order 1. This case admitting the use of such instruments as do not necessarily destroy the child. It will be observed, that in the arrangement of our author, the first and second positions of the vextex only are admitted into the class of natural labour, whilst the third, fourth, fifth and sixth positions of Baudelocque, are thrown into the class of preternatural labours under order 5. Malposition of the head. 45 346 Order 2. The obstacle to delivery being so great, as to re- quire that the life of the child should be sacrificed for the safety of the mother. Class VI. Impracticable Labour; labour in which the child, even when reduced in size, cannot pass through the pelvis. This comprehends only one order. Class VII. Complicated Labour; labour attended with some dan- gerous or troublesome accident or disease, connected in par- ticular instances with the process of parturition. This comprehends six orders. Order 1. Labour complicated with uterine hemorrhage. Order 2. Labour complicated with hemorrhage from other organs. Order 3. Labour complicated with syncope. Order 4. Labour complicated with convulsions. Order 5. Labour complicated with rupture of the uterus. Order 6. Labour complicated with suppression of urine, or rupture of the bladder. Calculations have been made, of the proportion which these different kinds of labour bear to each other in practice. Thus Dr. Smellie supposes, that out of a thousand women in labour, eight shall be found to require instruments, or to have the child turned,jin order to avoid them; two children shall present the superior ex- tremities ; five the breech; two or three the face; one or two the ear; and ten shall present with the forehead turned to the aceta- bulum. Dr. Bland has, from an hospital register, stated the proportion of the different kinds of labour, to be as follows: of 1897 women, 1792 had natural labour. Sixty-three, or one out of 30, had un- natural labour; in 18 of these, the child presented the feet; in 36, the breech; in 8, the arm; and in 1, the funis. Seventeen, or one out of 111, had laborious labour; in 8 of these, the head of the child required to be lessened; in 4, the forceps were employed; and in the other 5, the face was directed towards the pubis. Nine or one in 210, had uterine hemorrhage before or during labour. It is evident, however, that this register cannot form a ground for general calculation; and the reader will perceive, that the number 347 of crotchet cases exceeds those requiring the forceps, which is not observed in the usual course of practice.* Dr. Merriman says, the breech presents once in 86, the feet once in 80, and the arm once in 170, cases. Dr. Nagele, in the hospital of Heidelberg, out of 263 cases there were four twins; 256 children presented the head; and two of those the face; 5 the breech; 3 the feet; 1 the arm; 1 the breast; 1 the hip. Hence, 1 in 26 cases was pre- ternatural.^ • Farther information may be obtained, by consulting the Report of the Dub- lin Lying-in Hospital, by Dr. Clarke; and that of the Westminster Hospital, by Dr. Granville. Cbj From the register kept at l'Hospice de la Maternite, a lying-in hospital at Paris, under the direction of Baudelocque, it appears, that of 12,751 labours, 12,573 at least were natural: the assistance of art being necessary in 178 cases only, which is in the proportion of 1 to 711, of these, Cases- The face presented in- - - - - - -18 The shoulders .-----•- 38 The head and umbilical cord .-.--- 15 The thighs........22 The feet...... - - 11 Other parts not specified ...--- -4 Convulsions and floodings ....-- 4 As 1 to 961 132 The forceps were applied in 37 cases, which is as 1 to 344|. The cranium was perforated, or the crotchet applied, in 9 cases only. Gastrotomy was performed in one case only, and that to extract an extra-ute- rine firtus. It also appears from a late periodical publication, that there were admitted into the lying-in hospital at Paris, called Maison d'Accouchemens, between the 9th of December, 1799, and the 31st of May, 1809,17,308 women, who gave birth to 17,499 children; of which number 16,286 were presentations of the vertex to the os uteri. -. Proportions. 1 t R1 2 215 were presentations of the feet - - - - iw i^ 296 the breech ----- * -| 59 the face ------ - J- 296* 52 one of the shoulders x •> °* 4 the side of the thorax ... - - 1— 4374* 348 We cannot form an estimate of the proportion of labours, with much accuracy, from the practice of individuals, as one man may, from particular circumstances, meet with a greater number of diffi- cult cases, than is duly proportioned to the number of his patients. Thus Dr. Hagen of Berlin says, that out of 350 patients, he em- ployed the forceps 93 times, and the crotchet in 28 cases; 26 of his patients died. Dr. Dewees, again, of Philadelphia, says, diat in more than 3000 cases, he has not met with one requiring the use of the crotchet. 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 1 the head, and the feet - 2 the head, the hand, and forearm 37 the head, and umbilical cord 4374J 4374J 4374J 4374} 5833 5833 5833 17499 17499 17499 17499 8749$ 473 Of this great number of women, 230 were delivered by art, the rest were natiir ral births, being in the proportion of 1 to 76£; 161 were dehvered by the hand alone, the children being brought by the feet; 49 were delivered by the forceps, either on account of the small dimensions of the pelvis, the falling down of the umbilical cord, or the wrong position of the head, when the woman was exhaust- ed, or her life was in danger by convulsions, &c.; 13 were extracted by the crotchet after perforation of the head, on account of mal-conformation of the pelvis; in these instances the death of the child was first ascertained. The cesarean operation was performed in two cases, the diameter of the pel- vis being only one inch six lines from sacrum to pubis. 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 fcetus being extra-uterine; tfie child weighed 81b. 2oz. 349 CHAP. II. Of Natural Labour. § 1. STAGES OF LABOUR. Previous to the accession of labour, we observe certain pre- cursory signs, which appear sometimes for several days, oftener only for a few hours before pains be felt. The uterine fibres be- gin slowly and gradually to contract or shorten themselves, by which the uterus becomes tenser and smaller. It subsides in the belly: the woman feels as if she carried the child lower than for- merly, and thinks herself slacker and less than she was before. For some days before gestation be completed, she in many cases is indolent and inactive, but now she often feels lighter and more alert. At the same time that the uterus subsides, the vagina and os uteri are found to secrete a quantity of glairy mucus, rendering the organs of generation moister than usual: and these are some- what tumid and relaxed, the vagina especially becoming softer and more yielding. These changes are often attended with a slight irritation of the neighbouring parts, producing an inclination to go to stool, or to make water frequently, and very often griping precedes labour, or attends its commencement. The intention of labour is, to expel the child and secundines. For this purpose, the first thing to be done, is to dilate, to a suffici- ent degree, the os uteri, so that the child may pass through it. The next point to be gained, is the expulsion of the child itself: and last of all, the fcetal appendages are to be thrown off. The pro- cess may therefore be divided into three stages. The first stage is generally the most tedious. It is attended with frequent, but usu- ally short pains, which are described as being sharp, and sometimes so severe, as to be called cutting or grinding. They commonly begin in the back, and extend toward the pubis or top of the thighs ; but there is, in this respect, a great diversity with different women, or the same woman at different times. Sometimes the pain is felt 350 chiefly or entirely in the abdomen, the back being not at all affect- ed during this stage ; and it is generally observed, diat such pains are not so effective as those which affect the back. Or the pain produced by the contraction of the womb, may be felt in the ute- rine region; and when it goes off, may be succeeded by a dis- tressing aching in the back. In other cases, the pain is confined to the small of the back, and upper part of the sacrum ; and is ei- ther of a dull aching kind, or sharp and acute, and in some in- stances, is attended with a considerable degree of sickness, or ten- dency to syncope. The most regular manner of attack, is for pains to be at first confined to the back, descending lower by degrees, and extending round to the belly, pubis, or top and fore part of the thighs, and gradually stretching down the back part of the thighs, the fore part becoming easy : occasionally one thigh alone is af- fected. At this time also, one of the legs is sometimes affected with cramp. The duration of each pain is variable ; at first it is very short, not lasting above half a minute, perhaps not so long, but by degrees it remains longer, and becomes more severe. The aggravation, however, is not uniform, for sometimes in the middle af the stage, the pains are shorter and more trifling than in the for- mer part of it. During the intermission of the pains, the woman sometimes is very drowsy, but at other times is particularly irrita- ble and watchful. The pains are early attended with a desire to grasp or hold by the nearest object, and at the same time, the cheeks become flushed, and the colour increases with the severity of the pain. Tbe pains of labour often begin with a considerable degree of chilness; or an unusual shaking or trembling of the body, with or without a sensation of coldness. These tremors may take place, however, at any period of labour; they may usher in the second stage, and be altogether wanting during the first; or they may not appear at all, even in the slightest degree; or they may be present only for a very short time. They do not generally precede the uterine pain, but may be almost synchronous in their attack : in other cases they do not appear until the pain has lasted for a short space of time ; but whenever they do come on, it is usual for the uterine pain to be speedily removed. Hence it might be suppos- 351 ed that they should materially retard labour, but this is far from be- ing always the case. In degree, they vary from a gentle tremor to a concussion of the frame, so violent as to shake the bed on which the patient rests, and even to bear, some resemblance to a convul- sion. The stomach also sympathizes with the uterus during this stage, the patient complaining of a sense of oppression; sometimes of heartburn or sickness, or even of vomiting, which is considered as a good symptom, when it does not proceed from exhaustion ; or of a feeling of sinking or faintness, but the pulse is generally good. When there is in a natural labour, a sudden attack of sick- ness, faintishness, and feeble pulse, the patient is generally soon relieved by vomiting bile. These symptoms, however, are often wanting, or attack at different periods of labour: like the rigours, they may be absent during the greatest part of the first stage, or until its end, ushering in the second; but in general, they are con- fined to the first stage, going off when the os uteri is fully dilated. In consequence, partly of those feelings, partly of the anxiety and solitude connected with a state of suffering and danger, and partly from the pains being free from any sensation of bearing-down, the woman, duringjhis stage, is apt to become desponding, and some- times fretful T§he supposes that the pains are doing no good: that she has been, or is to be, long in labour; that something might be done to assist her, or has been done, which had better have been avoided; and that there is a wrong position of the child, or defi- ciency of her own powers. When the pains of labour begin, there is an increased discharge of mucus from the vagina, which proceeds from the vaginal lacu- nae, and from the os uteri. It is glairy, whitish, and possesses a peculiar odour. Wrhen the os uteri is considerably dilated, though sometimes at an earlier period, there is, in consequence of the se- paration of the decidua, a small portion of blood discharged, which gives a red tinge to the mucus. The distention of the os uteri is often attended with irritation of the neighbouring parts, the woman complaining of a degree of strangury; or having one or two stools with or without griping, especially in the earlier part of the stage. The pulse generally i* somewhat accelerated. 352 The os uteri being considerably dilated, the second stage begins*. The pains become different, they are felt lower down, they are more protracted, and attended with a sense of bearing-down, or an involuntary desire to expel or strain with the muscles ; and this desire is very often accompanied with a strong inclination to go to stool. A perspiration breaks out, and the pulse, which, during the first stage, beat rather more frequently than usual, becomes still quicker; the woman complains of being hot, and generally the mouth is parched. Soon after the commencement of this stage, it is usual for the liquor amnii to be discharged. This is often followed by a short respite from pain, but presently the efforts are redoubled. Sometimes there is no cessation, but the pains immediately be- come more severe, and sensibly effective. The perinseum now begins to be pressed outward, and the labia are put upon the stretch. The protrusion of the perinaeum gradually increases, but it is not constant: for when the pain goes off, the head generally recedes a little, and the perinaeum is relaxed. Presently the head descends so low, that the parts are kept permanently on the stretch, and the anus is carried forward. Then the vertex pressing forward, the labia are enlongated, and the orifice of the vagina dilated. The perinaeum is very thin, much stretched, and spread ewer the head of the child. As the head passes out, the perinaeum goes back over the forehead, becoming narrower, but still more distended la- terally. If the perinaeum did not move backward, as the head moved forward, it would run a greater risk of being torn; and in- deed even in the most regularly conducted labour, a part of it is often rent. Delivery of the head is accomplished with very se- vere suffering ; but immediately afterwards, the woman feels easy, and free from pain. In a very little time, however, the uterus again acts, and the rest of the child is expelled, which completes the second stage of labour. The expulsion of the body is gener- ally accomplished very easily, and quickly; but sometimes the woman suffers several strong and forcing pains, before the shoul- ders are expelled. The birth of the child is succeeded, after a short calm, by a very slight degree of pain, which is consequent to that contraction which is necessary for the expulsion of the pla- centa. This expulsion is accompanied and preceded by a slight 353 discharge of blood, which is continued, but in decreasing quantify, for a few days, under the name of the red lochia. § 2. DURATION OF THE PROCESS. • The duration of this process, and of its stages, varies not only in different women, but in the same individual in successive la- bours ; for although some, without any mechanical cause, be uni- formly slow or expeditious, others are tedious in one labour, and perhaps extremely quick in the next, and this variation cannot be foreseen from any previous state of the system. A natural labour ought to be finished within 24 hours after the first attack of pain, provided the pains be truly uterine, and are continued regularly; for occasionally, after being repeated two or three times, they be- come suspended, and the person keeps well for many hours, after which the process begins properly. In such cases, the labour can- not be dated from the first sensation of pain, nor deemed tedious. The greatest number of women do not complain for more than 12 hours; many for a much shorter period ; and some for not more than one hour. Few women call the accouoheur, until, from the regularity and frequency of the pains, they are sure that they are in labour, and feel themselves becoming worse. As the celerity of the process cannot be previously determined, many women thus bear their children alone, becoming rapidly and unexpectedly worse. On an average, it will be found, that in natural labour, the accoucheur is not called above four hours previous to delivery. The regularity and comparative length of the different stages is also various; but it will be generally observed, that when the wo- man has a natural labour protracted to its utmost extent, the delay takes place in the first stage ; and in those cases where the second stage is protracted, the delay occurs in the latter end of that stage. In most cases, the first stage is triple the length of the second. The first stage may be tedious, from the pains not acting freely on the os uteri, or being weak and inadequate to the effect intended, or becoming prematurely blended with the second stage ; that is to say, bearing-down efforts being made, before the os uteri be much 46 354 dilated. Various circumstances may conspire to produce this de- lay, such as debility of the uterus, rigidity of its mouth, premature evacuation of the water, improper irritation, injudicious voluntary efforts, &c. The second stage may be tedious, from irregularity of the uterine contraction, or from a suspension of the bearing-down efforts, or from the head not turning into the most favourable di- rection, or from the rigidity of the external organs. These, and other causes, which will hereafter be considered, may not only protract the labour, but may even render it so tedi- ous, as to remove it from the class of natural labours altogether. It is a general opinion, that a first labour is always more lingering than those which succeed. We should be led, however, to suppose, that parturition, being a natural function, ought to be as well and as easily performed the first time, as the fifth; the process not depend- ing upon either habit or instruction. But we do find, that here, as in many other cases, popular opinion is founded on fact; for al- though, in several instances, a first labour is as quick as a second, yet, in general, it is longer in both its stages. This, perhaps, depends chiefly on the facility with which the different soft parts dilate, after they have been once fully distended. Some have attributed the pain of parturition to mechanical causes,- ascribing it to the shape of the pelvis, and the size of the child's head. But this is not the case, for in a great majority of cases, the pelvis is so pro- portioned, as to permit the head to pass with great facility. The pain and difficulty attending the expulsion of the child in natural labour, are to be attributed to the forcible contraction of the sensible fibres of the uterus, and to the dilatation of the os uteri and vulva, in consequence thereof. Women will therefore, ceteris ptt,* ribus, suffer in proportion to the sensibility of the organs concerned, and the difficulty with which the parts dilate. In proportion as we remove women from a state of simplicity to luxury and refinement, we find that the powers of the system become impaired, and the process of parturition is rendered more painful. In a state of na- tural simplicity, women, in all climates, bear their children easily and recover speedily;* but this is more especially the case in those * " The Greenlanders, mostly, do all their common business just before and 355 countries where heat conspires to relax the fibres. The quality or quantity of the food has much less influence than the general habit of life, upon the process of parturition. In a savage state, women, though living abstemiously, and often compelled to work more than men, bear children with facility; whilst in this country, women who live on plain diet are not easier than those who indulge in rich viands. § 3. OF EXAMINATION. The existence and progress of labour, and the manner in which '« after their delivery ; and a still-born or deformed child is seldom heard of." Crantz's History of Greenland, Vol. I. p. 161. Long tells us, that the American Indians, as soon as they bear a child, go into the water and immerse it. One evening he asked an Indian where his wife was; " he supposed she had gone into the woods, to set a collar for a partridge." In about an hour she returned with a new-born infant in her arms, and coming'up to me, said, in Chippoway, " Oway saggonash payshik shomagonish;" or, « Here, " Englishman, is a young warrior." Travels, p. 59. " Comme les accouchemens sont tres-aises en Perse, de meme que dans les " autres pais chauds de l'Orient, U n'y a point de sages femmes. Les parentes " agees et les plus graves, font cet office, mais comme il n'y a gueres de vieilles " matrones dans le harm, on en fait venir dehors dans le besoin." Voyages de M. Chardin, Tom. VI. p. 230. Lempriere says, " Women in this country (Morocco,) suffer but little incon- " venience from child-bearing. They are frequently up next day, and go through « all the duties of the house with the infant on their back." Tour, p. 328. Winterbottom says, that, " with the Africans, the labour is very easy, and trust- " ed. solely to nature, nobody knowing of it till the woman appears at the door of " the hut with the child." Account of Native Africans, &c. Vol. II. p. 209. The Shangalla women " bring forth children with the utmost ease, and never «« rest or confine themselves after delivery; but washing themselves and the child " with cold water, they wrap it up in a soft cloth, made of the bark of trees, and " hang it up on a branch, that the large ants with which they are infested, and «the serpents may not devour it." Bruce's Travels, Vol II. p. 553. In Otaheite, New South Wales, Surinam, &c. parturition is very easy, and many more instances might, if necessary, be adduced. We are not, however, to suppose that in warm climates women do not sometimes suffer materially. In the East Indies, " many of the women lose their lives the first time they bring •« forth." Bartolomeo's Voyage, chap. 11. Undomesticated animals generally bring forth their young with considerable ease ; but sometimes they suffer much pain, and, when domesticated, occasionally rose their lives. 356 the child is placed, are ascertained by examination per vaginam. For this purpose the woman ought to be placed in bed, on her left side,* with a counterpane thrown over her, if she be not undressed. The hand is to be passed along the back part of the thighs to the perinaeum, and thence immediately to the vagina, into which the fore finger is to be introduced. It never ought to be carried to the fore part of the vulva, and from that back to the vagina. The introduction is to be accomplished as speedily and gently as pos- sible, and the greatest delicacy must be observed. The informa- tion which we wish to procure is then to be obtained by a very perfect, but very cautious examination of the os uteri and present- ing part of the child, which gives no pain, and consequently removes the dread which many women, either from some mis- conception, or from previous harsh treatment, entertain of this operation. The application of the hand to the abdomen, during the continuance of the pain, may ascertain, from the temporary hardness of the uterus, that its fibres are contracting universally.f When a woman is in labour, we should, if the pains be regular, propose an examination very soon after our arrival. It is of importance that the situation of the child be early ascer- tained, and most women are anxious to know what progress they have made, and if their condition be safe. As it is usual to ex- amine during a pain, many have called this operation " taking a pain;" but there is no necessity for giving directions respecting the proper language to be used, as every man of sense and deli- cacy will know how to behave, and can easily, through the medium of the nurse, or by turning the conversation to the state of the patient, propose ascertaining the progress of the labour. Some women, from motives of false delicacy, and from not understand- ing the importance of procuring early information of their condition, * A standing or half-sitting position has been proposed by some, and may doubtless, in certain diseases of the uterus, be proper, that it may, by its weight, come within reach. Sometimes in the early months of pregnancy, it is allowable from the same motives; but, during labour, it is not often that the uterus is so high that the examination cannot be performed in a recumbent posture. ■f This mark has been properly insisted on by Mr. Power, in his ingenious Treatise on Midwifery, p. 25. 357 are averse from examination, until the pains become severe.^ But this delay is very improper; for, should the presentation require any alteration, this is easier effected before the membranes burst, than afterwards. When the presentation is ascertained to be natu- ral, there is no occasion for repeated examinations in the first stage, as this may prove a source of irritation, and, should the stage be tedious, may be a mean of exciting impatience. In the second stage, the frequency of examination must be proportioned to the rapidity of the process. In order to avoid pain and irritation, it is customary to anoint the finger with oil or pomatum; but unless this practice be used as a precaution to prevent the action of morbid matter on the skin, it is not very requisite, the parts being, in labour, generally supplied with a copious secretion of mucus. It is usual for the room to be darkened, and the bed curtains drawn close, during an examination; and the hand should be wiped with a towel, under the bed-clothes, before it be withdrawn. The proper time for ex- amining is during a pain; and we should begin whenever the pain comes on. We thus ascertain the effect produced on the os uteri, and by retaining the finger until the pain goes off, we determine the degree to which the os uteri collapses, and the precise situation of the presenting part, which we cannot do during a pain, if the membranes be still entire, lest the pressure of the finger should, were they thin, prematurely rupture them. An examination should never, if possible, be proposed or made whilst an unmarried lady is in the room, but it is always proper that the nurse or some other matron be present. The existence of labour is ascertained by the effects of the pains on the os uteri; and its progress, by the degree to which it is di- lated, and the position of the head with regard to different parts of the pelvis. Before labour begins, the os uteri is generally closed, and direct- ed backwards towards the sacrum. When we examine in the com- mencement of labour, the os uteri is to be sought for near the sa- crum, at the back part of the pelvis, whilst between that spot and the pubis, we can pass the finger along the fore part of the cervix uteri. On this, the presenting part of the child rests, so that, in 358 natural labour, it assumes somewhat the shape of the head ; and, for the sake of distinction, I shall call it the uterine tumour. In some, it is so firmly applied to the head, and so tense, that a su- perficial observer would take it for the head itself. In this case the labour often is lingering. This tumour, or portion of the ute- rus, is broad in the beginning of labour, but becomes narrower as the os uteri dilates, until at last it is completely effaced, the head, either naked or covered with the membranes, occupying the vagi- na. The breadth of this portion of the uterus, therefore, as well as the examination of the os uteri, will serve to ascertain the state of the labour. The os uteri gradually dilates by the pains of labour, but this dilatation is easier effected in some cases than in others. In some, though the pains have lasted for many hours, and have been fre- quent, the os uteri will be found still very little opened. In others, a very great effect is produced in a short time; nay, we even find, that the os uteri may be pardy dilated without any pain at all. We cannot exactly foretell the effect which the pains may have by any general rule. We find, in different women, the os uteri in very opposite states. In some it is thick, soft, and protuberant; in others, thin and tu- bulated ; sometimes it is not prominent, but the edges of the mouth are on the same plane, like the mouth of a purse : these edges may be thin or thick, and both these states may exist with hard- ness or softness of the fibre. In some cases, they seem to be swelled, as if they were oedematous, and this state is often com- bined with oedema of the vulva, or it may proceed from ecchy- mosis. Now, of these conditions, some are more favourable than others ; a rigid os uteri, with the lips either flat or prominent, is generally a mark of slow labour; for as long as this state conti- nues, dilatation is tardy ; a thick oedematous feel of the os uteri is also unfavourable; and usually a projecting or tubulated mouth, especially if the margin be thick and hard * is connected with a more tedious labour than where the os uteri is flat. In some cases * If the margin be thin and soft, the os uteri sometimes, in the course of an hour, loses its projecting form, and becomes considerably dilated. 359 of slow labour, the os uteri, for many hours, is scarcely discerni- ble, resembling a dimple or small hard ring, perfectly level with the rest of the uterus. But although these observations may as- sist the prognosis, yet we never can form an opinion perfectly cor- rect ; for a state of the os uteri, apparently unfavourable, may be speedily exchanged for one very much the reverse, and the labour may be accomplished with unexpected celerity. Our prognosis, therefore, should be very guarded. When the pains produce lit- tle apparent effect on the os uteri; when they are slight and few; and when the orifice of the uterus is hard and rigid, or thick and puckered during a pain ; there) This includes the fourth and fifth presentations of the vertex, according to the division of Baudelocque, and have already been explained in our note on the Classification of Labours, Rook II. chap. 1. 400 being turned into the hollow of the sacrum; and by continuance of the pains, the forehead either turns up within the pubis, and the vertex passes out over the perineum ; or the face gradually de- scends, and the chin clears the arch of the pubis, the vertex turn- ing up within the perineum towards the sacrum till the face is born. The first is the usual process in this presentation ; all the steps of the labour are tedious, and often, for a considerable period, the pains seem to produce no effect whatever. In the last stage, die perineum is considerably distended, and it requires care and pa- tience to prevent laceration. This presentation is difficult to be ascertained, at an early stage, before the membranes burst; and sometimes the duration of the labour is attributed to weakness of the uterine action, and not to the position of the head. If it be discovered early, it is certainly proper to rupture the membranes, and turn the vertex round ; a proceeding which is easily accom- plished, and which prevents much pain and fretfulness. If this opportunity be lost, we may still give assistance. Dr. Clarke says, that, in thirteen out of fourteen cases, he succeeded in turning round the vertex, by introducing either one or two fingers between the side of the head near the coronal suture, and the symphysis of the pubis, and pressing steadily, during a pain, against the parietal bone.(q) Of the advantage of this practice, I can speak from my own observation; and I have, even when the head had descended so low as to have the nose on a line with die arch of the pubis, succeeded in turning the face found to the hollow of the sacrum with great promptitude, and with so much facility, that the patient did not know that I was doing more than making an ordinary ex- amination. Some have advised, that we should keep up the fore- v (q) The editor can also unite from his own experience, in recommending the attempt at altering and correcting this malposition of the head, as above recom- mended; it has often proved successful in his own practice. It will be found #iat tlus mode of proceeding was first inculcated by Baudelocque, from ob- serving that nature herself sometimes obviated difficulties, and accelerated the termination of the labour, by converting the fourth position into the second and the fifth into the first; or, in bringing the posterior fontanelle from the right or left sacroiliac symphysis, to the right or left acetabulum. Vide Art des Accoucbemens, 401 head during a pain, to make the vertex descend ; or that we should, with the finger, depress the occiput. The fontanelle, or crown of the head, may also present, although the face be turned to the sacro-iliac junction. In this case it is felt early, and, by tracing the coronal suture, we may ascertain whether the frontal bones lie before or behind. It is a much more un- common presentation than that noticed above. The labour is, at first, a little slower than in a natural presentation, but, by degrees, the head becomes more oblique, the vertex descending; and this may be assisted, by supporting the forehead with the finger during a pain. Should any untoward accident require the delivery to be accelerated, we have been advised to turn the child, and, in doing so, to use the left hand, if the occiput lie on the left acetabulum, and vice versa. But this operation can seldom be requisite. The crown of the head may also present with the face to the pubis or the sacrum, but these positions are extremely rare.(VJ In time, the head will generally become more diagonal, and de- scend obliquely, but we ought not to trust to this. We should rectify the position, for it is by no means difficult to move the head with the finger, if we attempt it early. We may even carry the forehead from the pubis to the sacro-iliac junction. The process is still more simple, when the occiput is turned to the pubis, if we perform it early. If, however, we neglect it, we find that in a few instances the head does not turn at all, but enters the pelvis in the original direction, and becomes wedged^sj requiring the use of instruments. This is oftenest the case, when the occiput is turned to the pubis; for the forehead being broad, does not, by a conti- nuance of labour, slip to the side of the promontory of the sacrum so readily as the occiput would do. 2d, The side of the head may present. In this case, the presen- tation is long of being felt, but it is recognised by the ear. If, how- (~rj These constitute the third and the sixth positions of the vertex, according to Baudelocque. The comparative infrequency of their occurrency is illustrated in the table, appehded to the chapter on the Classification of Labours. (~sj This by the French writers is termed enclavement, and by the English im- paction, or the locked head. -rv2 402 ever, it has been long pressed in the pelvis, it is extremely difficult to determine the case. It is very rare, and has even been deemed to be impossible. In some instances the child has been turned, but it is most common to rectify the position of the head, by intro- ducing the hand. / 3d, The occiput may present, the triangular part of the bone being felt at the os uteri. It is known by its shape, by the lamb- doidal suture, and its vicinity to the neck. The forehead rests on some part of one of the psoae muscles, and from this oblique posi- tion of the head, the labour is tedious. It has been proposed, in this case, to turn ; but it is better, if we do any thing, to rectify the position of the head with the hand. Nature is, however, ade- quate to the delivery, even if not assisted. Some advise, that the woman should, by a change of position, endeavour to remedy the obliquity, making the child incline, so as to affect the situation of the head, but this has not much power in altering the position of the presentation, at least after the water has been evacuated. 4th, The face may present with the chin to one of the acetabula, or to the sacro-iliac junction, or to the pubis or sacrum. The first two are the best, the second is more troublesome, and the last is worst of all. When the face presents, the labour is generally tedi- ous and painful, for it is little compressible, and affords a broad surface, not well calculated to take the proper turns in the pelvis. The head, also, being thrown back on the neck, a larger body must pass, than when the chin is placed on the breast. By a continuance of the pains, the face becomes swelled ; and although at first it was recognisable by the mouth and features, yet now it is indistinct, and has been taken either for a natural presentation or the breech. By rude treatment, the skin may be torn; and even under the best management, the face, when born, is very unseemly, and sometimes quite black and elongated, so that it has been known to measure nearly seven inches. This is especially the case when the chin is directed to the sacrum, and some children die from obstructed circulation, owing to the continued pressure on the jugular veins. Face presentations have been attributed sometimes to convulsive vomiting, cough, or frequent examination, but generally no evident 403 cause can be assigned; and in the beginning of labour, the face h> self does not present, but only the forehead : hence La Motte tells Us, that although at first he thought the head presented properly, yet, when the membranes broke, the face came down. Some have advised that the child should be turned; others that the chin should be raised up, to make the upper part of the face come down ; or that if the head be advanced, a finger should be inserted into the mouth, to bring down the jaw under the pubis. Others leave the whole process to nature; but many endeavour with the hand to rectify the position. If the presentation be discovered early, there can be little doubt as to the propriety of rectifying the position, but if the labour be advanced, this is difficult; and then it only remains that we should endeavour, if the labour be severe and tedious, to make the face descend obliquely, by cautiously but firmly supporting with a fin- ger, during the pains, the chin or end which is highest, in order to favour the descent of the lower end. When the chin has advanced so far as to come near the arch of the pubis, we may follow a dif- ferent method, and gently depress it, which assists the delivery, for generally the chin is first evolved. If, however, the process go on regularly and tolerably easy, we need not make these attempts. As the perineum is much stretched, we must support it, and avoid all hurry in the exit of the head. When the chin is directed to the sacrum, the labour is sometimes so tedious as to require the application of instruments. ORDER 6. OF THE UMBILICAL CORD. Sometimes the cord descends before or along with tbe presenting part of the child. This has no influence on the process of delivery, but it may have a fatal effect on the child; for, if the cord be strongly compressed, or compressed for a length of time, the child shall die, as certainly as if respiration were interrupted after birth. If the cord be discovered presenting before the membranes burst, or if the os uteri be properly dilated when they burst, the best practice is to turn the child. It has indeed been proposed, to push 404 the presenting part, or hook it upon one of the limbs ; but, if the hand is to be introduced so far, it is better at once to turn the child. If the os uteri be not sufficiently relaxed, we must not use force to expand it; and little can be done, except by rest, to prevent as much as possible, the evacuation of the water. As soon as die os uteri will admit the introduction of the hand, the child should be turned, if it can be easily done. But if the presentation be ad- vanced before we are called, and turning be difficult, then we must endeavour to keep the cord slack, or remove it to that part of the pelvis where it is least apt to be compressed ; or it will be still better, to endeavour with two fingers to push the cord slowly past the head, and prevent it, for two or three pains, from coming down again.f^ This is less violent, and safer, than attempts to turn in an advanced stage of labour. Should this not be practicable, and the pulsation suffer, or the circulation be endangered, we must ac- celerate labour by the forceps. If the pulsation be stopped, and the child dead, when we examine, then labour may be allowed to go on, without paying any attention to the cord. The sum of the practice then is, that when the os uteri is not dilated, so as to per- mit of turning, we must not attempt it; when turning is practicable, it is to be performed; when the head has descended into the pel- vis, the cord is to be replaced, or secured as much as possible from pressure; but if the circulation be impeded, the woman must be encouraged to accelerate the labour by bearing down, or instru- ments must be employed. When the presentation is preternatural, these directions are likewise to be attended to, and the practice is also to be regulated by the general rules applicable to such labours. CO Mauriceau, in these cases, recommends turning the funis, and pushing a piece of soft linen after it, the end of which may remain hanging without. Dr. Mackenzie, a celebrated accoucheur of London, in a case where the funis pre- sented, pulled down as much as he could, which he enclosed in a leathern purse; and thus returned it, pushing them up together into the uterus ; in this case the child was born alive. He afterwards pursued the same practice, and sometimes succeeded; and others have since followed his example. 405 ORDER 7. PLURALITY OF CHILDREN AND MONSTERS. Various signs have been mentioned, whereby the presence of a plurality of children in utero might be discovered, previous to their delivery. These are, an unusual size, or an unequal distention of the abdomen, an uncommon motion within the uterus, a very slow labour, or a second discharge of liquor amnii during parturition. These signs, however, are so completely fallacious, that no reli- ance can be placed upon them, nor can we generally determine the existence of twins, until the first child be born. Then, by placing the hand on the abdomen, the uterus is felt large,* if it contain another child; and, by examination per vaginam, the second set of membranes or some part of the child, is found to present. This mode of inquiry is proper after every delivery. Soon after the first child is born, pains usually come on like those which throw off the placenta, but more severe ; and they have not the effect of expelling it, for it is generally retained till after the de- livery of the second child. No intimation of the existence of an- other child is to be given to the mother, but the practitioner is quietly to make his examination, rupture the membranes, if they have not given way, and ascertain the presentation. If it be such as require no alteration, he is to allow the labour to proceed ac- cording to the rules of art, and usually the expulsion is very spee- dily accomplished. If the first child present the head, the second generally presents the breech or feet, and vice versa ; but some- times the first presents the arm, and, in that case, when we turn, we must be careful that the feet of the same child be brought down. This one being delivered, the hand is to be again introduced, to search for the feet of the second child, which are to be brought inte the vagina, but the delivery is not to be hurried. It sometimes happens, that after the first child is born, the pains become suspended, and the second is not born for several hours, • In a case related by Mr. Aitkin, the uterus was felt, after delivery, large and hard, as if it contained another child, but none was discovered. In the course of a fortnight the tumour gradually disappeared. Med. Comment. Vol. II. p. 300, 406 Now this is an unpleasant state, both for the patient and practition- er. She must discover that there is something unusual about her; he must be conscious that hemorrhage, or some other dangerous symptom, may supervene. The first rule to be observed is, that the accoucheur is upon no account to leave this patient till she be delivered. The second regards the time for delivering. Some have advised that the case be entirely left to the efforts of nature, whilst others recommend a speedy delivery. The safest practice, if the head present, lies between the two opinions. If effective pains do not come on in a quarter of an hour, the child ought to be delivered by turning. The forceps can seldom be required ; for if the head have come so low as to admit of their application, the delivery most likely shall be accomplished without assistance. If the second child present in such a way, as that the feet are near the os uteri, as for instance, the breech, or any part of the lower ex- tremities, then the feet are cautiously, but without delay, to be brought down into the vagina, and the expulsion afterwards left, if nothing forbid it, to nature. If, however, the position of the second child be such as to re- quire turning, we are to lose no time, but introduce the hand for that purpose, before the liquor amnii be evacuated, or the uterus begin to act strongly on the child. Turning, in such circumstan- ces, is generally easy. In the event of hemorrhage, convulsions, or other dangerous symptoms, supervening between the birth of the first and second child, the delivery must be accelerated, whatever be the presenta- tion, and managed upon general principles. When there are more children than two, the woman seldom goes to the full time, and the children survive only a short time. There is nothing peculiar in the managament of such labours. It still remains to observe, that we ought to be peculiarly care- ful in conducting the expulsion of the placentae of twins. Owing to the distention of the uterus, and its continued action in expelling two children, there is a greater than usual risk of uterine hemor- rhage taking place. The patient must be kept very quiet and cool, moderate pressure should be made with the hand externally on the womb, or gentle friction may be employed, and no forcible 407 attempts are to be permitted, for the extraction of the placentae, by pulling the cords. If hemorrhage come on, then the hand is to be introduced to excite the uterine action, and the twO placentae are to be extracted together. The application of the bandage, and other subsequent arrangements, must be conducted with cau- tion, lest hemorrhage be excited. The placentae are often connected, and therefore they are naturally expelled together, but this adds nothing to the difficulty of the process. Sometimes they are separate, and the one is thrown off before the other; or it may even happen, that the pla- centa of the first child is expelled before the second child be born, but this is very rare, and is not desirable. Women, who have borne a plurality of children, are more dis- posed than others to puerperal diseases, and must therefore be carefully watched. It rarely happens, that they are able to nurse both children without injury. It is possible for two children to adhere, or for one child to have some additional organ belonging to a second, as, for example, an arm or a™ead. Such cases of monstrosity may produce consider- able difficulty in the delivery; and the general principle of con- duct must be, that when the impediment is very great, and does not yield to such force as can be safely exerted, by pulling that part which is protruded, a separation must be made, generally of that part which is protruded, and the child afterwards turned, if necessary. Unless the pelvis be greatly deformed, it will be prac- ticable to deliver, even a double child, by means of perforation of the cavities, or such separation as may be expedient, and the use of the hand, forceps, or crotchets, according to circumstances. A great degree of deformity may render the caesarean operation ne- cessary. With respect to children who are monstrous from deficiency of parts, I may take the present opportunity of observing, lhat no difficulty can arise, during the delivery, except in ascertaining the presentation, if the malformation be to a great extent, as, for in- -rance, in acephalous children. 408 CHAP. V. Of Tedious Labour. ORDER 1. FROM IMPERFECTION OF MUSCULAR ACTION. If the expulsive force of the uterus be diminished, or the re- sistance to the passage of the child be increased, the labour must be protracted beyond the usual time, or a more than ordinary de- gree of pain must be endured. Tedious labour may occur under three different circumstances: First, The pains may be from the beginning weak or few, and the labour may be long of becoming brisk. Second, The pains during the first stage, may be sharp and fre- quent, but not effective; in consequence of which the power of the uterus is worn out before the head of the child have fully en- tered into the pubis, or come into a situation to be experred. Third, The pains, during the whole course, may be strong and brisk, but from some mechanical obstacle, the delivery may be long prevented, and it may even be necessary to have recourse to artificial force. It is farther necessary for me to premise, that the same patient, in different labours, shall be delivered with varying celerity and ease, although the size of the children be the same. The protrac- tion, therefore, cannot depend on purely mechanical causes, but is rather to be attributed to resistance afforded by the soft parts, as living organs, and the state of action of the uterine fibres. The de- livery of the child depends on contraction of the uterus, and relax- ation of its orifice, and that of the vagina, and muscles connected with the perineum; and these two processes are not only influ- enced by, but are also generally proportionate to each other. Easy and speedy relaxation is productive of rapid and great contraction, which is not to be measured or determined by the degree of pain or sensation, but of efficiency. Powerful contraction of the uterus, is attended wTith proportionally rapid relaxation of the opposing 409 soft parts, or at least of the os uteri; and if the latter state do not take place, the former cannot easily exist. When mechanical as- sistance does stimulate to more frequent and violent action, it is often more in appearance than reality, at least so far as the uterus is concerned. The sensation may be greater, but the actual effort made by the uterus, is not always so great as the sensation would imply. The abdominal muscles act more powerfully, and doubtless the uterus itself is at last roused or excited to strong action, when the resistance is continued, as for instance, by a contracted pelvis, or bad position of the child. The patient says, She feels as if she would burst; and in some cases the uterus is actually ruptured, but in many more inflammation is excited by the efforts. Nevertheless, even in this kind of resistance, which does not depend on the os uteri, it is usual for the action of the uterus at first to be impeded; the primary stage of labour is slow, and the pains inefficient. But this is more remarkably the case, when the resistance is seated in the os uteri; for then, although the pains may be frequent, they are long of becoming powerful. Then the abdominal muscleSf co-operate strongly and press down the uterus, along with the head, into the pelvis. This is particularly illustrated by cases of morbid contraction, or obliteration of the os uteri. Various causes may protract labour; and although I have thought it right to divide tedious labour into two orders; yet, in point of fact, the causes sometimes operate in such a way, as to make the case a mixed one, referable partly to both divisions. They may be arranged under the following heads: First, feeble or sluggish and languid action of the uterus. Second, partial or spasmodic ac- tion of the uterus. Third, restrained action, the energy of the uterus being prevented from being put forth by some other cause. Fourth, an unusual obstacle to the issue of the child. These states or causes, may be excited by circumstances in many respects differing from one another, and which, at first view, we would not suppose to act on one principle. The most important of these, we must presently consider separately. When again we come to view the means which we possess of counteracting their causes, and accele- rating labour, in order that we may choose the one best adapted to the case, we find that they may be referred to the following: 53 410 First, diminishing resistance, or promoting relaxation, which in- creases contraction. Under this head may be included blood- letting, gently dilating the os uteri, rupturing the membranes, im- proving the position of the presentation. Second, exciting the ac- tion of the uterus by stimulating its fibres, directly or by sympathy. Under this head may be included, the effect of cordials prudently given, heat, friction, gende exercise, clysters, spontaneous vomit- ing.ftt) Third, suspending weak and useless, or wearing-out, action, by a suitable anodyne, in order that the energy of the womb and of the system may recruit by rest. Fourth, removing partial or spasmodic action by a full dose of opium. Fifth, allaying general irritation of the system, which is interfering with the individual ac- tion of the uterus, by a small or moderate dose of laudanum, and thus concentrating the action in the uterus; or premising venesec- tion, if the state of the vascular system indicate this. Sixth, re- moving undue action from other parts, which are acting in place of the uterus, and checking or subducting its action, on the principle of the sympathy of equilibrium, which I have alluded to in page 340, and more fully explained in another work. Seventh, if none of these are applicable or effectual, then it only remains to employ artificial or instrumental aid. Having made these general remarks, I now proceed to consider Cuj In cases where the contractions of the uterus are inefficient from want of energy or irregular action of the uterine fibre, provided the cervix and os ute- ri, as well as the external parts are sufficiently dilated or disposed to dilate; re- course may be advantageously had to the ergot, or spurred rye. Under these circumstances the editor has frequently derived the most decided advantage from its use, given in fine powder, in the dose of about one scruple in syrup, and has seldom had occasion to repeat it. In about twenty minutes after the exhibi- tion of the article, the contractions of the uterus are invigorated, and the process accelerated in some instances probably several hours. In judicious and discriminating exhibition, this article of the materia medica may be considered as a valuable acquisition in the practice of midwifery; al- though, like all other powerful medicines, in rash and inexperienced hands may possibly do harm. For fuller information on this Subject the reader is referred to the papers of Drs. Stearns, Prescott, and Bigelow. The credit of introducing this medicine into obstetrical practice generally is exclusively due to the practitioners of the United States. 411 particular states. The first to be noticed is, that dependent on a weak or inefficient action of die uterine fibres. This may be occa- sioned by general debility or inactivity, but more frequently it pro- ceeds from the state of the uterus itself. It is marked by feeble pains, which dilate the os uteri slowly, and are long of forcing down the head. But although the pains be feeble, they may pro- duce as great sensation as usual, for this is proportioned rather to the sensibility than to the vigour of the part. It is, however, usual, when labour is protracted from this cause, for the pains to be less severe than in natural labour. They may come much seldomer, or, if frequent, they may last much shorter, and be less acute. The whole process of labour is sometimes equally tedious, but, in most cases, the delay principally takes place in one of the stages, gene- rally in the first, if the cause exist chiefly in the uterus. If, how- ever, it proceed from general debility, we often find, that if the first stage be tedious, the powers are thereby so exhausted, that the se- cond can with difficulty be accomplished. Hence, although con- sumptive patients often have a rapid delivery, yet if the first stage be slow, the head frequently cannot be expelled without assistance. It is not always easy to say what the cause of this slow action of the uterus is. Sometimes it proceeds from contraction commenc- ing rather prematurely; or from the membranes breaking very early, and the water oozing slowly away; or from some other organ becoming too active; or from the uterus being greatly distended by liquor amnii, or a plurality of children; or from fear, or other passions of the mind operating on the uterus; or from torpor of the uterine fibres, frequently combined with a dull leucophlegmatic habit, or with a constitution disposed to obesity; or from general weakness of the system. In a state of suffering and anxiety, the mind is apt to exaggerate every evil, to foresee imaginary dangers, to become peevish or de- sponding, and to press with injudicious impatience for assistance, which cannot safely be granted. Great forbearance, care, and judg- ment, then, are required on the part of the practitioner; who, whilst he treats his patient with that gentleness and compassionate encouragement, which humanity and refinement of manners will dictate; is steadily to do his duty, being neither swayed b'y her 412 fears and entreaties, nor by a selfish regard tP the saving of his own time. Some women seem constitutionally to have a lingering labour, being always slow. In such cases, unless the process be consider-i ably protracted, or attended with circumstances requiring our inter- ference, it is neither useful nor proper to do more tiian encourage the patient, and preserve her strength. A variety of means were at one time employed for exciting the action of the uterus, such as forcible dilatation of the os uteri, and the use of emetics, purgatives, or stimulants. A very different prac- tice now happily obtains; the patient is kept cool, tranquil, and permitted to repose; the mildest drink is allowed; all fatiguing efforts are prohibited; and she is encouraged by the mental stimuli of cheerfulness and hope, rather than by wine and cordials. But, whilst in cases where labour is only a little protracted, and the cause not very well marked, we trust entirely to this treatment, with the addition of a saline clyster, which is of much service, and ought seldom to be omitted, yet, where it is longer delayed, some other means are allowable, and may be necessary. The pains in tedious labour, connected with defective uterine action, may be continuing regular, but weak, not from exhaustion, but rather from the uterus not exerting the power it has; or there may be a tendency to remit, the pains coming on seldom. In the first of these states, we have to consider whether there be heat of the skin, full pulse, with thirst and resdessness. If so, and especi- ally if the os uteri be not relaxed, venesection will be of great bene- fit, by making the uterus act writh more freedom, and its moutii yield with great readiness. We know that in most cases of uterine hemorrhage, the os uteri, even where there is no effective labour, and scarcely any pain, is not merely dilatable, but is partially di- lated. In this instance, however, the benefit of evacuation cannot be derived, for the discharge injures and impairs the whole power of the uterus, and in proportion as the os uteri is extended, the quantity of the blood which flows is increased; besides, the evacua- tion usually begins before labour commences, and pains do not come on till the loss of blood excite them. We learn, h#wever from this example, the influence of hemorrhage in relaxing the os 413 gteri, and if we can do this without impairing the power of the womb, we have certainly a powerful mean of accelerating labour; venesection does this in certain cases. It can do no good, but much harm, in cases of exhaustion, or in cases where the resist- ance is afforded by a contracted pelvis, and all other circumstances are right. But in cases where the parts, through which the child must pass are rigid or dry, or hot and tender, or where the pains are great, but irregular and inefficient, or the membranes have given way prematurely, the pains sharp, but abortive, and the os uteri thick or hard, or the patient is feverish, blood-letting is safe, and may be expected to do good. That it is safe, we know from the experience of former ages and other countries, as well as from our own observation in cases of convulsions, where a great quan- tity of blood is taken away with present advantage and future im- punity. It is, however, a remedy, which if imprudentiy employed, may do much mischief. In cases of exhaustion, for instance, it must be dangerous; and in every constitution, and under every circumstance in which it would, independent of labour, be im- proper to evacuate, it is evident that it will be hurtful, unless we can thereby save the patient prolonged exertion and exhaustion. In natural labour, it is neither necessary nor proper; in labour not greatly protracted, nor unusually severe and slow in its steps, it is not to be resorted to. It is better to trust, in these cases, to the use of clysters, to gentle motion and change of posture, or to sleep, if it offer naturally, and the patient require to be recruited. The effect of venesection in shortening the process of labour, and in rendering the pains in many cases brisker, is to be explained by its power in relaxing the parts, and diminishing the resistance afforded. It is a fact not sufficiently attended to, that in many cases a very moderate resistance, which we should think the ute- rus might easily overcome, does retard the expulsive process, and render the pains irregular or inefficient. Thus, I know from ex- perience, that the membranes may be so tough as not readily to give way, and in this case the pains do become less effective, and the labour is protracted till they are opened. Whenever the re- sistance is removed, the pains become brisk and forcing. In the 414 sunie way, relaxing the os uteri by blood-letting, excites the ute- rine fibres to brisker action. If the woman be fatigued or debilitated, and the pulse weaker than in lingering labour, we shall derive advantage from the use of a smart clyster, followed by thirty drops of laudanum, or a pro- portional quantity in an injection. This does not suspend the pains, but rather excites them. A similar stimulus is sometimes given by a gentle purge, but this is more slow and uncertain in its effects. When there is a strong tendency in the pains to remit, or keep off, we are to follow pretty nearly the same conduct with regard to venesection, in the circumstances which I have pointed out, as admitting of it; but it is much more rarely required in those cases, than where the pains are less freqt#ent. When it is em- ployed, it either procures a remission and sleep, followed by brisk action, or it excites more immediately the pains; for whatever diminishes the resistance or obstacle, whatever produces relaxa- tion, speedily acts as a stimulus to the uterus to contract: cordials and stimulants are more doubtful in their effect. If, however, blood-letting be improper, we give a clyster, and then forty drops of laudanum, which either makes the pains effective and brisk, or suspends them for a time, till the womb recruit. There is another state in which the pains are weak, or remiss, or are ineffective from absolute exhaustion or debility; and we distinguish this case by the weak pulse, languor, and previous fatigue, and in part by the constitution of the woman. This is the only case in which cordials are proper, and they must even here be given prudently, lest they produce a febrile state. It is also useful to suspend for a time the uterine action, and procure rest by an anodyne clyster. We must take care that we do not delay delivery too long, or trust too much to nature. Premature rupture of the membranes, is apt to occasion spasmo- dic action of the uterus, or irregular and inefficient pains; besides, a little water passes between the head of the child and the os uteri during every pain, and the effect is rather to press out gradually the water, than to open the os uteri, which is seldom effectually 415 acted on, till the whole, or almost the whole water, has been evacuated, so as to allow the head to be pressed on the orifice, and the uterine fibres to act on that orifice over the presenting part. In a natural state, the bag remains entire, until the os uteri have been considerably opened, and every pain gently dilates it, both by the uterus acting on the orifice, and also by the membranes when pushed out, doing naturally, what is effected in some cases artifi- cially by the finger, that is, mechanically dilating the mouth. The pressure of the membranes also excites active pains. When die presentation is preternatural, the os uteri is longer of opening than When the head presents; the membranes do not protrude so broadly, nor does die presentation act so well on the os uteri, or excite it so effectually. Whilst rupture of the membranes, then, may in some cases prove a useful stimulus, in others, when it is without judgment or necessity resorted to, it must be prejudicial. If the water be discharged very early in labour, or before the pains come on, the process is often lingering, but is not always so. The os uteri is, when we first examine, projecting, then it becomes flat, but the lips thick; tiien they become thinner and more dilated, and presently very thin ; and the lower part of the uterus is per- haps applied so closely to the head, that at first it might be taken for the head itself. In favourable cases these changes may take place quickly, but they may also be very slow, and the labour tedious, the pains sharp and ineffective, and the water discharged in small quantity with each pain. The pains are severe, but pro- duce very little effect, and often when they go off, are succeeded by a most distressing uneasiness in the back, lasting for nearly a minute after the pain ; indicating in general the existence of spas- modic action. A saline clyster is of much benefit in this kind of labour ; and it is useful to press up the head, especially during the pains, to favour the evacuation of the water; for, whenever this is. accomplished, naturally or artificially, the action becomes much stronger. It is also useful to detract blood, if the os uteri be rigidx die parts not disposed to yield, and the pains very severe. It is peculiarly proper when the woman has rigours. When the organs are firm, and the pains are lingering, it causes relaxation, and quickens the pairis. If, on the other hand, die os uteti be lax and 41 fj thin, or soft, it is both safe and advantageous to dilate it gently with the finger during a pain. If this be done cautiously, it gives no additional uneasiness, whilst the stimulus seems to direct the action of the uterine fibres more efficiently towards the os uteri, which sometimes thus clears the head of the child very quickly, and the pains which formerly were severe, but, in the language of the patient, unnatural, and doing no good, become effective and less severe, though more useful. This advice, however, is not meant to sanction rash and unnecessary attempts to dilate the os uteri, which sometimes render labour more tedious by interrupt- ing the natural process, and also lay the foundation for inflamma- tory affections afterwards. When the pains are irregular, and are succeeded by aching of the back, if the state of the os uteri do not indicate venesection, a full dose of laudanum, not less than forty drops, may be given with advantage. In the case I have just considered, I have spoken of the effects of dilating the os uteri, but I do not mean to say, that the practice is useful in such a case alone ; for, in most cases of tedious labour, it is beneficial, and, as the subject is important, I shall explain my sentiments on it fully. Forcible and irritating dilatation of the os uteri, even when it is not productive of dangerous consequences, is apt to occasion irregular or spasmodic action of the uterus. Two circumstances are necessary to render it safe : the os uteri must be lax and dilatable, and the dilatation must be gradually and gently effected during the continuance of a natural pain. If attempted in the absence of pain, and especially if attempted so as to give pain, it is apt to excite partial or spasmodic action, and, under any circumstance, violent or forcible dilatation, besides injuring the uterine action may lay the foundation of future disease. It is done best by pressing on the anterior edge of the os uteri, during a pain, with two fingers, with such moderate force as shall not give additional pain, and shall appear to excite the natural dila- tation as much as to produce mechanical opening. By doing this for several pains in succession, or occasionally during a pain, at intervals, according to the effect produced and the disposition to yield, we shall soon have the os uteri completely dilated. This is an old principle, but it was rashly practised, and too universally 417 adopted, which made it meet with just reprobation, and some, knowing this, may be surprised at meeting with such an advice in modern times. Let not the principle suffer from its abuse, else where is the plan which could stand its ground ? It is perfectly clear, that when the process is going on well, interference is im- proper, but it is no less evident, that if a long time is to be spent in accomplishing the first stage of labour, or dilatation of the os uteri, the vigour of the uterus and strength of the patient may be impaired so much as to render the subsequent stage dangerously tedious, or to prevent its completion, at least consistently with safe- ty ; the first stage of labour ought always to be accomplished within a certain time, varying somewhat according to the constitu- tion of the patient and the degree of pain. It is an undeniable proposition, that there is in every case a period beyond which it cannot be protracted without exhaustion ; and it is no less certain, that if we wish to avoid this exhaustion, which may be followed by pernicious effects, we have only the choice of either suspending the action altogether for a time, or of endeavouring to render it more efficient, and of effecting the desired object within a safe pe- riod. The first is sometimes adopted, but is not always practi- cable, nor is it always prudent to counteract uterine action by strong opiates. The second is safer, and one of the means of doing so is that under consideration. If the pain be continuing without suspension, or an interval of some hours, and the labour be going on all the time, but slowly, it is a good general rule to effect the dilatation of the os uteri within ten or twelve hours, at the farthest, from the commencement of regular labour. This is done, if the os uteri be flat and applied to the head, by the method above described. If it be somewhat projected, it is aided by in- troducing two fingers, and extending them laterally with gentle- ness, during a pain. The dilatation is easily and safely effected, if the case be proper for it; if not, bleeding or an opiate, if the former be not indicated, will soon bring about a favourable statei Of the benefit and perfect 6afety of this practice I can speak posi- tively, and am happy to strengthen my position by the authority of Dr. Hamilton, who makes it a rule to have the first stage of labour finished within a given time. I need scarcely, however* add that, 54 418 in enforcing this rule of conduct, it should be recollected that, to render it proper, the pains must be continuing so often and so decidedly, that the patient can be said to be in actual labour all the time. There are many cases where pains, at first regular, have gone off for many hours, or where they have come occasionally in a dull slight way, for a couple of days, but they have given little inconvenience, have scarcely interrupted sleep, and had little effect on the os uteri. They are more of the nature of false pains : the patient can hardly be said to be in labour, and is in no respect fatigued. If interference be proper in such cases, it is by other means, by opiates, by enemata, or remedies and applications evi- dently pointed out by the nature of the pains which have formerly been considered. If, again, in lingering labour, the membranes be entire, the os uteri soft, lax, and considerably dilated, and the presentation na- tural, it is allowable and beneficial to rupture the membranes; and this is more especially proper, if the uterus be unusually dis- tended. The evacuation of the water is succeeded by more pow- erful action, a circumstance which, whilst it points out the advan- tage of the practice in the case under consideration, forbids its em- ployment in natural labour, where the process is going on with a regularity and expedition, consistent with the views of nature, and the safety of the woman. I have also already pointed out the injurious effects which fre- quently follow premature evacuation of the water ; but under the circumstances at present enumerated, the rupture of the membranes is beneficial. Taking away, at a favourable time, the resistance afforded, tends to excite efficiently the action of the uterus, and promotes labour. If the os uteri be lax, and especially if its edges be thin and soft, and the orifice considerably dilated, the same ef- fects may be produced on it by this practice, that would be in cases of greater rigidity by venesection ; for both excite labour by diminishing resistance. The more that the os uteri is dilated be- yond the size of half-a-crown, the more beneficial, ceteris paribus, will the practice be: on the other hand, when the os uteri is firm and little dilated, and the other soft parts rigid, this practice so far from being useful, is hurtful and dangerous. 419 An erect posture ip another mean which operates in part on the same principle, for it calls in the aid of gravity, adding the pressure of the child to the action of the uterus. The water is allowed to run freely out, and the continued application of the presentation to the dilating os uteri, excites action. The child must be more ea- sily propelled, surely, if it be in such a situation as to allow it to fall out by its own weight, were it not prevented by the soft parts, than if it rested on a horizontal surface and required to be moved along that, by muscular effort, as is the case in a recumbent pos- ture. The difference of facility, then, becomes truly a stimulus. Besides, the muscular motion, or walking, which is employed in an erect position, does good, either by exciting the womb directly, or by removing sympathetic pains in the muscles. Sometimes, after the first stage is advanced, and the os uteri is nearly dilated, the second does not commence for some hours; but the first kind of pains continue in different degrees of severity without producing any perceptible effect. If no particular cause require our interference, it is best to trust to time ; but, if there be no change soon, labour may be accelerated by rupturing the membranes, or, if they have already broken, we may place two fingers on the margin of the os uteri, which is next the pubis, and gently assist it, during the pains, to slip over the head. 3 When a woman is greatly reduced in strength, previous to la- bour, that process is looked forward to with apprehension. It is, however, often very easy. But, if it should be protracted, the patient is to be kept from every exertion. The general plan of treatment pointed out for such cases is to be followed, and, if the strength fail, the child must be delivered. We must be particular- ly careful that hemorrhage do not take place after delivery, or that it be prompdy stopped. If the head rest long on the perineum in tedious labour, the pains having little effect in protruding it, especially if the first stage have been lingering, it comes to be a question, whether we shall deliver die woman. This case is different from that where the difficulty proceeds from a contracted pelvis, for the head is low down, the bones are not squeezed nor misshapen, there is only a swelling of the scalp,, the finger can be passed round the head, and 420 two or three strong pains might expel it. The propriety of em- ploying the forceps in such cases, will fall soon to be considered. An inefficient state of uterine action may be produced, by some other part acting too much, or being in a state of irritation ; and so long as that continues, the womb cannot be expected to con- tract briskly. We ascertain this by examining the sensations and state of the patient. If the stomach be irritated, she is sick and op- pressed, and probably desponding, and sometimes, almost at every pain, has an inclination to vomit. The treatment must depend some- what on a knowledge of the habitudes of the patient, with regard to certain medicines. If opium agree with her, a moderate dose alone, or with some aromatic, is useful; a little spirit of lavender, or a glassful of hot water, or a little hartshorn, may be employed, or the epigastric region rubbed with some stimulant embrocation. Vomiting, without distressing sickness, and not dependant on ex- haustion, but occurring early in labour, often excites rather than retards the action. In other cases, the bowels suffer, and, in these, twenty drops of laudanum generally give relief. A dis- tended bladder also is a cause of protracted labour. In other cases, the muscles of the back or belly become painfully affected, producing what Daventer called " wild and wandering pains," or that state in which the pains no sooner seem to come on than they " are changed into a colic, or a cramp, and an impotency of la- bour." In such cases he forbade forcing medicines, and advised anodynes. This advice is a good one-; and, in all these cases, twenty-five drops of laudanum will be useful, at the same time that the pained part be rubbed with the hand, or an embrocation. In cases of muscular pain, walking or change of posture often gives relief; when there is no particular organ or part affected, but only a general irritation, attended with teazing inefficient pains, the same remedy is often of service, and the energy is directed pre- sently to the uteps. In all those kinds of cases, it is also useful, in general, to endeavour to excite the uterus itself by a warm sa- line enema, or by some of the other means already or still to be mentioned, or by rubbing the uterine region itself. This has been particularly recommended by Mr. Power, who has insisted more fhan any other writer on metastasis of action, and on the utility of 421 this remedy, in exciting uterine action. He employs it by draw- ing die fingers and thumb rapidly together over the uterus so as to make a brisk friction on the part. That general agitation of the muscular system known under the name of rigor, which often at- tends the first stage of labour, if carried too far, or continued too long, may also retard delivery, but, in general, it goes off spon- taneously, and the action concentrates more powerfully in the ute- rus. Hence, it is a practical remark, that these rigors often are followed by a brisk labour. This effect, and consequently the propriety of interfering, must depend on their prolongation, and on their influence in carrying off the uterine pain. When we re- quire to interpose, the practice is similar to that recommended above for allaying general irritation. In tedious labour, it is not necessary to confine the woman to bed, or to one posture; she may be allowed to sit, lie, or walk, as she feels inclined; and we are not to urge her to stand long, or use exertion by way of promoting labour. She has generally nOf much inclination for food, but, if the process be protracted, it is useful to give some light soup, and a little wine, if she desire it. If the urine be not regularly passed in tedious labour, the cathe- ter ought to be introduced. It is not necessary tiiat the practitioner remain constantly with the patient. It will have a better effect upon her, if he see her at proper intervals ; whilst he is thus pre- vented himself from being so fatigued, as he otherwise would be, and is therefore better able to discharge his duty with firmness and judgment. The second general cause of tedious labour is irregular action of the uterine fibres. After the child is born, the uterus some- times contracts like a sand-glass, and retains the placenta. The same spasmodic action may occur before the child be expelled. Many causes, and some of them obscure, may excite the spas- modic action: it is apt to take place when the membranes have given way prematurely, and before the os uteri be in a relaxed state, or have begun to dilate. Improper irritation of the os uteri eften excites it, especially attempts to dilate it in absence of a pain, or hurriedly during one; Letting out the water, when the uterus is not contracting, and where there is no pain at the time, 422 may also cause it, probably by allowing die lower part of the uterus to collapse suddenly around die head or presentation. Pre- ternatural distension of the womb may also produce it, even pre- vious to the discharge of the water. Irritation of the bowels., and mental anxiety may also be viewed as causes of spasmodic action. It is marked by pain coming or increasing at intervals, like pro- per pains, but it is confined to the belly, and has little effect on the os uteri, or in forcing down the child, nay the os uteri some- times seems even to contract during a pain. The pain does not go entirely off as in natural labour; but the patient complains of constant uneasiness in the back, or some part of the belly, but generally in the former. The contraction does not go off with the pain, it only lessens; hence the band of fibres still compresses the child, or ovum, and, if the membranes have not broken, they are often kept so tense, as at first to resemble a part of the child, and may mislead the practitioner with respect to the presentation. There is often a frequent desire to void urine, and die spirits are generally depressed. If this affection be slight, it may soon go off; but, if the spasm be strong, it sometimes continues for many hours. A smart clyster is often of great service. Blood-letting sometimes does good, but I prefer opening the membranes if the presentation be good, and the os uteri lax ; this I have found very successful. If, on the contrary, the os uteri be rigid or undilated, and espe- cially if the presentation be not determined, they must be kept en- tire, until the os uteri will permit of turning, should the position of the child require it. In such cases, and even when the state of the os uteri has warranted the rupture of the membranes, but the ex- pected benefit has not accrued, we may derive advantage from giving a large dose of opium; for in this spasm, like tetanus, opium may be given safely in prodigious doses. Even ten grains have been given, but in general four are sufficient; or an anodyne clyster may be employed. After the child is born, the hand should be introduced into the uterus, not to extract the placenta quickly, but to come easily in contact with it, and excite the uterus to regu- lar action; for generally the spasm returns, and the placenta may be long retained, or hemorrhage produced. 423 A frequent cause of tedious labour, is a state of over-action of unproductive action in the first stage, by which the powers of the Uterus are exhausted, and the subsequent process is rendered very slow. This exhaustion may also be produced by the continuance of debilitated action, or feeble and useless pains. In the first case, the pains are sharp and frequent, but do not dilate the os uteri pro- perly, nor advance the process in general. It may be produced by irregular, action of the fibres, or by premature rupture of the mem- branes. In the second case, the pains are lingering, short, and usually weak. I have already considered the remedies for these states; blood-letting, clysters, gentle dilatation of the os uteri, he. and have here only to observe, that the exhaustion of the uterus, and consequently an additional prolongation of the labour, is to be prevented, either by suspending the pains for a time, or by ren- dering them more effective ;(x) and upon this subject, T refer to what I have already said in the beginning of this chapter. Unpro- ductive action ought never to be allowed to continue so long as materially to impair the action of the womb. If we cannot safely render the action more efficient, we must endeavour to suspend it; by which the womb recruits, and the retarding cause may in the mean time be removed, or cease to exist. Another cause of tedious labour is the accession of fever, with or without local inflammation. Fever is recognised by its usual symptoms, and may be produced by the injudicious use of stimu- lants, heated rooms, irritation of the parts, he. It is to be allayed by opening the bowels, keeping the patient cool in bed, and giving some saline julap; at the same time that the mind is to be tran- quillized, If these means do not immediately abate the heat, fre- quency of pulse, he. and render the pains more effective, it will generally be proper to detract blood, especially if the head or chest be pained. When local inflammation accompanies fever, it is com- monly of the pleura, or peritoneum, or vagina. The first is dis- covered by pain in the thorax, cough, and dyspnoea; the second by pain in the belly, gradually increasing and becoming constant; (~xj Which may frequently be safely done by the judicious use of the ergot. or spurred rye. 424 pressure increases it, and in some time the patient cannot lie down, but breathes with difficulty, or is greatly oppressed, and vomits. The labour pains are sometimes suspended; on other occasions, they do ultimately expel the foetus, but the woman dies in a few hours. On the first appearance of these symptoms, blood should be freely detracted, the bowels opened, and a gentle perspiration excited. In all these cases of inflammation, if immediate relief be not obtained, the child must be delivered by the forceps. If the vagina be hot and dry, we are also to deliver immediately, as these symptoms indicate danger from inflammation* Labour may also be rendered tedious, by the different stages not going on regularly, but efforts being prematurely made to bear down. In consequence of these, the uterus descends in the pelvis before the os uteri is dilated, and the process is often both painful and protracted. In some cases, the womb prolapses, so that its mouth appears at the orifice of the vagina. This prolapsus may take place during pregnancy, or after parturition begins. It is of- ten met with, in a slight degree, whilst the os uteri is not greatly dilated, and uniformly injures the labour. We are to prevent it from increasing, by supporting the head or the uterus with two fingers, during the continuance of a pain; at the same time that the woman avoids, as much as possible, every bearing-down effort, and re- mains in a recumbent posture. If the os uteri be slow of dilating, some blood should be taken away, and an opiate administered, or the os uteri gently but completely dilated, during successive pains. It has happened that, by neglecting these precautions, the uterus has protruded beyond the external parts. In this case, no time is to be lost in attempting the reduction, which will be rendered easier * It is observed, generally, that women in labour bear well the loss of blood. Bleeding, undoubtedly, when used judiciously, facilitates the expulsion of the child, and secures a more speedy recovery, or " getting up." It moreover ob- viates the train of unpleasant consequences to which women are liable from the tendency in their systems to inflammation at the time. As a remedy to suspend uterine action with a view of turning the child, bleeding is never to be neglected, provided the woman is not exhausted. But when it does not produce that effect which will often happen, then opium in a large dose may be resorted to with ad! vantage. It is correct practice, however, in most cases to let bleeding precede the anodyne. C. 425 by cautiously pulling back the perineum.* If this cannot be done, the os uteri, if lax and yielding, must be gently further dilated, the membranes ruptured, the child turned, and the uterus replaced.f The os uteri has been cut,J but this can never be necessary if the structure of that part be natural. When the womb does not actu- ally protrude, the vagina may be inverted like a prolapsus ani. A soft cloth, dipped in oil, should be placed on the part, and pressure made with the hand. Giesman cut the inverted vagina on a probe, but this operation can rarely be required. If the womb prolapse before labour, as happened to Rcederer's patient, we must manage the case as a simple prolapsus. She had severe pains, although she was not in labour. ORDER 2. FROM SOME MECHANICAL IMPEDIMENT; There exists, naturally, such a proportion between the size of the head and the capacity of the pelvis, that the one can pass easily through the other. But this proportion may be destroyed, either by the head being larger or more completely ossified, or the pelvis smaller than usual. In such cases, which are to be discovered by careful examination, it is evident that the labour must be more te- dious, and more painful, than it otherwise would be. The first stage of the process is generally, but not always slow; the second is uniformly so; the head is long of descending into the pelvis, it rests long on the perineum, the pains are frequent, severe, and often at last very forcing, but the woman says they are doing no good. Now this state requires both patience and discretion. The bowels should be opened with a laxative; the urine regularly expelled; the strength preserved by quietness, avoiding unnecessary exer- tion, indulging any disposition to sleep which may exist, and taking a little light nourishment occasionally ; the mind is to be soothed, and the hopes supported. The rule formerly laid down, with re- gard to effecting the dilatation of the os uteri, or accomplishing the * Vide Mem. of Med.Soc. Vol. I. p, 213. fVide Portal's 10th Obs.; and Ducreux's case,in Mem.de l'Acad. deChir. Tome III. p. 368. See also a case by Saxtorph. * Vide case by Dr. Archer, New York Med. Rep. Vol. I. p. 323. o5 426 first stage of labour within a certain period, is to be attended to, by which the energy of the uterus is saved, and it is enabled to go through the second stage more readily and safely. If the pains begin to slacken, whilst the strength remains good, an opiate may be given, to procure some rest. How long the case may be trust- ed to nature, must depend on the strength of the patient, and the degree of suffering; but, assuredly, we are not at liberty to carry the trial to a great extent. The consideration of this question, how- ever, must be reserved for the next chapter. Malposition of the head may likewise retard the labour; but this has already been considered. Much suffering may be avoided by attending to this cause, as the position is often rectified by pres- sure with the finger alone. Another cause of tedious labour is, rigidity of the soft parts, which may be dependent on advancement in life, or some local peculi- arity ; and these causes generally act more powerfully in a first than a subsequent labour. This rigidity may exist in the os uteri, in the external parts, or in both; and if, along with this, there be prema- ture rupture of the membranes, the difficulty is always increased. When it exists in the os uteri, that part is very long of dilating; the effect of the pains, for a long time, is rather to soften than to di- late ; and after the woman has been many hours in labour, it is found, when the pain goes off, to be collapsed, and projecting like the os uteri in the eighth month of pregnancy. In this case, the first stage is very slow, lasting, if we do not interfere, sometimes two or three days; and the second is likewise tedious. The whole process takes up, perhaps, three days or more. When the rigidi- ty exists chiefly or partly in the external parts, they are found to be at first dry, tight, and firm. By degrees, they become moister and more relaxed ; but they may still be so unyielding, as to keep the head for many hours resting on the perineum. Some methods have been proposed for abating the rigidity -r such as baths, fo- mentations, and oily applications; or digitalis and sickening medi- cines given internally; but these have no good effects, and some of them do harm.* Blood-letting is the best remedy in such cases. * These remedies are mostly inefficient or injurious. The warm bath is pro- ductive of no advantage, and is apt to detach (he placenta, occasioning thereby 427 Dr. Rush informs me, that in America it has been used with great advantage ; and Dr. Dewees has politely sent me a dissertation on this subject, which contains very good cases of its efficacy, when pushed freely. In some instances, fifty ounces were taken before the parts relaxed. In determining on the use of blood-letting, we must attend to the state and habit of the patient. Debilitated wo- men,* and those who are exhausted by fatigue, especially among the lower classes in large cities, are injured rather than benefitted by this practice. Robust women, of a rigid fibre, in the middle class of society, or who live in the country, bear blood-letting bet- ter, and derive more benefit from it. In them it is especially pro- per, if any degree of fever attend the labour, and in whatever part the rigidity exists, if the patient be not previously reduced, or very delicate, blood should be detracted pro viribus. If, however, the state of the patient forbid this, then an opiate clyster is the appro- priate remedy. The direction already given, respecting the completion of the first stage of labour within a reasonable time, must be attended to, and is always practicable when the means of relaxation have been employed. When the head descends to the perineum, it is of ser- vice to keep the patient for some time in an erect or kneeling pos- ture. We must not allow either the general or the uterine vigour to be too much diminished, but must finish the labour by the for- ceps, before any considerable exhaustion takes place. dangerous hemorrhages. But I confess, my objections to it arise rather from what I have learnt of others in whom I can confide, than from my own experi- ence, having rarely seen the bath employed. J\"auseating medicines, of different kinds, I have tried, but with no good effect. "Where the external organs are ri- gid, and dry, and swelled, local fomentations, and oily applications, may, perhaps, be of some service. Blood-letting, if regulated by a sound discretion, is undoubtedly the remedy in these cases. It may often be pushed to a considerable extent. 1 have drawn as much as fifty ounces of blood in the course of a day, or night, where the os tincse obstinately refused to yield. In rigidity of the vagina, owing either to natural or acquired causes, and in tumefaction of the external parts, attended with soreness to the touch, it is equally useful. C. * Dr. Dewees bleeds even delicate women, and those who are disposed to faint on being bled, but takes a smaller quantity from them. 423 In some cases, the os uteri or external parts, instead of being rigid, are tumid, and apparently cedematous.fy,) In these, the la- bour is often protracted for several hours, especially when the os uteri is affected., In tedious labour, the os uteri sometimes becomes swelled, as if blood wrere effused into its interstices. This requires venesection, and then a smart clyster. The os uteri may be naturally very small. In some instances, it has, with difficulty, admitted a sewing needle; and in two cases, during labour, I found it almost impervious, hard, circular, and with difficulty discovered; but it gradually dilated. Venesection is, in this state, of service. Sometimes it is hard and scirrhous, so that it has been deemed necessary to make an incision into the os uteri, to make it dilate.* It is also possible for the os uteri to be Cyj A case of this kind occurred not long since to the Editor, where, in con- sequence of the great tumefaction of the labia and parts in the vicinity, it be- came necessary to have recourse to punctures, to prevent the bursting or lace- ration of the immensely distended integuments, The. tumefaction was so great*. that the patient could only lay on her back, with her knees drawn up, and her Uiighs supported by pillows—the canal of the vagina was so lessened by pressure from the effusion in the surrounding parts, that the examination to discover the state of the labour, was made with considerable difficulty. After the punctures in the labia (which jointly appeared to be as large as a child's head,) were made, the fluid continued oozing out for several hours, and it was supposed by a judi- cious assistant, that nearly tliree pints of water had been evacuated. The labia ultimately were completely reduced, and indeed became flaccid, and the labour then progressed, and was accomplished without any great difficulty, but the child wa9 dead. * A case of this kind occurred to Dr. Simson of St. Andrews, and another to a practitioner in America. Dubosc mentions a woman 40 years of age, who had convulsions for two days, during labour, from this cause. The face was pale and the extremities cold. The orifice was very rigid, and little dilated. He cut it and she was delivered of a dead child. Gautier mentions a case where, after la- bour had continued 15 hours, no os uteri could be found. The uterus had de- scended considerably in the pelvis, and there was no reason to suppose the os uteri was high from obliquity; an incision was made, and the child extracted by the forceps. In 6 weeks the patient menstruated, and when examined after that, the uterus was found in an adherent state of antiversion. Other cases are to be met with in the Diet, des Sciences Medic. Art. Hysterotomie. 429 loosed in consequence of inflammation, so that it has been neces- sary to make an artificial opening* Contraction and cicatrices in the vagina, likewise retard labour, and cause very great pain, until they either relax or are torn, but it is seldom necessary to perform any operation. If it should, they must be cut. Excrescences proceeding from the os uteri, an enlarged ova- rium remaining in the pelvis, or tumoursf.*) attached to the liga- ments, or a stone in the bladder, may all ohviously retard the la- bour, some of them so much as to require instruments. A stone in the bladder ought either to be pushed up beyond the head, or extracted. A small vagina may require a long time to be dilated. A great degree of obliquity of the uterus protracts labour. The os uteri may be turned very much to one side, but oftener it is di- • Vide case by Campardon; in Recueil Period. Tom. XII. p. 227. Moscati gives a case where, in consequence of injury by die forceps, the os uteri was so small that it would not admit a probe. A number of incisions were made round it, after which it dilated. In the next pregnancy slighter incisions sufficed, and in the last none were required. Aubertin performed, in a case of the kind, the cesarean operation. In a subsequent pregnancy, in the 7th month, the cicatrix was ruptured, and, by very httle enlargement, a child was successfully extracted. In a case given by Gautier, the os uteri was obliterated after a labour in which the shoulder presented. The menses were retained, and required a perforation for their evacuation. (*) Two very interesting papers on tumours within the pelvis, obstructing par- turition, have been published of latter years ; the first by II. Parke, esq. of Li- verpool, in the 2d Vol. of the Medico-chirurgical Transactions, and also in the Eclectic Repertory, Vol. IV. The next and the most important memoir is by Dr. Merriman, in the Medico-chirurgical Transactions, Vol. X. It would appear from the cases related or referred to in these papers, tha*. Embryulcia and the Crochet can be rarely necessary in such instances. From the evidence we at present possess, as has been observed by Mr. Parkl- and Dr. Merriman, the most eligible practice would generally appear to be, to puncture the tumour, or to make an incision into it, which gives both the mo- ther and child the best chance of existence. In Uie case related by Professor Francis, in a note to his valuable edition of Denman's Introduction, it neverthe- less appeared to be necessary, after puncturing and breaking down the tumour, to deliver by the crotchet. The woman recovered, and again became preg- nant. 430 rected backwards and upwards, and may be out of the reach of the finger. Time rectifies this, but much time and pain may be spared, by gently pressing the os uteri forward with the finger. Daventer, who was both a candid and an experienced man, has per- haps made die moderns too inattentive to obliquity of the womb, by going to the opposite extreme. Retroversion of the uterus may likewise prove a cause of te- dious labour, and can only be remedied by cautiously attempting to press down the os uteri from above the pubis. Malformation of the organs of generation may afford great ob- stacles to the passage of the child, so that even an incision may be required, as happened in the case related by Mr. Bonnet, in the thirty-third volume of the Philosophical Transactions. By shortness of the umbilical cord, or still more frequently, by the cord being twisted round the neck, the labour may be retard- ed, particularly the latter end of the second stage. The cord may be on the stretch, but it never happens that it is torn, and very seldom that the placenta is detached. We have no certain -sign of the existence of this situation; but there is presumptive evidence of it, when the head is drawn up again upon the reces- sion of each pain.fa) It often remains long in a position, which we would expect to be capable of very quick delivery. By pa- tience, the labour will be safely terminated ; but it may often be accelerated, by keeping the person for some time in an erect pos- ture, on her knees. After the head is born, it is usual to bring the cord over the child's bead, so as to set it at liberty ; and this is very proper when it can easily be done, as it prevents the neck from being compressed with the cord in the delivery of the child, by which the respiration, if it had begun, would be checked, or die circulation in the cord be obstructed. Some have advised that the cord should be divided, after applying the double ligature ; but (a) This retraction of the head during the recession of a pain, is more fre- quently owing to the rigidity of re-action of the external parts; and may often be obviated if necessary, by venesection. We believe it is rarely owing to the cause here assigned for it by our author. 431 this is rarely necessary, for tbe child may be born, even although the cord remain about the neck.(b) Preternatural strength of the membranes may also to a certain- ty prove a cause of tedious labour. This is at once obviated, by tearing them, which is done by laying hold of them when slack, during the remission of the pains. It sometimes requires a con- siderable effort to rupture them, CHAP. VI. Of Instrumental Labour. ORDER 1. CASES ADMITTING THE APPLICATION OF TUB FORCEPS OR LEVER. Various causes may render it necessary to accelerate delivery, such as, spitting of blood, convulsions, uterine hemorrhage, em- physema, the existence of aneurism, &c. These are, however, to be considered as in some respects adventitious; and, at present, I mean to confine myself, to an account of those, which are more immediately connected with the power of expulsion. It must be very evident, that if the head of the child be unusu- ally large, or the capacity of the pelvis be diminished, a mechanical obstacle must arise to the delivery of the child. Of these two states the last is by far the most frequent, and constitutes one pro- minent cause of instrumental labour. I have already explained, the effect of resistance in checking the free and brisk action of the uterus, until, at last, the muscular power is more roused, and strong efforts made. These circumstances require to be maturely consi- (A) In some cases where it has been found impracticable, without great dan- ger of rupturing the cord, to bring it over the head of the child, it has an- swered to pass it over the shoulders of the infant, and thus suffer it to be bom through the noose of thecorfl. 432 dered, for, in such cases, the first stage of labour is very frequently, although not invariably, slow; and if not accelerated by proper management, the action of the uterus is apt to become exhausted, and its vigour prove inadequate to the safe accomplishment of the second stage. Different effects must be produced by the resist- ance, according to its degree, the constitution of the patient, and concomitant circumstances. A slight opposition may operate, chiefly by impeding or rendering irregular and inefficient the action of the uterus, and the consequences may vary much in different labours, and under different treatment. A greater degree of resistance must invariably produce, from the obstacle afforded, a protracted and severe labour ; and, in particular, we apprehend the occurrence of two different conditions which are very often conjoined. First, The head, by the gradual and severe efforts of the uterus, and abdomi- nal muscles, is pressed more or less into the pelvis, and becomes impacted there, so that it cannot, by the power of nature, be forced lower, and can even with difficulty, in many cases, be raised in any degree upward by the accoucheur. This is known techni- cally under the name of the locked head, or case of impaction. It is evident, that in this state delivery is next to hopeless, for all farther efforts are generally unavailing. Secondly, The continued pressure of the head on the soft parts, is productive of farther dimi- nution of the capacity of the pelvis, for inflammation is excited, and, at the same time, the return of blood by the veins is obstructed, and of serum by the lymphatics. This impairs the power of the soft parts, and renders the inflammation of the low kind, so that, even when delivery is accomplished, sloughing succeeds, whereby very dreadful or loathsome effects are produced, if these, indeed,. be not prevented by the death of the patient, in consequence of a similar low inflammation being communicated to the uterus or peri- toneum. This swelling of the parts contained within the pelvis may take place, although the head be not impacted, but tjie head cannot be long impacted without producing that. Here then is one effect of a most formidable and alarming nature, which we ap- prehend in the case under consideration. But this is not the whole of the evil; for the upper part of the vagina or the cervix uteri, may be lacerated in consequence of this debilitated state, or any 433 part of the uterus may be ruptured by strong or spasmodic action; or uterine or peritoneal inflammation may be excited previous to delivery, proving fatal in a few hours after labour is terminated ; or hemorrhage may occur to a fatal degree from want of energy in the uterus after delivery ; or general irritation and exhaustion are produced, the pulse becomes frequent and at last feeble, the mouth parched, the skin hot, the mind confused and the strength sunk; or tfte powers of life may be worn out, so that the patient shall die with- out any decided inflammation, or disease referrible to a common nosological system. Such may, and must, in general, be the result, if assistance be long withheld, or if the patient, from unusual strength, or some fortunate yielding of the cranial bones, be able at last to bring forth her child. When we turn from the mother to the fcetus, we find that this continued pressure alters the shape of the head, and affects the action of the brain, or the important function of cir- culation : first, the scalp minifies, and we think the head is descend- ing, when in reality it is stationary, and the integument is only becoming raised; then, the bones are squeezed closer together, and the presenting part of the cranium forms an angle, more or less acute, which has been compared to a sow's back. In some in- stances, the two parietal protuberances are not more than two inches and a half distant from one another, but the head is not al- ways lengthened in the same proportion; on the contrary, in a few cases, it is even shortened, from one bone sliding under ano- ther. Children have been brought to me, where the bones have been separated, and the one parietal bone forced completely be- neath the other. Last of all, partly from pressure on the brain, but independently of that, from continued pressure on the cord or organs of circulation, the child perishes; and whether born by the natural efforts, or delivered by art, is dead. Such, then, are the effects, to parent and child, of a locked head; effects which can only be avoided by accelerating the progress of labour, and calling in the aid of extraneous force. When we talk of a case of impaction, we must not, however, suppose that the head is literally and entirely immoveable. That it is, in the strict sense of the word, sometimes impacted, and can- not be moved, is no doubt true.; but more frequently the hand can 56 434 make it recede a little, although the uterus cannot make it advance any more. Levret took the word in its strictest meaning, and imagined that the head was jammed between two points of the pelvis. Roederer went farther, and maintained that every part of the head was so fixed and pressed on, that not even a needle could be passed any where between it and the pelvis. If so, how can the forceps be applied? If the head be jammed at every point, even making allowance for the elasticity of its bones, we could not introduce the finger between it and the pelvis, or reach the ear. We can be at no loss to ascertain the existence of this state. The slow progress of the labour, the severity of the pains, the tardy descent of the head, its gradual impaction, or increasing immo- bility, its alteration of shape, the deformity or diminished capacity of the pelvis, the progressive tumefaction of the vagina, the station- ary condition of the head;—all point it out, too clearly to be mis- taken ; and many of these symptoms, together with those of gene- ral irritation and exhaustion, increase with the period to which labour is allowed to extend. This state may be anticipated, when the pelvis is ascertained to be deformed. We know that if the pelvis measure, in its diameter, only three inches and a half, then we must have a painful and difficult labour, because, as the head measures as much in its lateral extent, it must be compressed more or less in order to pass. If the brim, however, measure somewhat less, the head of a child, at the full time, cannot pass, until it have been pressed so long as to diminish its breadth, perhaps half an inch* The more, then, that the brim is reduced below its natu- ral dimensions, the longer and more painful must the labour be^ until we come to such a degree of contraction, as will either ren- der expulsion altogether impossible, or delay it until great danger have been induced. It is difficult to draw the line of distinction betwixt that degree of contraction which will render it impossible for delivery to take * The head can bear much more pressure before the child is born, than after it has breathed. Respiration is more under the influence of the brain, than the action of the heart is ; and the action of the latter, after birth, ceases when the brain is injured or compressed, not so much because it is directly affected, as because respiration, with which it is associated, ceases. 435 place naturally, and that which will only render it extremely diffi- cult. It has been proposed to ascertain this, by a rule founded on the dimensions of the pelvis. But this method cannot be brought to a sufficient degree of perfection, for the result of cases.is much influenced by the size of the child, the pliability of its head, the vigour of the uterus, and other causes. Besides, it is difficult, if not impossible, to determine, with minute precision, the dimensions of the pelvis in the living subject; and they are apt to vary, accord- ing as the soft parts within the pelvis, are more or less swelled. There is another case of protracted labour requiring instrumen- tal aid, when the head is not impacted ; the pelvis may even be of ample size. It is known under the name of the case of arrest, or by the French writers la tete arretee au passage. The head is not fixed or jammed, the finger can more readily be passed round it, the scalp may be swelled, but the bones are never misshapen, and the retardation appears to arise rather from the nature of the pains, or the unyielding state of the soft parts at the outlet of the pelvis, than from any actual obstruction offered by the pelvis to the deli- very. It is a mere case of tedious labour, but a case protracted to the utmost limits of prudence, in spite of the employment of those means which have been pointed out in the last chapter. It may arise from some slight disproportion between the size of the head, and the capacity of the pelvis, or more frequently from va- riations and irregularities of the uterine action, which have al- ready been fully considered, and it is much more frequent in its occurrence than the locked head. The case of impaction is clear- ly marked by the symptoms formerly detailed: that of arrest is ascertained by the simple condition of the head being stationary, but not jammed in the pelvis. There are many cases, then, of ar- rest which are safely terminated by nature, and which are placed under the class of tedious labour; but there are many others, where it becomes prudent to accelerate delivery by artificial force, and the question for deliberation is, at what period we shall thus in- terfere, or when further delay is hazardous ? I have fully, and I hope practically, detailed and considered the causes which render labour tedious, and have pointed out the im- propriety of permitting the first stage to be protracted, for thereby 436 the uterus becomes enfeebled, and less able to accomplish the se» cond. But when this advice has not been acted on, or when the treatment proper for the particular cases already described, has not been successful in effecting delivery, what is the consequence ul- timately of delay ? The uterus, by continued, but inefficient action, or unavailing contraction, becomes gradually debilitated ; and when at last delivery is effected, it cannot contract with vigour and regu- larity, whereby hemorrhage is occasioned, or the same event is produced by spasmodic action of the uterus. Here then, is one very serious evil which may be anticipated. Next, there is a strong disposition given to puerperal disease, not merely to those trouble- some, though less dangerous complaints, known under the name of weeds, or irregular febrile paroxysms; but also to more formidable affections, of an inflammatory nature, especially of the womb or pe- ritoneum. Accordingly, we find that a much larger proportion of women die after protracted, than after natural, labour. Here, then, is another class of evils to be apprehended. Again, although the same local mischief is not so apt to take place, that we meet with in locked head; yet, the patient is not exempted from risk even of that; by continuation of labour, the soft parts at last inflame and swell, which adds not only to the difficulty of delivery, but al- so greatly to the danger of the case. If it be necessary to enume- rate other hazards, I may set down the consequence of protracted irritation and exertion, marked by the induction of a state of fever, and at last of great exhaustion, insomuch that the patient may ac- tually die undelivered, but this event, as well as rupture of the ute- rus, is less apt to occur than in locked head. Besides all these ha- zards to the mother, the child is in danger of perishing, not from compression of the brain, but from the continued pressure of the uterus, after the evacuation of the water, interfering with the regu- lar performance of the function of circulation. These are surely no trivial evils resulting from protracted labour ; and the utmost that I feel at liberty to concede in favour of delay, is, that it may be per- mitted longer in cases of arrest, than of impaction. Many eminent men, have placed an undue confidence in the power of nature and have been hostile to the use of instruments. For a long time I was influeaced by the high authority and plausible arguments, as well 437 as bold assertions of these practitioners, but experience has com- pelled me to adopt the opinion, I am now, with a firm and solemn belief of its correctness and importance, to maintain in this chapter. From the strength of the recommendations of the partizans of na- ture, we should suppose, that whenever the child could actually be born without aid, no hazard occurred, and, on the other hand, that instruments must of necessity prove not only very painful in their application, but dangerous in their effects. Now, the first supposi- tion is notoriously wrong, for innumerable instances are met with, where the mother does bear her child, without artificial aid, and much, doubtless, to the temporary exultation of the practitioner, but nevertheless death takes place, or, at the best, a tedious and bad recoveiy is the consequence. The second supposition is just as positively unjust; for in the majority of cases, if the practitioner be humane and gentle, the introduction of the instrument gives lit- tle or no pain; in so much so, that in many books we meet with strong and just reprehension of the clandestine and unnecessary use of instruments, which could never possibly take place, if their application were attended in such cases with much pain. Then, as to the pain occasioned by extraction, that may be greater than the patient was just before suffering, and yet not be greater than is often experienced in a natural labour; or even granting it to be uni- formly greater, a concession I make for the sake of argument, it is but for a short time, and, on the whole, the suffering of the patient is less than if nature had been allowed at length to expel the child. These positions are perfectly correct in all cases of arrest, when the practitioner is well instructed and cautious. Next, as to the dan- ger to be apprehended, I cannot in cases of arrest see any source whence it can arise. The mere introduction of the forceps, if gently accomplished, can scarcely be more hazardous than the in- troduction of the finger, for no force is, or ought to be exerted. If there be hazard, it must be in the process of extraction, and this, it is evident, can arise only, either from pressure of the instrument on the soft parts, or from the head and instrument lacerating the perineum. The last event, must, in general, be the consequence of want of caution, and the first can never be carried to any dan- 438 gerous degree in a case of arrest, if the operator know how to direct his efforts. In such cases, then we may experience much evil, from trusting too long to nature, but add little to the sufferings, even for a short time, of the patient, and nothing to her hazard. When, however, we turn our attention to cases of impaction, the case is different. There is greater difficulty in introducing and fixing accurately the instrument, and doubtless more pain even in this stage is given than in cases of arrest. When again we come to act with it, the suffer- ing or pain must be increased, even in the hands of a gentle ope- rator, in proportion to the resistance to be overcome. The soft parts have already been pressed on during labour by the head, they must still be pressed on to a greater degree ; and even if the maxim, that time is equivalent to force, were acted on to a certain extent, it would be vain to deny that there must be both greater suffering and greater danger than in natural labour, or than in cases of arrest. These sufferings, and this danger, must be in a certain degree proportioned to the tenderness which has already taken place in the soft parts, and therefore may be greatly lessened, but cannot be increased by an early application. Their production depends on the obstacle afforded. When the head has arrived at a station rendering the application of the forceps practicable, no good can arise from delay; we only add unprofitably to the suffer- ing in the meantime, or lay the foundation of a state which is to render the later application of the instrument more painful and more hazardous. When mischief arises from the application of the forceps, it always is owing either to harsh and unskilful con- duct, or to the state induced by delaying their use too long. If it require strong efforts to extract the child, could that child ever have been born by the power of nature, or could the uterus and abdominal muscles, after long action, retain vigour sufficient to exert a force equal to that which is often required to extract an impacted head. Indeed our best writers, however fond they may have been of delay in cases of arrest, are disposed to deliver whenever the head has been locked. Nothing can be expected from delay except sloughing, and the alternative of speedy death or a miserable existence. 439 Holding the opinion I have been laying down, it is not without astonishment and regret, that I find Dr. Osborn stating, that in a case requiring the use of the forceps " all the powers of life are exhausted, all capacity for farther exertion is at an end, and the mind as much depressed as the body, they would at length sink together, under the influence of such continued but unavailing struggles, unless rescued from it by means of art." If such a state be allowed to take place, even in a case of arrest, but more especi- ally of impaction, it is much to be dreaded that the interference of art shall prove as unavailing as the struggles of nature. Were this the opinion only of Dr. Osborn, I should pass it in silence ; but unfortunately it is the prevailing doctrine of the day; and die mo- dern disciples of the school of patience, men of talent and obser- vation, carry their fears of the mischief resulting from the use of the forceps to an extravagant length, and place a mistaken confi- dence in the efficacy and safety of a continued action of the expul- sive powers. I have much pleasure, however, in strengthening my opinion with the authority of Dr. Hamilton, the present excellent Professor of Midwifery in Edinburgh, who has long seen the hurt- ful effect of the temporizing system, and of Dr. Osiander, the ac- tive and experienced Professor in Gottingen.* To place the argument in a yet stronger light, I shall examine the result of delay, as deduced from the tables published by Dr. Breen of the cases occurring in the Dublin Hospital, because these are the latest I have beside me, and were published without re- ference to any particular opinion. In the course of 57 years, 78,001 women were delivered, of * In Dr. Smellie's time, he calculated that the forceps were required once in 125 cases of labour; since then there has been rather a deterioration in prac- tice, so far as delay is concerned, for the more modern calculations are 1 in from 158 to 188. One gentleman, for whom 1 have great respect, states, that the for- ceps were not necessary in the hospital practice, above once in 728 cases, and in private practice, above once in 1000. Dr. Merriman's practice comes nearer the line of safety, for it exhibits 1 in 93. Dr. Naglee has employed tiiem once in about 53 cases, which corres- ponds very much with my own list. In former editions of this work, I express- ed an opinion, which I still adhere to, that of two evils, it is infinitely safer, fen- the mother, to interfere too soon, than to procrastinate. 440 whom one out of every 92 died, and one child out of every 18 was stillborn. If, however, we were to exclude cases of tedious labour, and attend to the rest of cases of natural labour, or the consequen- ces of a correct and healthy process of parturition, we would find the proportion of deaths to be altogether trifling : I am willing how- ever to adopt this average. Let us now see the result of tedious labour. In women, who were in labour of their first child from between 30 to 40 hours, one in 34 died, and one child in 5 was stillborn. Here then is a prodigious difference, between even the average re- sult of all labour, good and bad, and a protracted labour. During the same period of labour, amongst women who had previously borne children, and therefore, if requiring instruments, might be supposed to have a more permanent obstacle or contracted pelvis, though this is not stated, about one in every 11 died, and one child in every 6 was stillborn. When labour was protracted between 40 and 50 hours, in wo- men who had not previously borne children, one in 13 died, and the proportion of stillborn children was as one in 3£. If labour were protracted other ten hours, that is, between 50 and 60, one-eleventh of the women died, and when we proceed to the period of between 60 and 70 hours, one-eighth died, and nearly one-half of the children. It is observable, however, that only one-twelfth died in the next ten hours, but tiiis variation must arise from accidental circumstances. It is impossible to give any comparison of these results, with those afforded in the same hospital by the use of instruments, for artificial aid, it is evident, was always long delayed, unless in cases where dangerous symptoms not essential to labour occurred. In- struments were used, on account of tedious labour, in 44 cases, and of these 18 died. Now, taking the proportion of deaths in the parturient state, to be, including all disasters whatever, as 1 in 92, it is most important to observe the progressive fatality arising from delay. Suffering above 30 hours destroys one in 34; in other 10 hours the danger more than doubles, for 1 in 13 dies; then 1 in 11, and next 1 in 8, to say nothing of the children. 441 To deliver a system of rules precisely applicable to every casb, is quite impossible, for much must be left to the judgment of the practitioner, who is to be guided by general principles. I can therefore only offer for his consideration, the following observations. First, It is important in every case of parturition, but more es- pecially if there be reason to anticipate a tedious labour, to prevent the first stage from being protracted. Whenever the uterus is in a state of unsuspended action, that is to say, the pains decidedly par- turient, and continuing without long intervals, but producing a slow effect on the os uteri, the means formerly pointed out for effecting its dilatation, within a limited time, generally twelve hours, ought to be resorted to. Second, Whenever the os uteri is completely dilated, but not sooner, the forceps can be applied, if the case admit of relief by the use of that instrument. But the lower that the head has de- scended, the easier is the application, with the exception of those instances in which the head is very firmly impacted in the pelvis ; for in such it may be necessary to press the head up a little, in or- der to be able to introduce the blades. Third, It is ascertained that the head, at the full time, cannot, consistently with safety, bear to have its transverse diameter redu- ced, by pressure, to less than three inches. Most forceps, there- fore, are so constructed, that when joined, the blades at their most curved part which is to contain the parietal bones, cannot come nearer to each other than three inches. The pelvis then must, af- ter making an allowance for the soft parts, measure at least that space in its conjugate diameter, in every case where the forceps is applicable. It would, in a smaller pelvis, be dangerous, always dif- ficult, and often impossible, to introduce the blades, and, when in- troduced, they never could be brought through it, and indeed could only be locked by being carried above the brim. This fact, then, fixes the limits of that deformity, which permits the application of the forceps. The blades might doubtless be made to approach nearer, and to squeeze the head more, but as the child would per- ish, it is better to employ another method safer for the mother. Fourth, The forceps are merely small hands, and therefore, when the finger of the operator can be extended over the side ^ot 57 442 the head, one blade can be passed along that side, in whatever part the head is sitdated. This, it is indisputable, may be done, when very little, or even no part at all, of it has entered the brim of the pelvis. The possibility, however, of applying the corresponding blade, must depend on the dimensions of the conjugate diameter; and, if possible, it would be useless, unless there were space to de- liver a living child, or to bring out the locked forceps enclosing the head. We shall presently see that, in this high situation, the for- ceps cannot be applied without great care and dexterity; and that no small danger attends the attempt. Fifth, The lower that the head has descended, the more easy and the safer is the use of the instrument. In almost every case where the forceps are beneficial, the head has so far entered the pelvis, as to have the ear corresponding to the inner surface of the pelvis, and the cranial bones touching the perineum. Until this descent has taken place, the common or short forceps cannot be employed; and it is to this instrument that I confine my remarks, leaving the use of the long forceps to be specially considered. When the finger, without the introduction of the hand into the va- gina, can easily touch the ear, and when the cranium is in contact with, although not protruding the perineum, the forceps are appli- cable. Sixth, It has been laid down as a rule, that the head should have rested on the perineum for 6 hours previous to the use of the for- ceps ; but this is quite unsatisfactory, for it may, in many cases, be allowed to rest there longer, and in others, especially when the head is impacted, it would be both unnecessary, and dangerous, to permit it to remain so long. It is confessedly in every instance, allowing the labour, whether with or without propriety, to be con- tinued for six hours after delivery has become practicable. Seventh, Whenever the pelvis is ascertained to be contracted, we are to take care that the first stage of labour be not prolonged, and the vigour of the uterus diminished. As soon as the head has come within reach of the ordinary or short forceps, unless it be de- scending farther, and the labour going on briskly, we ought to de- liver, and whenever the head becomes impacted, we are warranted and called on, to interfere. In cases, then, where the'pelvis is dis- 443 proportionate to the head, we do not wait any definite time, and pay no regard to duration, farther than becoming, every hour that labour is prolonged, more solicitous that the head may come within reach of the short, and save the necessity of using the long forceps. The safest rule is, to deliver as early as delivery is easily practicable; but it may even be necessary to interfere be- fore the head has come within reach of the common forceps, and when considerable difficulty attends the application of the instru- ment; This is the case when the head has partly entered the brim, but has not for some hours yielded farther to the pains; and at the same time its deformity is not so great as absolutely to re- quire the crotchet. Eighth, Neither are we in cases of arrest, to proceed strictly on a rule founded altogether on time, unless we vary that according to the strength of the constitution, and the actual efforts made by the uterus. We cannot with reference to the present question, consider a patient to have been decidedly 30 or 40 hours in labour, who has had slight pains at first; then a suspension of these for a number of hours, and again, perhaps, a return of trifling pains, with long intervals scarcely affecting the os uteri. These can scarcely be called the pains of labour; and whether they should be checked or let alone, must depend on considerations formerly brought forward. We date our time from the commencement of evident and progressive effects on the os uteri, and are also in part regulated by the state of the pains in the second stage. The patient may have the os uteri fully dilated, and yet the next stage may be suspended for some hours, there may be a pause in the uterine action, occupied in sleep or passed in ease. It is quite different when there has, from the first, been continued uterine action, which has brought the head into the pelvis ; but, whether from weak or restrained, or irregular action, has not been efficient for its expulsion. In this case, presuming that the rule has been acted on, of having the first stage accomplished within a certain number of hours of actual labour, that pains producing little or no effect on the uterus or its mouth have been either stopped or ren- dered efficient, I am inclined to lay it down as a principle, that the second stage should be accomplished within a littie longer period 444 WW of time, than was allowed for the first. But to prevent all mis- take, in a rule which is connected with time, I must again ex- pressly state to the reader, that as I formerly spoke of the first stage being accomplished within a certain period of actual labour, and dated from the commencement not of mere pain, which may not even have been truly uterine, but of pain affecting the os uteri; so the second stage is to be considered also as a state of uterine pain, and is not to have included in its duration, the hours of suspension, which may have been passed in sleep or tranquillity. When I come to lay down a rule as to the time of interference, I would say, and that from reflection and experience, that few cases Ought to be trusted to nature for 36 hours, and in general it is safe and proper to interfere within 30. There may be cases where particular symptoms shall justify and call for aid, even witjiin 24 hours, and an impacted head may demand it within that timej but, in an ordinary state of health and strength, a mere case of ar- rest may be safely trusted till between 24 and 36 hours, and the point of interference in this range of 12 hours, must be regulated by the efforts which have been made, the uninterrupted con- tinuance of labour, the obstinacy of irregular action, the situation of the head, or length of time it has remained in a situation ren- dering the forceps applicable, and last of all, the general vigour of the patient. Finally, the longer that the first stage has been pro- tracted, and the more painful or severe that it has been, the shorter. should we wait in the second, and vice versa: this remark, how- ever, is only applicable to cases of arrest, and not of impaction. The doctrine I have now been supporting, rests on this princi- ple, that it is safer to extract the child with the forceps, than to al- low the uterus to remain long in a state of action, whether that be regular or spasmodic, and whether it lead directly to exhaustion, or ultimately to disease arising from irritation. If I have been tedious in my argument, or been betrayed into repetition, I plead that the great importance of the question to society has led me to trespass. Some patients urge the adoption of any means which can abridge their suffering, and are inclined to submit to delivery in Cases where the practitioner can by no means give his consent. 445 But in general an opposite state of mind prevails, and it is not un- til after much distress that the patient is reconciled to the use of instruments; The result of a labour is often uncertain : on this account, as well as from motives of humanity, no hint ought, in the early part of the process, to be given of the probability of in- struments being required. But as their necessity becomes more apparent, and the time of their application draws nearer, it will be proper to prepare the mind of the relations for what may be ne- cessary, if the delivery be not naturally accomplished. With re- gard to die patient herself, we must proceed according to her disposition. If she be, from what we have already learned, strongly prepossessed against interference, it will be necessary to give such prudent hints, and such explanations of the practice as relating to others, though not to herself, as will prepare her for her consent. But if we can perceive diat she is disposed to agree readily to whatever may be necessary, nothing ought to be said till very near the time, as the anticipation of evil is often as distress- ing as the enduring of it. When we are to deliver, it is useful to explain shortly and delicately what we mean to do, which has a great effect in calming the mind. When the child could not be born by the efforts of nature; it was anciently the practice to apply strong forceps, which destroy- ed the child, or to open the head, and pull it out with a hook. To give the child a chance of living, it was next proposed, and soon became a general practice, to turn the child, and deliver by die feet, as thereby much force could be exerted. If the resis- tance were great, however, death was invariably the consequence, nay, in many instances, the body was pulled away from the head, which was left in utero. This gave rise to many inventions for the extraction of the head under this circumstance. Fillets or. bands of cloth, were also applied over the head, to enable the practitioner to pull it out. These were preferred by Daventer, who informs us at the same time, that single or double hooks might also be employed, and these sometimes even brought out a living child. 1 have been in possession of these instruments, which con- sist of two blades, like the forceps, and lock like them. The blades are narrow, and end in a hook which is fixed at the ear. 446 The danger of this instrument arises from its hook, which in all eases of contracted pelvis, must have sunk through the cranium. In cases of arrest, it might sometimes only go through the integu- ments, and these are the cases where living children were born. It is surprising that it did not at once occur to practitioners, that by taking away the hook, this danger might be avoided, and still the head remain fixed between the blades. It only illustrates, what I have often shown in my lectures on surgery, that men come frequently within a single step of a great improvement, without taking that step, and often rest satisfied with imperfect knowledge, and hazardous, if not almost fatal practice, rather than exert the faculties of reflection and investigation. That it is owing to this cause, and not to any superior degree of the inventive faculty, in the man who actually does make the discovery, is evident from this, that no sooner is the fact published, that an improvement has been made, than skilful men discover it, in spite of every endeav- our to conceal it. Dr. Chamberlain, in 1672, published a trans- lation of the treatise of Mauriceau, in the preface to which he men- tions, that his father, himself, and his brother, possessed a secret by which they could deliver women, without destroying the child, although the pelvis were small. Previous to this publication, how- ever, he had gone over to Paris, in hopes of selling his nostrum ; but rashly boasting that he could thereby deliver a woman, whom Mauriceau had declared could not be delivered otherwise than by the caesarean operation ; and failing to effect what he promised, he was obliged to return with empty pockets and little reputation. Next he went to Holland, where he sold at least part of his secret to Roger Roonhuysen, from whom it passed to the celebrated Ruysch, as thorough a quack as any of them ; nor was it made public till 1753, when De Vischer and Van de Pole purchased the information, and divulged it. The instrument so revealed, is known under the name of the lever, but it is now ascertained that Chamberlain also employed the forceps. Whether he only sold one half of his secret to Roonhuysen, or whether the latter pre- ferred the lever, or only made others acquainted with it, preserv- ing the forceps to himself, may, like the lithotomy of Raw, be im- 447 portant in the history of quackery, but is of little consequence to- us. Of late, the original instruments of Chamberlain have been discovered, which, it is supposed, he had manufactured himself; one of them is a lever, the other two are forceps ; one of which is a litde more improved than the other. Soon after this, other practitioners in Britain seem to have devised similar instruments, which they also kept secret, and, perhaps, the first public descrip- tion is to be found by Mr. Buder, in the Edin. Medical Essays, for 1733. In the same volume, Chapman is severely reprimand- ed for concealing the instrument, which he gives intimation of in his treatise. This fault he made reparation for in his next edition. Dr. Smellie, in 1752, published his system, containing, amongst other useful instructions, a full account of the mode of using the forceps, the construction of which he improved ; and nearly about the same time, Levret, in Paris, performed a similar service to his countrymen. I do not conceive it necessary to detail the va- rious alterations which have been made on the forceps and lever* but shall proceed to explain the manner of applying and using (hose instruments. I have long been of opinion, that, although practice may en- able a man to use either the lever or the forceps with dexterity, yet a young practitioner shall be less apt to injure his patient, and less likely to be foiled in his attempt, with the latter, than with the former; and, therefore, I give a deoided preference to the forceps. It has been said, that we may operate with the lever earlier than with the forceps, but that can scarcely be the case, if the long for- • Plates of the different forceps and levers at present in use may be seen in Savigny's engravings ; and a very concise account of all the different improve- ments and alterations of these instruments, from their discovery to the present time, may be found in Mulder's Hist. Liter, et Critica Forcipium et Vectium Obstetriconim. I do not think it necessary to describe the forceps, nor do I con-> aider the slight variations made by different practitioners as of great importance. A particular kind of forceps, with three blades, was employed by Dr. Leak, but it is never used. M. Asalini has altered the forceps somewhat, and I understand, makes the junction at the extremity of the part which is held by the operator, and not at the union of the blade and handle as we do. Some have made one of the handles to screw off, others tp fold by a joint, at the commencement of the blade. 448 ceps be used; and next, it has been maintained, that the lever might be fixed on the bead, when both blades of the forceps could not be applied. I have never known such a case, but I am not prepared altogether to refute the assertion, and therefore conceive that the former instrument may, with propriety, be in the posses- sion of every accoucheur.f cj When the lever is to be employed, we are to apply the extre- mity of the instrument on the mastoid process of the temporal bone,* or side of the occiput. The patient ought to be placed on her left side, in the usual posture; and we then, with the fore finger of the right hand, feel for that ear which is next the pubis, and take it as our guide in passing the lever. Three directions must be particularly attended to. The first is, to keep the point of the in- strument, during the introduction and operation, close to the head of the child, lest the bladder or rectum be injured. The second is, that the concavity of the instrument be kept in contact with the curvature of the head, by which it will be much more easily intro- duced, than if it be separated to an angle from the head. It will, therefore, be necessary to keep the handle back towards the peri-- neum, in the beginning of the process; and it will be useful, espe- cially to the young practitioner, to have more than one lever of different degrees of curvature, for he may sometimes be able to in- troduce one which is very little bent, when one more concave shall be applied with difficulty. It is-a general remark, that within a certain range, the greater the curvature, the more is the difficulty of introducing it, but the greater is its power over the head. The foj I am pleased to find that the author has corrected some opinions too fa- vourable to the use of the lever, advanced in the former editions of this work, and which the Editor then controverted ; and now repeats his decided recom- mendation to young practitioners, rarely to make use of the vectis or lever, ex- cept to rectify malpositions of the head. He agrees with Dr. Osborn, that the «• vectis never ought, because it never can, be used with safety, when the child's •' head is not sufficiently low to admit the forceps." For a full view of the ques- tion with respect to the comparative advantages of the two instruments, the reader is referred to Dr. Osborn's Essays on the Practice of Midwifery, in natu- ral and difficult labours. * This process is very indistinct in the foetus, but the direction may still be retained, as it refers to a well known spot. 449 third is, to attend to the, axis of that part of the pelvis in which the head is placed, and pass the instrument in that course. In the usual position, the blade will be placed behind the symphysis pubis, or per- haps a'little obliquely, and the handle will be directed back towards the perineum. As the blade is curved at its extremity, and as, in order to get it passed, its surface must be kept in contact with the head, it will be requisite to direct die handle more or less back- ward, according as the blade is more or less curved ; and when it is introduced, the handle will be brought farther forward. When we act with the instrument, we must not make any part of the mother a fulcrum; and, indeed, whatever fulcrum be em- ployed, we ought not to raise the handle much, or suddenly, in order to wrench down the head. Instead; at first, of raising the handle considerably, we rather attempt to draw down the head, as Mr. Gifford did with the single blade of his extractor, using the instrument more like a hook or tractor, than a lever. With the left hand placed upon the shank of the blade, we press it firmly against the head, which both prevents it from slipping, whilst we draw down with the right hand grasping the handle, and also serves as a defence to the urethra, should the handle be a little too much raised like a lever. At first, we should pull or act with the instru- ment gendy, to see that it is well fixed, or adapted to the head. Afterwards we act widi more force, but not rashly or unsteadily. These attempts will renew the pains if they had gone off, and then they ought only to be made during the continuance of a pain ; for every practitioner knows, that the co-operation of pains add pro- digiously to the utility of the instrument. The head being brought fully into the pelvis, and the face turned into the hollow of the sa- crum, we must act in the direction of the outlet; and for this pur- pose, it will be useful to withdraw the instrument, and apply it cautiously over the chin, which, as less force is now necessary, will not suffer by the operation. Or the forceps may now successfully be applied, and should be used whenever there is necessity for a speedy delivery. Sometimes the natural pains will, without any further assistance, finish the delivery. We must be careful of the perineum. 5¥ 450 The forceps with a single curve,^ may 1 believe be very safety and early employed; but it is usual to prefer those which have the blades curved laterally also. In this case they must be so intro- duced, that the convex edge of the blades shall be next the face. It is therefore necessary, to determine which blade shall be placed next the pelvis, before we begin; and this we do by ascertaining to which side the face lies, by examining the position of the ear, as well as the general shape of the presentation. Were the forceps with a single curve employed, it would be a matter of indifference which blade were first inserted. The instrument is to be gently heated, by placing it in tepid wa- ter, and the blade first to be used is to be placed so as to prevent mistake. The bladder being emptied, the patient is now to lie on her left side, in the usual posture, but with the pelvis near the edgo of the bed; a female assistant is to go to the opposite side, to al- low the patient to hold by her, if she wish it; whilst another may be required to support and hold up the knee and thigh, when ther second blade is introducing. All things being prepared, and the head being supposed to be> placed in the same position as in natural labour, the operator gent- ly introduces two fingers between the head and the pelvis, in the same way as he would do in an examination: he feels for the ear, (~dj Such are those which are now generally preferred and employed in this city, under the name of Haighton's Forceps: by increasing the breadth of the blades, and enlarging the fenestra or opening in the blade, which is to be ap- plied over the parietal protuberance, a firmer hold is obtained in consequence of the greater space of the cranium, which is grasped by the instrument. These forceps are also very conveniently portable, which is no trivial advantage, as it regards practitioners in the country. The following are the dimensions of Haighton's Forceps, as now made by Henry Schively, Surgeon's Instrument-maker, Philadelphia. Inches. The whole length.........jji Blade from the angle of the joint, --..... 63 Handle to the angle of the joint, ...... 5* Breadth between the blades in the widest part of the curve, - 3 Breadth of the blades near the point, ~ js Do. of do. at its centre,...... 21 Do- of do. near the handles, - 2i 451 that he may know llie part of the head on which he has his fingers;- then taking up the blade, he carries the extremity of it along the hollow of the hand, cautiously and gently, into the vagina, sliding it between the two fingers and the head. In this introduction, but more especially in its passage oveMhat part of the head which it first touches, it is, owing to the curve of the blade, necessary to have the handle directed backwards, and almost parallel with the perineum ; but as the blade advances, the handle will come more downward and forward. The point of the blade is gendy to be in- sinuated between the head and the pelvis, with a slight wriggling motion ; and when the fingers are no longer useful, in guiding the point, they are tfo be so far withdrawn as not to occupy room. When the extremity gets opposite to the ear, it in general slips very easily inward; and the full introduction is sometimes suc- ceeded by a gush of water, which may be foetid, and tinged with meconium, although the child be alive. When the blade is fully inserted, the handle is in a line nearly parallel with the inner sur- face of the symphysis pubis, but not always perfectly correspond- ing to the axis of the brim of the pelvis, for it is often, as we shall soon observe, carried on a hide too far. The blade itself passes over the lateral part of the head, and a very little before the parietal protuberance, it traverses the ear, and its extremity rests on the lateral part of the jaw; or in some cases it does not, particularly if the blade be pretty much curved laterally, extend farther than about the angle of the jaw, or neighbourhood of the mastoid process. But in the introduction, and application of the blade, we do not nicely attempt to describe any given line; but are sure, if we introduce it directly behind the pubis, and fairly over the ear, onwards, till it rest, and the handle be brought forward, that it is in a right direc- tion. If we carry too much to either side of the pelvis, we have an insecure and bad hold of the head. If too far forward on the ear, and the blade traverse a line nearer die face than that described when introduced as directed, it slips. If too far back, it presses on the bulging part of the head, only with its anterier edge, and in- jures it; or holds so unsteadily, that it slips as in the former case. The first blade being applied, it seldom requires to he support-" ed but remains sufficiently fixed, between the head and the pubis; 452 and the operator proceeds to introduce the second, exactly in a reversed manner. When Jhe first was inserted into the vagina, its handle was placed almost directly backward ; when the second is inserted, its handle is directed forwards; and therefore, at this time, the thigh of the patient must be raised from the other, by an assis- tant. The extremity is to be guided past the root of the first blade, into the passage, by the finger; and directed, by it, between the perineum and the head. By moving the handle backward, and carrying, in the same degree, the extremity of the blade up along the sacrum, it traverses the head, in a line, corresponding to the blade, on the opposite side. It glides easily between the head and vagina, along the curve of the sacrum ; and in doing so, comes sometimes very readily and at once, to meet the lock of the other blade, and join correctly. But, more frequently, it requires a lit- tle address to lock the instrument so, and it may be necessary to withdraw the one or the other a little, generally the first, which has been pushed too far on, in order to make them meet. If this be not sufficient, it will generally be found that the difficulty arises from the blades not being correctly placed on parallel lines, on the opposite sides of the head, but the one a little nearer die face, or occiput, than the other; so that when we attempt to join them they do not lock, but the handles cross or pass each other. This is rectified by moving the one which seems wrong placed gently to a correct position; or, if this cannot be done, it must be withdrawn and re-introduced. To attempt, by force, to thrust the handles together, to make them unite, would give pain; and, most likely, the instrument would slip, when we began to act; and if a young prac- titioner, who tries the forceps for the first time, were foolishly to attempt to pull with the blades, without locking them, he would only pull them out, without bringing away the head. In joining the instrument, care must be taken, that neither the nympha, nor any other part of the mother, be included in the lock. The finger is therefore passed round the point of junction, before the handles are pressed together, or correctly locked. As the blades are fixed along the sides of the head, which is lying in the axis of the brim of the pelvis, it is evident that when they are joined, the handles will be situated in the same line or axis, and therefore will he 453 Erected downward, and backward ; die luck resting on the mar- gin of the perineum. In this process, we must be deliberate and cautious. We must never restrict ourselves in point of time, nor promise that it shall be very speedily accomplished. If we act otherwise, we shall be very apt to db mischief, or, if we find difficulty, to abandon the attempt. When the pelvis is so contracted as to make it just practicable to introduce the forceps or lever, that part of the head which is above the pubis sometimes projects a little over it, so that we cannot pass the blade until we press backward a little with the finger, on that part which we can reach, or when the head is impacted, we may find it necessary to endeavour to raise it a little, in absence of a pain, before we can insinuate the forceps, so far as to facilitate the introduction of the blade. All attempts to overcome the resistance by force, every trial which gives much pain, must be reprobated. But, on the other hand, as long as his conduct is gentle and prudent, the young practitioner must not be deterred because the patient com- plains, for the uterine pains are often excited by his attempt; or some women, from timidity, complain when no unusual irritation is given to the parts. Slow, presevering, careful trials, must be made ; and I beg, as he values the life of a human being, and his own peace of mind, that he do not desist, and have recourse to the crotchet, in cases at all doubtful, until it has been well ascer- tained that neither the lever nor forceps could be used. The instrument being joined, we pull it downward, and move it a little, to ascertain that it is well applied. We then begin to extract, taking advantage of the first pain. If the pains still con- tinue, we pull die instrument downward, and backward in the di- rection of the axis of die brim. Then we move the handle a little forward, toward the pubis; and again, after halting a second, move it slowly back again, still pulling down. We must not carry the instrument rapidly or strongly forward or backward, against the pubis or perineum, but die chief direction of our force should be downward, in die direction of the axis of the brim. The mo- tion of the pendulum kind is intended to facilitate this, but, if per- formed with a free, rapid, and forcible swing, the soft parts must be bruised, and great pain occasioned. The operation of extract,- 454 ing is not to be carried.on rapidly, or without intermission; on the contrary, we must be circumspect, and imitate the steps of nature. We must act and cease to act alternately, and examine, as we go on, the progress we are making, and also ascertain tiiat the instru- ment is still properly adapted to the head; for it sometimes slips, or shifts; and this is particularly the case, if it have not been, at first, correctly applied. In this event, we must stop and rectify the error; and, in every instance, must ascertain that the head i* descending along with the instrument, otherwise the forceps may come suddenly away. The head being made to descend, the face begins to turn into the hollow of the sacrum, and in the same de- gree, the handles must move round on their axis; and when the face is thrown fully into the hollow, the handles must be turned more forward and upward, being placed in the axis of the outlet. The pendulum kind of motion must now be very little, and is to be directed from one ischium toward another. As the head pas- ses out, the handles turn up over the symphysis pubis. In this stage we must proceed circumspecdy, otherwise the perineum may be torn. This is more apt to happen, if we be not attentive to the correct position of the forceps on the head. The blades are apt to slip a little, and not embrace the head properly, but when it has descended, and is just about to turn, the blades press xnuch on die perineum, and when the head does turn, the con- vex edge is apt to act so much on the perineum, as readily to tear it. The power required to be exerted in bringing down the head, must evidently be proportioned to the resistance, and is sometimes very considerable. But much pain to the mother, and fatigue to the operator are sometimes produced, by not pulling or acting in the proper direction. If the fontanelle present, the blades of the forceps are to be placed directly over the ears, with their extremities a little more backward than in the natural presentation. If the lever be used its point will rest on, or near, one of the mastoid processes. If the face present, the lever will rest on the back part of the tem- poral bone, or on the occipital bone: the forceps will have their 455 points ^directed toward the vertex, but in face cases, the lever, not being apt to slip, may be used with advantage.^ If the forceps or lever be injudiciously introduced, the bladder or uterus may be perforated ; or if the head be allowed to remain too long jammed in the pelvis, some of the soft parts may slough. The under and posterior part of the bladder is apt to slough off', leaving the woman incapable of retaining her urine.fej This is best prevented, by being extremely attentive in every case, espe- cially in those where the soft parts have suffered much or long from pressure, to evacuate the urine regularly twice a-day, em- ploying, if necessary, the catheter. The parts ought also to be kept very clean, and may be frequendy bathed with decoction of camomile flowers. Having offered these practical directions forthe use of die forceps, in cases where the head has descended considerably in the pelvis, I am next to state, that sometimes it remains long very high, or is- absolutely prevented, by the contraction of the brim, from making any great progress. When it is altogether above the brim, or only a small part, after many pains, has entered, and the conjugate diameter is evidendy under three inches, the forceps, even if the blades could be applied, could not, when joined, be brought through, if they do not approach nearer to each other than is com- patible with die safety of the child ; and therefore the head must be lessened. The blades of the forceps may be made with little curvature, so that, when joined, they shall not be above two inches and a half from each other; and, when applied, they may be, by force, brought perhaps to this proximity. But can the head be ex- fd) We are obliged here to dissent from the respectable authority of our au- thor. The forceps, even in face cases, will rarely slip if properly applied. It is generally owing to improper application, not having first accurately ascertained the preoise position of the head, that we hear complaints of the forceps not keeping a firm hold. They are to be preferred to the lever even in the cases. above alluded to. fej The rectum likewise, where it passes over or near the projection of the sacrum, may, by long continued pressure of the head, have its life destroyed, and s'oughing take place into the vagina, through which the feces will be dis- charged. These deplorable effects sometimes follow cases of impaction, or the locked head, where instruments have not been used. 456 jfected in general to bear this degree of pressure ? But, if no suck deformity exist, we may contemplate the application of the long forceps in a high situation of the head. There are two causes which may keep the head high. The first is, such a degree of con- traction of the brim, as renders it difficult for the uterus to force the head so low, as in ordinary forceps cases, and dangerous to wait until time ascertain, practically and experimentally, the im- possibility of accomplishing this. The more yielding parts of the cranium have entered, the scalp probably is swollen, but all the more solid and resisting part of the head is still above the brim. The finger must be carried high, to feel the ear, and ascertain the position, and the common forceps are too short to be applied, as part of the handle would be buried in the vagina. The second cause is, spasmodic action of the uterus, complicated with some degree of contraction in the brim, but not so much as to prevent regular and efficient action from forcing down the head; for I have known this state occur in those who have formerly borne living children without aid. When spasm in such instances take place, and is not speedily removed, this very formidable state may be met with; and so far from the head being forced lower by the pains, it is sometimes rather raised a little during the pain. Long delay, in this state, is dangerous; and whatever practice is to be adopted, must be resorted to promptly. Inflammation is a frequent conse- quence, and may begin previous to delivery. It long ago was, and still with many is, the practice, in this state, to turn the child; but the force required to pull the head through a contracted pelvis, can scarcely fail to be fatal to the child, to say nothing of the difficulty and danger of turning in a uterus much contracted. Lessening the head implies, to a certainty, the death of the child, which is barely possible to be avoided by the other practice; but it does not, in any degree, endanger the mother. A third practice, and that which comes before us now for considera- tion, is the application of long forceps. It is vain to propose this^ when the head possesses its usual firmness, and is of the ordinary size, if the pelvis do not, with the soft lining, measure three inches • for if this be not the case, the forceps, when joined, could not be brought through the pelvis, unless they were so shaped, as; to per- 457 ■wiit of squeezing the head to a degree most probably incompatible with life. Can the blades be introduced when the conjugate diame- ter does measure three inches ? They certainly may: but it is oiie thing to introduce them, and quite another thing to apply them over corresponding parts of the head, so as to be able to lock them, and obtain a secure fixture. The blade, at the pubis, may be .applied in a proper direction, but the projection of the sacrum may turn the other blade more easily aside than an unexperienced man would suppose; and those who have most frequently tried it, will best know the difficulty of adjusting the blades. I have seen mtich want of dexterity in introducing the common forceps, and the practitioner repeatedly baffled by the instrument slipping. The; application of the long forceps requires more dexterity and expe- rience ; and as great danger may arise from the fruitless irritation which is given in those unsuccessful attempts, which, besides, end at last in the use of the perforator, and often in the loss of the mo- ther, I cannot conscientiously advise any practitioner, until he have become well acquainted, practically, with the application of the common, to attempt the use of the long forceps. It is easy to say, let such a man send for another who has more dexterity. Such a person may not perhaps be in his vicinity; and he must, therefore, act according to the best of his skill; and certainly ought not to make a painful and rash attempt to apply the long forceps, but had better lose the child, than destroy both parent and child. A sen- sible man will make cautious, and possibly successful, attempts to apply the forceps, without danger to the parent: he will satisfy himself whether he can succeed in this way. He will try early, and before the parts are in such a state as to be irritated by his trial; and if, after a well conducted attempt, he fail, he has not in- jured his patient, and can still use the crotchet successfully. It is not so with the man of inexperience, for too often his attempts only add to the danger; and it is still worse for the patient if two such practitioners meet; for both must try their skill, and double suffer- ing he inflicted. My opinion, then, on this question, is, that a well instructed practitioner ought to make a cautious, steady, but gende attempt, to employ the long forceps, when the crotchet is not de- cidedly necessary; but he ought never to make reiterated and irfF 59 458 taring efforts, which can only end in the production of fatal inflam- mation.* I cannot say that I have known the lever prove success- ful, when the forceps failed, although, a priori, a superiority might have been expected, as only one blade requires to be introduced.(e) When we are going to use the long forceps, in the ordinary po- sition of the head, it may be sufficient to introduce two fingers, to guide the blade; but sometimes it is necessary, or useful, to intro- duce the hand into the vagina, as thereby the blade can be more safely and readily conducted over the head. The manner of ap- plication is the same as with the short forceps. The blades being fixed, and locked, we next pull a little, and with gradually increas- ing strength, to see that the hold is secure : being satisfied of this, we endeavour to bring down the head, by drawing, as has formerly been described, in the proper direction, that is, downward and backward. If the head be of full size, and firm, and the blades made to approach considerably nearer each other, than three in- ches, at their greatest curvature, the handles at first cannot touch each other, nor come quite in contact, till so much pressure have been applied, as shall diminish the size of the head sufficiently. This strong pressure it is always possible to employ, but not al- ways safe; and therefore, if the blades are made to approach near each other, we never ought to make more pressure than is neces- sary. If it be often difficult to extract the head when it is impacted, within reach of the short, it must be still more so, to bring it down with the long forceps, for less has entered the brim, and the re- sistance is greater. Tn this attempt, it is not the child, only, that is at stake, but the mother is in jeopardy, from the pressure on the soft parts, and this pressure must, in spite of all our caution, and * Smellie and Pudecomb first used the forceps in this high situation. Levret does not even notice such a case; succeeding writers have held various opinions. Baudelocque prefers turning, when that is practicable ; Capuron joins with him, when the conformation of the pelvis is good; but when it is a little contracted, he prefers the forceps. In greater degrees, he looks on the instrument as mur- derous. Fkmant and Gardien prefer it to turning. Dr. Hamilton and Dr. Osi- ander both use it. Saxtorph and Plenk, again, positively forbid it. fej But when introduced can it grasp the head so as to act with any effect in bringing it through the brim or superior strait ? 459 all the time we can take, often be great, but it never ought to be unprofitable. For instance, if the forceps be completely closed, showing thatthey cannot be made less, and if, by the finger, we find that the blades are in a manner jammed in the conjugate diameter, and that the most curved part has not yet passed, is it not evident, that farther attempts must befruidess, and inexpressibly dangerous? Is it not physically impossible, indeed, to deliver, unless the pelvis give way, or the blades be not tempered but yield, and come clo- ser together? This danger may be avoided, it may be replied, by diminishing the curve, or distance of the blades. True: it is pos- sible to crush the head, into a very small size ; but is it not better, as this must destroy the child, to open the head, and deliver with safety at least to the mother. ORDER 2. CASES REQUIRING THE CROTCHET. It unfortunately happens, that sometimes the pelvis is so greatly deformed, as not to permit the head to pass, until it have been les- sened by being opened. It is universally agreed, that a living child at the full time can- not pass througha pelvis whose conjugate diameter is only two in- ches and a half. It has been even stated, by high authority, that if the dimensions were " certainly under three inches, a living child could not be born." This opinion is generally correct, and the few exceptions depend on the original size and peculiar constitu- tion of the child; together with the pliability of the cranium, or the peculiar shape of the pelvis; and the force and activity of the ute- rus, as well as the general strength of the woman. There have been instances, where, even by the efforts of nature, living children have been expelled through a pelvis measuring only three inches; and there are similar examples of the delivery being, under the same conformation, accomplished by instrumental aid.* Every * M. Baudelocque relates a most interesting case, where there were decided marks of the foetus being dead in utero, and yet these were delusive; for, by the forceps, the woman was deliveredof a living child, although the pelvis measured only about three inches. L'Art des Accouch. last edition, sect. 1917.—Case9 in 460 one knows, that, even at the full time, the child is sometimes very small; or the head, when not very diminutive, may be extremely pliant. But in making up our judgment in a case of deformity, we are not justified in calculating on the happy coincidence of such a state ; but ought, unless the finger can inform us to die contrary, to reason on the ordinary size and firmness of the cranium. We are not warranted, therefore, instantly to open the head, merely be- cause we estimate that the pelvis does not, in its conjugate diame- ter, measure fully three inches; but because we have ascertained, by a sufficient but not a dangerous trial, that the uterine action can- not force down the head, so that the forceps or vectis may be ap- plied or acted with effectively. In all cases where the dimensions and circumstances of the case are barely such, as to warrant a be- lief that the head must be opened, an attempt ought previously to be made, not in a careless or hasty, far less in a dangerous manner, but deliberately and attentively, to introduce and act with the vec- tis or forceps. We may, however, if the dimensions be much under three inches, be assured, that delivery cannot be accomplished without the destruction of the child. But as it is a matter of great nicety to determine, within a fraction of an inch, the capacity of the pel- vis, a practice founded altogether on arithmetical directions must be unsafe. In every case, therefore, we ought to allow some time for the pains to produce an effect; and this time should be longer or shorter according as, in our estimation, the dimensions diminish below three inches. When this is the case, even in a small degree, we have no reason to expect that the head can pass, unless it be unusually soft and small, or burst * or be artificially opened ; and therefore it should, for the advantage of the mother, be perforated as soon as the os uteri is properly dilated; and this ought always point may also be seen in Dr. Alexander Hamilton's Letters, pp. 94. 102. 13.__ Similar instances have come within my own knowledge. * So far as I can judge, the sutures yield sooner than the scalp, and the brain is effused, or pushed out like a bag. AVhen the integuments open first', it is owing, I apprehend, to sloughing from pressure and injury. A very distinct case of spontaneous bursting of the cranium may be found in Dr. Hamilton's Cases p. in. 461 to be effected in, at the farthest, the time formerly specified; but until the os uteri be fully opened, no attempt to introduce the per- forator can be sanctioned. One circumstance, however, must be attended to in our consideration, namely, that the promontory of the sacrum may be directed somewhat obliquely, in which case, although the conjugate diameter measured from that to the front, do not extend to three inches, yet toward the side, the diameter be greater. The thickest part of the head may find its way down there, whilst a narrower or more compressible portion may pass at the smaller part. In cases at all doubtful, it is imperative to wait for some time to ascertain what can be effected ; not that delay is less injurious in crotchet than in forceps cases, but because inter- ference in the latter, may be productive of much benefit, without purchasing that at the risk of any mischief; whilst in the former, the greater safety, or abridged suffering, of the mother, arising from the perforation, necessarily implies the destruction of the child. Some eminent men on the continent seem to think, that the long forceps may in most cases supersede the necessity of the crotchet; but I must dissent from this opinion, and whilst I endeavour to prevent the unnecessary loss of die child, I cannot place out of consideration the danger, if not the destruction, of the mother, which may follow from improper and injudicious delay. But although it be thus laid down as a general rule, that the pelvis which measures fully three inches in its conjugate diameter, may possibly admit a living child to pass, either by the application of the vectis or forceps, or still more rarely by the efforts of the womb, yet it is nevertheless true, that sometimes the child must be destroyed, even when the space is above three inches. This maj become necessary, owing to the great size of the child and firmness of the cranium, or a hydrocephalic state of the head ;* or the soft parts in the pelvis may swell so much as to diminish, in an increas- ing ratio, the size of the pelvis, and effectually to obstruct delivery.f * I have seen a cranium so enlarged with water, that when it was inflated after delivery, so as to resume its former size, it meijjfcired twenty-two inches in circumference. f Baudelocque l'Art. des Accouch. sect. 1705.—See also a case in point in Dr. A. Hamilton's Letters, p. 83.—Every attentive practitioner must, from his own •xperience, admit the foct. 462 The parts may also be so tender as to render even a common exa- mination painful, and to prevent the application of the forceps, or their effective action, in a case merely equivocal. Alarming con- vulsions may likewise induce us to perforate the head in a case of deformity, where it is perhaps possible that the vectis or long for- ceps might succeed, after a greater delay or length of time than is compatible with the safety of the mother ; but tiiis Combination of evils must be rare. No practitioner, I believe, in this city, has met with such a case. At one period, however, the crotchet was em- ployed in cases of convulsions, where the vectis or forceps would now be used. By the rash and unwarrantable use of the crotchet, living chil- dren have been drawn through the pelvis with the skull opened, and have survived in this shocking state for a day or two.* To prevent all risk of bringing a living mutilated child to the world, and to avoid, at the same time, killing or giving pain to the ehild,f even in those cases which clearly demanded the use of the perforator, some have delayed operating until the child appeared to have been destroyed by the expulsive efforts, or other causes, and have therefore been anxious to ascertain the signs by which the death of the child might be known.J It was still more desir- * Vide Mauriceau, obs. 584.—La Motte, case CXC—Hamilton's Letters, p. 153.—Peu La Pratique, p. 346.—Crantz de Re Instrument., &c. sect. 38. + It has been disputed, whether the child in utero was capable of sensation, "but both facts and reasoning are in favour of its sensibility. i The signs of a dead child have been described to be a feeling of weight, or sensation of rolling in the uterus, want of motion of the child, pallid countenance and sunk eye, coldness of the abdomen, with diminution of size, flaccid breasts which contain no milk, foetor of the discharge from the vagina, liquor amnii co- loured apparently with meconium, although the head presents, puffy feeling of the head, want of firm tumour formed by the scalp when the head is pressed in a narrow pelvis, no pulsation in the cord, &c. Most of the cases requiring the crotchet cannot be benefited by any marks characterizing the death of the child in the progress of gestation ; and we well know, that the child may die during labour, without testifying this for a length of time by any sensible signs ; and that those enumerate^ above are deceitful, I believe every attentive and un- prejudiced practitioner will join with me in maintaining. Nothing] but unequi- vocal marks of putrefaction of the child itself can make us certain, and these can- not be discovered for some time. Foetor of the discharge is not a test of this; 463 able to know these, at a time when the forceps were undiscovered. But the signs are in general extremely equivocal, nor is this much to be regretted, for we do not operate because the child is dead, but because it is impossible for the woman to be otherwise deliv- ered. The steps of the operation are very simple : the rectum, but es- pecially the bladder, being properly emptied, we place the fore- finger of one hand on the head of the child, and with the other hand convey the perforator to the spot on which the fingers rest. The instrument, being carried cautiously along the finger as a di- rector, can neither injure the vagina nor os uteri, and in general no difficulty is met with in this part of the operation. Sometimes, however, in very great deformity, the os uteri is placed so oblique- ly, that it must previously be gendy brought into the most favour- able, that is, the widest part of the pelvis ; and afterwards, the perforator, being placed on the head, must have its handle in the axis of the brim, which may require the perineum to be stretched back. These points being attended to, the scalp is then to be pierced, and the point of the instrument rests onthe bone, through which it direcdy, or after a momentary pause, is to be pushed, ei- ther by a steady thrust, or a boring motion.^/) Itls to be carried on, till checked by the stops. The blades are then to be opened, so as to tear up the cranium ; and in order to enlarge the opening, they may be closed and turned at right angles to their former po- sition, and again opened, so as to make a crucial aperture. If the liquor amnii have been well evacuated, and a portion of the cra- nium have entered the pelvis, the perforation can be made without any assistance ; but if the whole of the head be above the brim, Vide Mauriceau. Obs. 281. When a woman bears a child which has been for some time dead, we must watch lest her recovery prove bad. 1 may notice here, that, in order to get rid of the crotchet, small forceps have been applied over the collapsed head, or a kind of crutcli or tire-tete has been inserted within the cranium. Some have employed a trephine in place of a perforator. (/) Where one of the sutures or fontanelles can he conveniently reached, the operation is facilitated by perforating through these, as must occur to every one. 464 it may be necessary to have it kept steady, by pressure above tho* pubis. It may be proper to add, diat if the face present, we must perforate the forehead, just above the nose. If we have turned the child, and wish to open the head, the instrument must be in- troduced behind the ear. The brain is next to be broken down, by turning the perforator round within the head. If part of the cranium have entered tire pelvis, some of the brain will come out with a squirt, whenever the bones are opened; and at all times we have more or less hemorr- hage from the vessels of the brain. Sometimes the blood flows very copiously. We have been advised always to delay a consi- derable time after opening the head before we apply the crotchet, and doubtless, if the perforation have been made early, we may leave the case for a little to the operation of the uterine efforts, which, although they may not effect delivery, yet may force the yielding head down, and render the action of the crotchet less se- vere. But when the labour has been already long protracted, die propriety of this direction is to be disputed, on grounds I have for- merly explained, relating to instrumental aid. If there be reason to believe that the crotchet can at once be easily used, what ad- vantage is there in delay ? In greater deformity there may, on the other hand, be advantage in delaying for some time. Dr. Osborn, in his Essays, advises, that the head should be opened early, and that we should then delay to extract for thirty hours. In cases of deformity, decidedly requiring the use of the crotchet, the first di- rection is important; but the delay of the specific number of thirty hours is, in most cases, if not in every instance, much too longj and I question if it be sufficient to produce, in any case where the child was alive when the skull was perforated, such a degree of putrefaction as materially to facilitate the operation. The iJiief benefit of delay, is to bring as much of the cranium as possible into the pelvis. If the deformity have been no more than just sufficient to require the use of the perforator, then, if the pains become strong, it is possible for the head to be expelled without further assistance. But if the deformity be greater, or the pains weak, only the pliable part of the cranium will descend, and the face and basis of the skull re-r- 465 main above the brim of the pelvis, until artificial force be used.- When this aid is required, which is generally the case, the crotchet is to be introduced through the aperture of the cranium, and fixed upon the petrous bone, or such projection of the sphenoid bone, or occiput, as seems to afford a firm fixture. We then pull gently, to try the hold of the instrument; and this being found secure, we proceed to extract in the direction of the axis of the brim, by stea- dy, cautious, and repeated efforts, exerting, however, as much strength as may be necessary to overcome the difficulty. In doing this, we must always keep a hand, or some of the fingers, in the vagina and on the cranium, to save the soft parts, should the instru- ment slip. If the force be steadily and cautiously exerted, we may always feel the instrument slipping or tearing the bone, and have warning before it comes away. We should, in extracting, co-ope- rate as much as possible with the pains. Sometimes an extractor, in the form of pincers is used in place of the crotchet, or different iire-tctes have been proposed. But it may happen, that the pelvis is so small, as to require die head to be broken down, and nothing left but the face and base of the skull. This is an operation which will be facilitated by the softening of the head, which takes place some time after death, rather by pressure dian putrefaction. If die child be recently dead, flie bones adhere pretty firmly; and, in a contracted space, it will require some management to bring them away. But if the parts have become somewhat putrid, or been much squeezed, or the. child have been dead, before labour began, the parietal and squa- mous bones come easily away, and the frontal bones separate from the face, bringing their orbitary processes with them. We have then only the face and basis of the skull left, and if the pelvis will allow these remains to pass, then the crotchet can be used. I have carefully measured these parts, placed in different ways, and en- tirely agree with Dr. Hull, a practitioner of great judgment and ability, that the smallest diameter offered, is that which extends from the root of the nose to the chin. For, in my experiments, after the frontal bones were completely removed, this did not in general exceed an inch and a half. It is therefore of great advantage, to convert the case into a face presentation, with the root of the nose 00 466 directed to the pubis. The size of the crotchet, which ought to be passed over the root of the nose, and fixed on the sphenoid bone, must, however, be added to this measurement. I never have yet been so unfortunate as to meet with what may be considered as the smallest pelvis, admitting of delivery per vias naiurales ; but I would conclude, that whenever the pelvis, with the soft parts, measures fully an inch and three-quarters,-]- or, if the head be un- usually small, the child not being at the full time, an inch and a half, the crotchet may be employed, provided the lateral diameter of the aperture in the pelvis be three inches, or within a fraction of that, perhaps two inches and three-quarters, if the head be small or very soft: and the operation will be easy, as we extend the dia- meter of the pelvis beyond what may be considered as the mini- mum. It is scarcely necessary to add, that if the outlet be much contracted, it will make the case more unfavourable ; and where we have any hesitation, owing to the shape and dimensions of the brim, will determine us against this operation. It ought not to be forgotten, that it is one thing to extract, and another to extract safe- ly in extreme deformity. Gardien mentions, that Boyer, and other judicious practitioners, had witnessed repeatedly, the mutilation and extraction of the child by eminent men, but the mother sunk immediately. In two of these cases the uterus was rup- tured. In this manner of operating, the face is drawn down first, and the back part of the occipital bone is thrown flat upon the neck like a tippet. If we reverse this procedure, and bring the occiput first, and the face last, fixing the instrument in the foramen mag- num, then, as we have the chin thrown down on the throat, we must have both the neck and face passing at once, or a body equal to two inches and three quarters. If on the other hand, we fix * I cannot learn that any case of extreme deformity in a pregnant woman, Such as to render it barely possible to deliver with the crotchet, or necessary to have recourse to the cesarean operation, has occurred in this city, [Glasgow] since the year 1775, when Mr. Whyte performed the latter operation. ■j M. Baudelocque considers the crotchet as inadmissible, when the pelvis mea- sures only an inch and two thirds*. 467 the instrument on the petrous bone, which is certainly preferable to the foramen magnum, and, bring the head sideways, we must have bodi that bone and the vertebrae passing at once, or a sub- stance equal to two inches and a half in diameter; and if the head pass more obliquely, then it is evident that the size must be a little more. Although, therefore, Dr. Osborn be correct, in saying, that the base of the cranium, turned sideways, does not measure more than an inch and a half; yet we must not forget, that when the opposite side comes to pass, the neck passes with it, which in- creases the size. The head being brought down and delivered, we then fix a cloth about it, and pull the body through; or, if this cannot be done, we open the thorax, and fix the crotchet on it, endeavour- ing to bring down first a shoulder, and then the arm. In operating with the crotchet, we must always bring the head through the widest part of the pelvis; but where the deformity is considerable, no small force is requisite. This is produc- tive of pain during the operation, and of danger of inflammation afterwards, which may end in the destruction of some of the soft parts; or, affecting the peritoneum, it may prove fatal to the patient. From injury done to the bladder, retention of urine may be produced, which, if neglected, is attended widi great risk, Incontinence of urine is less to be dreaded, as it is sometimes cured by time. Severe pain in the loins and about the hips, with lameness, is another troublesome consequence. If the patient be not affected with malacosteon, the warm, and at a more advanced period, the cold bath, friction, and time, generally prove success- ful. Much advantage is also derived in this kind of pain, from applyiug a compress on the sacro-sciatic notch, and binding it on with a roller, wound firmly round the pelvis, and all the upper part of the thigh. In considering the necessity of using the crotchet, I have not, more than in the observations on the forceps, made any special remarks on those instances, where the capacity of the pelvis is diminished by an enlarged ovarium, or other tumours, as the prac- tice is the same, or when a different course is proper, that has been pointed out in the commencement of this work. 468 To avoid tho destruction of the child, and the severity oi the operation of extracting it, the induction of premature labour has been proposed ;* and the practice is defensible, on the principle of utility as well as of safety. We know that the head of a child, in the beginning of the seventh month, docs not measure more than two inches and a half in its lateral diameter; two and three quarters in the end of that month ; and three in the eighth month. We know further, that there is no reason to expect tiiat a full grown fetus can be expelled alive, and very seldom, even after a severe labour, dead, through a pelvis whose dimensions are under three inches ; and lastly, we have many instances where children born in the seventh month have lived to old age. Whenever, then, we have, by former experience, ascertained beyond a doubt, that the head, at the full time, must bef perforated, it is no longer a matter of choice, whether, in succeeding pregnancies, premature labour ought to be induced.^) It is certainly easier for the mother than the application of the crotchet, and no man can say that it is worse for the child.f All the principles of morality, as well as of • This practice was first adopted about the middle of the last century, by Dr. Macauly in London, and was afterwards followed out by others. About twenty years after this, it was proposed on the continent by M. Roussel de Vauzeme; and lately Mr. Barlow, in the eighth Vol. of Med. Facts, 8tc. has given several cases of its success.—See also Med. and Phys. Journal, Vols. XIX. XX. and XXI. It may not be improper for me to mention as a caution, that 1 have been called to consider the expediency of evacuating the liquor amnii, where there was no deformity of the pelvis, but merely a collection of indurated faces in the rectum. Dr. Merriman has a very sensible paper on this subject, in Med. Chir. Trans. Vol. iii. p. 123. where he states that, out of 47 cases of premature labour, induced on account of distorted pelvis, 19 children have been born alive, and ca- pable of sucking. He very properly advises that, before puncturing the mem- branes, it should be ascertained that the presentation is natural. If it be not, it may become so, in a day or two. CffJ The reader is referred to a case of premature labour, artificially induced, where the child lived some time after delivery, related in the Eclectic Reper- tory, Vol. I. p. 105, and seq. The same woman was afterwards prematurely de- livered of a child before the expiration of the eighth month, which lived and did well. f It has been proposed, by low diet, to restrain the growth of the child, but this is a very uncertain and precarious practice. 469 science, justify the operation ; they do more, they demand the operation. The period at which the liquor amnii should be evacuated must depend upon the degree of deformity ; and where that is very great, it must be performed at a period so early, as to afford no prospect of the child surviving: it must be done in this case to save the mother, or sometimes it may be requisite to use the lever, even when labour has been prematurely brought on. There are cases, and these cases are not singular, where the bones gradually yield, and become so distorted, as at last to prevent even the crotchet from being used. Now, granting a succession of pregnancies to take place in this situation, it follows, as a rule of conduct, that if the deformity be progressive, we should regu- larly shorten the term of gestation, exciting abortion, even in the third month, if necessity require it, and treating the case as a case of abortion, enjoining strict rest, and plugging the vagina to save blood. Some may say, Shall we thus, by exciting abortion, des- troy many children to save one woman ? This objection is more specious than solid. Those who make it would not, in all proba- bility, scruple to employ the crotchet frequently; and where is the difference to the child, whether it be destroyed in the third or in the ninth month ? How far it is proper for women in these cir- cumstances to have children, is not a point for our consideration, nor in which we shall be consulted. I would say, that it is not proper ; but it is no less evident, that when they are pregnant we must relieve them. The interval which elapses between puncturing the membrane, and the accession of labour, varies from two to five or six days. If shivering come on before pain, an opiate is the best remedy. 4ff0 CHAP. VII. Of' Impracticable Labour. It may be urged against the reasoning in the conclusion of the last chapter, that the caesarean operation ought to be performed; and, doubtless, in cases of extreme deformity, if the proper time for inducing labour be neglected, it must be performed. But the danger is so very great to the mother, that this never can be a mat- ter of choice, but of necessity. In balancing the caesarean opera- tion against the use of the crotchet or the induction of abortion, we must form a comparative estimate of the value of the life of the mother and her child. By most men, the life of the mother has been considered as of the greatest importance, and therefore, as the caesarean operation is full of danger to her, no British practi- tioner will perform it, when delivery can, by'the destruction of the child, be procured per vias naturales. As, in many instances, the woman labours under a disease found to be hitherto incurable, it may be supposed, that the estimate will rather be formed in favour of the child. But, in the first place, we cannot always be certain that the child is alive, and that the operation is to be successful with respect to it; and, in the second place, it ought to be consi- dered, how far it is allowable, in order to make an attempt to save the child, to perform an operation, which, in the circumstances we are now talking of, must, according to our experience, doom the modier to a fate, for which, perhaps, she is very ill prepared. There are, I think, histories of twenty-three cases, where this operation has been performed in Britain; out of these only one woman has been saved,* but eleven children have been preserved. On the continent, however, where the operation is performed more frequently, and often in more favourable circumstances, the number of fatal cases is much less.f If we confine our view to the success * Vide a case by Mr. Barlow, in Med. Records and Researches, p. 154 •. t According to Dr. Hull, we had, when he published, at home'and abroad, re- .cords of 231 cases of this operation, 139 of which proved successful—Vide Translation of M. liaudelocqug's Memoir, p. 233, m pf the operation in this island, [Great Britain} we must consider it as almost uniformly fatal to the mother. This mortality is owing, not only to the injury done to the cavity of the abdomen, and the consequent risk of inflammation, even under the most favourable circumstances, and with the best management; but also to the mor- bid condition of the system, at the time when the operation was performed, many of the women being affected with malacosteon, which would in no very long time have of itself proved fatal. These dangers have, probably, sometimes been increased by delaying die operation, until much irritation had been excited. From this un- favourable view, it may perhaps arise as a question, whether nature, if not interfered with, might not, as in extra-uterine pregnancy, re- move by abscess the child from the uterus ? It has been said, that this event has taken place ; but 1 do not recollect one satisfactory case upon record. Whenever this has happened, the uterus has either been ruptured, and the child expelled into the cavity of the abdomen; or, in a very great majority of the instances, the child has, evidently from the first, been extra-uterine. We are tiierefore led to conclude, that the mother who cannot be delivered by the crotchet, must submit to the caesarean operation, or must inevitably perish, together with die fruit of her womb. It has been asserted by Dr. Osborn, that this operation can sel- dom if ever be necessary; never where there is the space of an inch and a half from pubis to sacrum, or on either side: and that he himself has, in a case where the widest side of the pelvis was only an inch and three quarters broad, and not more than two inches long, delivered the woman, by breaking down the cranium,- and turning the basis of the skull sideways. As the patient reco- vered, and afterwards, I think, died in the country, where she could not be examined, we cannot say to a certainty what the di- mensions of the pelvis were. Dr. Osborn must only speak accord- ing to the best of his judgment. I have the highest respect for his character and for his works, and nothing but irresistible arguments could make me doubt his accuracy. But from the statement which I have already tgiven of the dimensions of the head, when bro- ken down at full time, as well as from the experiments of Dr. Hull, and the arguments of Dr. Alexander Hamilton and Dr. Johnson, I 472 am convinced that there must be some mistake in Sherwood's cast. Had the child been brought by the face, there might have been room for it to pass, so far as the short diameter of the passage is concerned; but the lateral diameter is too small for the head, if of the usual size, to pass, in that which I consider as the most favour- able position. In the cases related by Dr. Clarke,* who was a practitioner of the highest authority, we are informed, that the short diameter of the passage did not exceed an inch and a half, but we are not informed of the lateral extent. As the women both recovered, the precise dimensions and construction of the pelvis cannot be determined. It is likewise much to be regretted, that the diameter of the cranium, or cranium and neck, in the state in which they may have been supposed to come through the passage, was not taken after delivery. Where, and only where, it can be ascertained, that the head placed in the position in which it was drawn through the pelvis, does not form, in any part, a substance measuring more than an inch and a half by two inches or three inches, it is allowable to infer, that the cavity through which it passed may have been as small as that. T Finally, this is a question on which, although we may lay down a general rule, we must admit of some exceptions; for a premature, or a very small child, may be brought through a pelvis which will not permit, by any means, an ordinary sized foetus to pass. But it behooves us, in our reasoning, to judge every child to be at the full time, unless we know the contrary, and to make an estimate on the average magnitude; and until the contrary is proved, by dis- section of the mother, or careful and rigid measurement of the child after delivery, I must hold to the position formerly laid down, that the crotchet cannot be used when the child is of the full size, unless we have a passage through the pelvis, measuring fully an inch and three-quarters in the short diameter, and three inches in length ; or, if the child be premature and soft, an inch and a half broad, and two inches and three-quarters long.f It is in this ex- * Vide Dr. Osborn's Essays, p. 203, and London Med. Journal, VII. p. 40. * -j-1 believe few will dispute, that the precise deformity requiring the caesa- rean operation, must to a certain extent, be modified by the dexterity of" the 473 treme deformity even questionable whether extraction be not as dangerous as the caesarean operation, and we always ought to con- sider well, before we give die preference to mutilation, in such cases. The operation itself, although dangerous in its consequences, and formidable in its appearance, is by no means difficult to per- form. Some advise the incision to be made perpendicularly in the linea alba^Ajothers transversely, in the direction of the fibres of the transversalis muscle. Perhaps the precise situation and direc- tion of the wound must be regulated by the circumstances of the case, and the shape of the abdomen; but in general, I apprehen/d, that the transverse wound will be most eligible. The length of the incision, through the skin and muscles, ought to be about six inches ; and if a vessel bleed, so as to require the ligature, it will be proper to take it up before proceeding further. The uterus is next to be opened by a corresponding incision; and as the fun- dus, owing to the pendulous shape of the abdomen, is the most operator. I shall suppose that a surgeon in a remote part of the country, far from assistance, is called to a patient, whose child is evidently alive, and whose pelvis measures just as much as would render it barely possible to use the crotchet, were he dexterous; but he has not a belief that he could accomplish the delivery with that instrument. Would that man be wrong in performing the caesarean operation ? In such a case I would say, upon the principle that a man is to do the most good in his power, that if no operator more experienced can be had within such time as can be safely granted, the surgeon ought, after takiiig the best advice he can procure, to perform the caesarean operation, by which he will save one fife at least. By the opposite conduct, there is ground to fear that both would be lost. In a case related in the Jour, de Med. for 1780, a woman, in the village of Son, had the child turned, and even the limbs separated without delivery being accomplished ,• four days afterwards, the cesarean operation was performed, and the woman died. Chj Mauriceau, Baudelocque, Capuron, Soiayres, and the generality of the modern French Accoucheurs and Surgeons who have had the greatest success in performing the Caesarean operation, prefer making the incision in the linea alba. Cooper agrees in recommending this mode. Vide Diet, of Surgery; Dorsey's Edition, Vol. I. p. 163. Some of the reasons assigned for this pre- ference, are that the incision is made with greater facility and is less painful, because there are fewer parts to be divided ; and the hemorrhage is less profuse. The uterus is readily brought into view, and it is cut in its middle portion, and parallel to its principal fibres. 61 474 prominent part, the incision will in general be made there, unless the external wound be made lower than usual. The child is next to be extracted, and immediately afterward the placenta. One assistant is to take the management of the child, whilst another takes care to prevent the protrusion of the bowels. In this part of the operation, although pretty large vessels are divided, yet the hemorrhage is seldom great: it has, however, proved fatal. The external wound is now to be cleansed, its sides brought together, and kept in contact by a sufficient number of stitches passed through the skin alone, or the skin and muscles, avoiding the peri- toneum. Adhesive plasters are to be placed carefully in the inter- vals ; and a bandage with a soft compress being applied, the patient is to be laid to rest. An anodyne should be given, to diminish the shock to the system; and our future practice must, upon the general principles of surgery, be directed to the prevention or re- moval of abdominal irritation or inflammation. The patient may die, although there be very little inflammation of the peritoneum. It has been proposed by Dr. Hull, to whose work I refer for more particular information, to operate as soon as the os uteri is dilated, and before the membranes burst, in order that the wound of the uterus may contract into a smaller size. In order to supersede the caesarian operation, and even to avoid the use of the crotchet, it was many years ago proposed to divide the symphysis pubis, in expectation of thus increasing the capaci- ty of the pelvis. This proposal was founded on an opinion, that the bones of the pelvis, either always or frequently did spontane- ously separate, or their joinings relax, during gestation and partu- rition, in order to make the delivery more easy. In deformity of the pelvis, the symphysis was first divided by a knife during la- bour, by M. Sigault, in 1777, assisted by the ingenious M. Al- phonse Le Roy. The operation was afterwards repeated on the continent, with various effects according to the degree of deformi- ty, and extent of the separation.^) It has only once* been adopt- (»*) It has of late again been recommended, by some French writers of emi- nence ; vide Capuron cours theorique et pratique, &c. p. 673 and seq. Gardien Traite d'Accouchemens, Tom. 3, p. 20, and seq. and J. B. De Mangeon, De as- sium pubis Syncbondrotomia. Paris'us, 1811. * Vide case by Mr. Whelchman, in London Med. Jour, for 1790, p. 46. 475 ed in this country, because it is not only dangerous in itself to the mother, but also of limited benefit to the child. We have already seen, that there is a certain degree of deformity of the pelvis, which must prevent a child at the full time, and of the average size, from passing alive, or with the head entire. Now, in a case where it is barely impracticable to use the lever or forceps, and where it just becomes necessary to open the head, the division may per- haps save the child, and with less danger to the mother than would result from the caesarean operation, which is the only other chance of saving the infant. If we increase the contraction of the pelvis beyond this degree, then the chance of saving the child is greatly diminished ; and the extent to which the bones must be separated to accomplish delivery, would in all probability be attended with fatal effects. In such a case, the crotchet can be employed with safety to the mother, and .continues to be eligible, until we find the space so small as to require the caesarean operation; and in this case, the division can do no good. It cannot even make the crotch- et eligible, owing to the shape of the pelvis in malacosteon, and the great mischief which would be done to the parts after the di- vision, by the necessary steps of the instrumental delivery. There is only one degree of disproportion, then, betwixt the head and the pelvis, which will admit of the division ; but the smallest de- viation from this, destroys the advantage of the operation. Now, as this disproportion is so nice, we cannot, in practice, ascertain it j for although we could determine, within a hundredth part of an inch, the capacity of the pelvis, yet we cannot determine the pre- cise dimensions of the head, and thus establish the relation of the two. On this account, the division of the symphysis pubis can- not be adopted with advantage, either to the mother or child. 476 CHAP. VIII. Of Complicated Labour. ORDER 1. LABOUR COMPLICATED WITH UTERINE HEMORRHAGE. During labour, there is always a slight discharge of bloody slime, when the membranes begin to protrude ; for the small ves- sels of the decidua, near the cervix uteri, are opened. In some cases, a very considerable quantity of watery fluid, tinged with blood, flows from the womb, but this is attended with no inconveni- ence. It may happen, however, that pure blood is discharged, and that in no small quantity. If this take place in the commencement of labour, it differs in nothing from those hemorrhages which I have formerly considered. But occasionally the flooding does not begin, till the first stage of labour be nearly or altogether complet- ed. If the membranes be still entire, it proceeds certainly from the detachment of part of the placenta or decidua, and often is connected with unusual distention of the uterus, from excessive quantity of liquor amnii, or with ossification of the placenta. If the membranes have broken, then we must consider the possibi- lity of its proceeding from rupture of the uterus, and must inquire into the attending symptoms. Sometimes it will be found to pro- ceed from tedious and exhausting labour, from improper exertion, or rude attempts to dilate the os uteri, or alter the presentation ; or it may be caused by rupture of the umbilical cord. Now, in this order of labours, the practice is very simple, and admits of little difference of opinion. For every experienced practitioner must admit, that when the hemorrhage is considerable, and is increas- ing, or continuing, the only safety consists in emptying the uterus. If the pains be smart, frequent, and effective, the labour advancing regularly, and there be reason to. suppose that it will be finished before the hemorrhage have continued so long as to produce injuri- ous effects, we may safely trust to nature. We must keep the pa- tient very cool, and in a state of perfect rest. But if the pains be weak, ineffective, and rather declining than increasing, whilst the 477 hemorrhage is rather increasing than diminishing, we must deliver the woman, either by turning the child, or applying instruments, according to the circumstances of the case, and the situation of the-head. Opiates are useful. ORDER 2. WITH HEMORRHAGE FROM OTHER ORGANS. When hemorrhage takes place from the lungs or stomach dur- ing parturition, we ought to have recourse, in the first place, to blood-letting, or such other means as we would employ were the patient not in labour. If the hemorrhage continue violent, or be increased by the pains of parturition, we must consider, whether artificial delivery, or a continuance of the natural process, will be attended with least exertion and irritation, and consequently with least danger, and we must act accordingly. In general, these cases can seldom be trusted to nature, and prompt delivery is requisite. It is scarcely necessary to add, that a complication of labour, with other diseases than hemorrhage, but which may be incurred by it to a dangerous or fatal degree, will equally justify interference. ORDER 3. WITH SYNCOPE. Syncope may proceed from various causes, such as hemorrhage, or rupture of the uterus; but these cases have been already, or will be considered. It may proceed from a delicate nervous con- stitution, from long continued labour, from particular states of the heart or stomach, and from passions of the mind. A simple paroxysm of fainting, unless it proceed from causes which would otherwise incline us to deliver, such as tedious labour, flooding, he. is not to be considered as a reason for delivering the woman. We are to employ the usual remedies, and particularly keep the person in a recumbent posture. Ammoniated tincture of valerian, or tincture of opium, are useful. But if the paroxysms be repeated, whatever their cause may be, we ought to deliver the woman, if the state of the os uteri will permit. We must be very careful to prevent hemorrhage, after the expulsion of the child. 478 ORDER 4. WITH CONVULSIONS. Convulsions may occur, either during pregnancy or labour, and are of different kinds, requiring opposite treatment. One species is the consequence of great exhaustion, from excessive fatigue, te- dious labour or profuse hemorrhage. This makes its attack with- out much warning, and generally alternates with deliquium, or great feeling of depression and debility; the muscles about the face and chest are chiefly affected, and the pulse is small, compressible, and frequent, the face pale, the eye sunk, the extremities cold. The fits succeed each other pretty quickly, and very soon terminate in a fatal syncope. This species naturally requires that we should, first of all, check the farther operation of the exciting cause, by restraining hemorrhage, or preventing every kind of exertion, and then husband the strength which remains, or recruit it by cordials. Opiates are of great service. Delivery is usually necessary. Hysterical convulsions are more common during pregnancy than labour, and have already been noticed. I have only to say here, that the muscles of the trunk and extremities are affected to a great- er degree than those of the face : there is an appearance of glo- bus, often considerable palpitation, and occasionally a kind of crowing or screaming during the fit. At the termination of it there is usually wind discharged from the stomach, and often as the struggling is about to end, the bowels seem to be much inflated, and suddenly subside. Part of this, however, is a deception, for the spine is in such cases frequently bent back, so as to render the abdomen apparently more prominent. In the interval there is a tendency to laugh or cry, or sometimes a childish appearance. This kind of convulsion is rare in the parturient state. If the face be flushed, or there be headach, and suffusion of the eyes, vene- section should be premised ; and if this be not sufficient, then we give antispasmodics. If on the other hand there be no undue vas- cular action or determination to the head, we may at once give an- tispasmodics, such as tincture of valerian, or assafcetida ; a smart clyster is also of great service. If these means fail, and the labour 479 be far advanced, it will be proper to employ the forceps, but in general artificial delivery is not required. The most frequent species of puerperal convulsions, however, is of the nature of eclampsia, which occurs a hundred times for once that the others appear. Convulsions may affect the patient suddenly and severely. She rises to go to stool, and falls down convulsed ; or, sitting in her chair, conversing with her attendants, her countenance suddenly alters, and she is seized with a fit; or, she has been lying in a sleep, and the nurse is all at once alarm- ed by the shaking of the bed, and the strong agitation of her pa- tient. Immediately all is confusion and dismay, and the screams of the females announce that something very terrible has happen- ed. Presently the convulsion ends in a short stupor, from which the woman awakes, unconscious of having been ill; and thus for a time, the apprehensions of the attendants are calmed. But in a short time the same scene is generally repeated ; or, perhaps, al- though the convulsion have gone off, the stupor remains ; and it is always more unfavourable when the patient continues insensible in the interval of the fits. It is, however, not unusual for the fit to be preceded by some symptoms, which, to an attentive observer, in- dicate its approach. These may even exist to a degree which cannot be neglected. They are, headach, which is sometimes dreadful; ringing in the ears ; dazzling of the eyes, or appearance of substances floating before them, either opaque, or, more fre- quently, of a fiery brightness. In other cases, the first indication is violent pain in the stomach, with insupportable sickness, for, sometimes, the stomach is the first part which suffers from irrita- tion of the origin of the nerves, and the patient may die before con- vulsions take place. The pulse usually is slow; the patient some- times sighs deeply, or has violent rigours, which, in the second stage of labour, are always hazardous. There is great drowsiness during the pains. It is neither uncommon nor dangerous for the woman to be drowsy between the pains; but here, even during them, she falls into a deep sleep. When the attack comes on, which very often is soon after these preludes appear, the muscles are most violently convulsed ; the whole frame shakes strongly, 480 and the face is dreadfully distorted* and often swollen. The tongue is much agitated, and is very apt to be greatly injured by the teeth ; foam issues from the mouth* and the convulsive inspi- ration often draws this in with a " hissing noise;" or she snores deeply, and cannot be roused during the fit. The skin becomes, during the convulsion, livid or purple. The pulse, during the whole of the disease, is often slow, but sometimes it does at last become frequent, small, and irregular. This attack may end at once in fa- tal apoplexy, but generally the patient recovers, and is quite insen- sible of having been ill. There may be only one fit; and without any interference, I have known the disease go off, and no return take place; but in general the attacks are repeated, and if they do not prove soon fatal, or are not averted by art, they recur with die regularity of labour pains, becoming more and more frequent as they continue. The woman appears to have no labour pains, yet the os uteri is affected, and sometimes the child is expelled, or if the patient become sensible in the intervals, and feel a pain coming on, it appears to be speedily carried off by a supervening convul- sion. The fit may last only a few seconds, or may continue with very little remission for half an hour. In some instances the patient is not sensible of bearing the child, and is afterwards long of recol- lecting her delivery. Convulsions may occur in any period of labour, or before it has begun, or after the delivery of the child; and in this last case, are sometimes preceded by great sickness or oppression of the sto- mach. Dr. Leak relates the case of a patient who had ten or eleven of these fits; the abdomen was swelled and tense, and she vomited phlegm mixed with blood, which probably came from the tongue. She recovered by means of blood-letting and clysters. Puerperal convulsions are quite different from epilepsy, for they recur at no future time, except perhaps in a subsequent pregnancy. They take place in greater number in a given time, than epilepsy does in general, and belong to the genus Eclampsia of Sauvages, " artuum vel musculorum plurimorum spasmus clonicus acutus, * Mr. Fynney gives a case, where the lower jaw was luxated during convul- sions, which came on in the birth of a second child, or twin. Med. Comment. Vol. IX. p. 380. m fum sensuum tjbscuratione." This differs from his definition of epilepsy, by the absence of the character " periodicus;" and on the same principle Vogel simply defines it " epilepsia acuta." The principal difference, and one of a highly important nature in prac- tice, is, that whilst the symptoms are the same in both diseases, they arise, in epilepsy, from some organic affection of the brain, or direct irritation of diat organ ; whilst, in eclampsia, they rather de- pend on some sympathetic and temporary cause. Hence, eclamp- sia may be produced by worms, by costiveness, indigestion, he. \ and occasionally, not only by the parturient condition of the uterus, but also by other affections of the same organ, in the virgin state. I have seen distinct cases of eclampsia, where the fits were very severe, and repeated, and accompanied, in the interval, with coma, or delirium, caused altogether by menstrual irritation, attended with severe pain in the hypogastrum and bearing-down sensation. In such cases venesection and purgatives give relief, and a blister on the head perfects the cure. Fomentations, or the hot bath, are also useful, but opiates are not to be given, at least at first. To re- turn from this digression, puerperal convulsions often recur exactly like labour pains, or are frequently accompanied or preceded by them ; though, when the convulsion comes on, the feeling of pain is suspended, and often, but not always, the uterine contraction i^ stopt or diminished.^ The same observation applies to excessive rigours, which are indeed a species of convulsions, but are not at- tended with distortion of the face, nor insensibility. If the patient be in a state of stupor, she frequently has the countenance distorted at intervals, accompanied with some uterine action. They are never preceded by aura, and the patient usually recovers sensibility much sooner, and more completely during the intervals, than in epilepsy; at the same time there have been instances of die patient fkj Dr. Clarke of London, thinking it necessary, in a case of convulsions, to turn the child and deliver it, a convulsion occurred whilst his hand was in the uterus, when, of course, he had an opportunity of observing how it was affected. —He remarked, that instead of a regular contraction taking place, the uterus deemed to flutter, or be irregularly and tremulously contracted and relaxed again quickly, and he was disposed to believe, that it was in that state during eveTy <-.Lse of puerperal convulsions. **shape of the uterine cavity. Lastly, we find, that if exertion have been used before the ute- rus has been perfectly restored, there may be excited a draining of blood, which does not come, in general, very rapidly; but, from its constant continuance, amounts ultimately to a considerable quantity, and impairs the health and vigour of the woman. This has been called menorrhagia lochialis. * When the abdomen has been bandaged too tightly, the parts within are in- jured. The patient is restless and uneasy; the pulse is frequent; she complains of pain about the uterus, and numbness in the thighs. Sometimes the lochia are obstructed; sometimes, on the contrary, pretty copious hemorrhage is produced. Relief is obtained by slackening the bandage; by giving an anodyne; and, if there be no hemorrhage, by fomenting the belly. •j- This, at first, is owing to muscular contraction ; afterwards, absorption forms part of the process. But if these operations shall be interrupted, or injured, then the vessels, which are still large, not being duly supported, will be very apt to pour out blood. 513 When hemorrhage, whether external or internal, takes place in. moderate quantity, immediately after the expulsion of the placenta, and when the system does not seem to suffer materially, we may be satisfied wkb firmly supporting the uterus by external pressure, and applying a dry cloth closely to die orifice of the vagina. The blood thus coagulates in the uterus, which, being supported by the external pressure or bandage, does not distend, and the action of its fibres is soon excited. After-pains are to be expected, but the fear of hemorrhage is removed. In some instances, when we have had no external hemorrhage, and die blood has been slowly pour- ed into the uterine cavity, little inconvenience is produced for some time. But presently, by the pressure of the womb on the neck of the bladder, a retention of urine is caused, attended with much pain in the belly. This is in general instantly removed, by introducing the finger into the vagina, and raising up the uterus. If it should not, the catheter must be employed. But whenever hemorrhage takes place to such an extent as to endanger the patient, and produce the effects 1 have already men- tioned, then we must interfere more actively : and I need not at- tempt to prove, that die only security consists in uterine contrac- tion. This is to be excited by the .application of cold, and by the introduction of the hrmd, not simply lo extract the coagula, but to stimulate the uterus, and,rather make it expel them. It in general will be found that die uterus is affected with spasm. Nothing is so useful as retaining the hand for some time in the lower part of the uterus, and occasionally gently dilating the contracted spot above, at the same time diat we rub externally. The extraction of coa- gula from the cavity is of signal benefit, and, if necessary this must he done oftener,than once. Gardien has made a practical remark, which perfectly agrees with my experience, that the successive emptying of. the uterus is the best remedy, yet this must not be done too rapidly. What good can accrue from allowing coagula to remain ? It cannot prevent the farther flow, for no vessels of such size as the uterine can be stopped lin.tliis way. No harm can arise from their removal; for if the womb do not contract, and the. flow continue, we re-introduce the hand, and are at least as well a» we were before. We must also proceed with opiates, cordials, 60' 514 and nourishment, upon the rules formerly stated for recovery; and we shall do well, not to be in a hurry to quit our patient, for the hemorrhage may be renewed, and she may be lost before we can see her. *•■• When the hemorrhage proceeds from irregular action of the ute- rus, and is attended with grinding pain, a full dose of tincture of opium is of advantage, and seldom fails' in relieving the patient. If the placenta have been torn, and a portion of it remain attach- ed to the uterus, the hemorrhage is often very obstinate. Both clotted and fluid blood will be discharged repeatedly. The clot has the shape of the uterus, and is expelled with fluid blood like an abortion. An offensive smell proceeds from the uterus, and at last the portaon of placenta is expelled in a putrid state, after the lapse of many days, or even weeks ; and this expulsion is often at- tended with severe attack of hemorrhage. By examination, the os uteri will be found soft, open, and irregular. If by the introduction of the finger we can feel any thing within the uterus, it should be cautiously extracted ; but we are not to uso force or much irritation, either in our examinations or attempts to extract, lest we inflame the womb. It is more advisable to pltig the vagina, and even the os uteri, so as to confine the blood, and excite the uterine contraction. We may also inject some cold and astringent fluid for the same purpose, or throw a full stream of cold water into the uterus, from a large syringe, by way of washing out the portion of placenta, if it have become nearly detached. A gentle emetic sometimes promotes the expulsion. The bowels are to be kept open, and the strength supported by mild and nou- rishing diet; but we must take care, on the other hand, not to fill the vessels too fast. If febrile symptoms arise, the case isstill more dangerous, as I will presently notice. When the hemorrhage proceeds from an interruption of the pro- Cess of restoration, our principal resource consists in exciting the contraction of the womb by the use of clysters—by friction on the abdomen—hy injecting cold and astringent fluids into the wTomb~— by the exhibition of a gentle emetic—and by throwing cold water from a syringe upon the abdomen, when the womb is expelling the coagulum. We also check the ^hemorrhage, and save bloo4t, 515 by the prompt application of the plug, and diminish the action of the vessels themserves, by allaying or removing every irritation, and avoiding the frequent use of stimulants, or attempts to fill the vessels too quickly. The feeling of sinking, sickness, tendency to syncope, he. are to be obviated by the means already pointed out. Lastly:—The menorrhagia lochialis is to be cured by rest, cool air, the use of tincture ofjikino, sulphuric acid, or odier tonics, bathing the pubis or back with cold water, and injecting an as- tringent fluid three or four times a-day into the uterus. Some- times whenever the discharge stops, the patient complains much .of stomachic affection. This is to be allayed by laxatives and aro- matics, or rubefacients applied to the epigastrium. When it alter- nates with diarrhoea, confectio catechu is useful, along with some bitter tincture. If the pulse be frequent, the exhibition of digitalis for a short time will.be of advantage. Pain in the back generally attends this disease, and is sometimes so severe as even to affect the breathing. In this case, a warm plaster applied to the back is often of service ; and, if the pulse be soft, an anodyne should be administered. In slight cases, the application of cloths dipped in cold vinegar, to the back, does goodft) fO Tne acknowledged efficacy of the ergot, in increasing the energy of uterine contractions, would appear to point it out as a proper remedy to be had recourse to in the cases of hemorrhage alluded to in this chapter; and as Dr. Bigelow has well observed, in females habitually subject to profuse hemorrhage; at the period of parturition, there is perhaps no better preventive than a full dose of ergot, administered just before delivery. The editor has been in the practice of exhibiting it in powder, in doses of a scruple, mixed in any syrup ; but it may also be given in infusion or decoction ; for instance, a drachm of the powder may be infused in half a gill of boiling water and a table spoonful of the turbid fluid, may be giyen every 20 minutes, till its effects are perceptible. £16 CHAP. 111. Of Inversion of the Uterus. Inversion of the uterus implies, that the inside is turned out, and down into the vagina. It may take place in different degrees, and it has been divided accordingly into the simple depression ; "the incomplete inversion, when the fundus is merely engaged in the orifice ; and the complete, when it protruded out of the vagina, and exacdy resembled the uterus after delivery, only the mouth turned upward. The vagina is, in this case, also partly reversed or inverted, so that the tumour is of considerable length. When it is partial, the tumour is retained altogether, or chiefly within the vagina, and the fundus only protrudes to a certain degree through the os uteri, forming a firm substance, something like a child's head.* When the uterus is inverted, the patient feels great pain, generally accompanied with a bearing-down effort, by which a partial inversion is sometimes rendered complete. The pain is obstinate and severe, she feels very weak, the countenance is pale, the pulse feeble, perhaps nearly imperceptible, a hemor- rhage very generally attends the accident, and often is most pro- fuse. But it is worthy of notice, that frequently complete inver- sion is not accompanied with hemorrhage,! whilst a very partial * Mr. White of Paisley describes it very well, as resembling a printer's ball. Med. Com. Vol. XX. p. 147. Sometimes it does not pass through the os uteri. Denman, II. p. 351. Mangetus, lib. IV. p. 1019, relates a fatal case, where the turoour was taken for the head of a second child. It was at first partially, and then completely, in- verted with excruciating pain. Mr. Smith relates a case of inversion, where the accident was followed'by syn- cope, subsultus, &c. The subsultus and frequent pulse continued for some days, with smart fever, and inability to move. Med. and Phys. Jour. Vol. VI. p. 503. In the same volume, Mr. Primrose gives an instance where a great part of the uterus sloughed off, and the woman recovered. \ This was the case, in the instance related by Dr. Hamilton. Med. Com. Vol. XVL p. 315.--In the case by Mr. Brown, the hemorrhage was considerable. 517 inversionAnay be attended with a fatal discharge ; although there be little hemorrhage, the face is pale, and the pulse weak and rapid, a sensation of dragging at the stomach or a feeling as if the bowels were pulled out of the belly, may accompany inversion. Fainting, and convulsions, are1 not unfrequent attendants, although the hemorrhage have been trifling. Inversion is suspected to ex- ist from the symptoms nt&itioned, and on examination, the womb is felt more or less protruded like a mass of flesh, whilst no hard uterus can be discovered in the hypogastrium. Inversion, in a great majority of instances, depends upon the midwife* endeavouring to extract the placenta, by pulling the cord.(u) Sometimes the uterus is directly pulled down, and the placenta still adheres; in other cases it is separated. It may also happen, if the child be allowed to be rapidly expelled; for if the cord be short, or entangled about the child, the fundus may receive a sudden jerk, and become inverted. From the same cause, or sometimes perhaps from sudden pressure of part of the intestines on the fundus uteri, occasioned by strong contraction of the ab- dominal muscles, a part of the fundus becomes depressed like a cup, and encroaches on the uterine cavity. This generally recti- fies itself if let alone; but if the cord be pulled, or if there be any tendency in the uterine action, to go toward the fundus, as happens when that part is lacerated, and may in like manner occur in the Annals of Med. Vol. II. p. 277. I have seldom seen much hemorrhage attend complete inversion. * Chapman relates a case of inversion, where the midwife pulled forcibly at the uterus, and excited convulsions, fainting, and death. Case 29, p. 123. (~uj Or probably, by pulling at the cord before that contraction of the uterus which is to expel the placenta from its S>IS^®!m0 AS our author has not fully illustrated the mechanism of labour, as was desirable, in the different presentations of the vertex, and as an accurate and precise knowledge of the posttion of the head is riecessary, preparatory to the proper application of and action with the forceps or vectis, we have thought it best to add the descrip- tion of the passage of the head through the straits and cavity ofthe pelvis in the six different positions of the vertex, as minutely laid down and detailed by Baudelocque and Gardien. To these au- thors we must therefore acknowledge our obligations for the pages that follow ; and we are persuaded, that to the student and young practitioner of midwifery, they will not be superfluous, but on the contrary, will deserve the most serious attention, as a compass to guide him in his course through, what would otherwise prove, a wilderness of doubt and uncertainty. We have also added a table from the last edition of Baude- locque's art des accouchemens, which shows the comparative fre- quency of the different presentations, [at least in Paris] and of those difficult and preternatural cases which peremptorily require the assistance of art, either by means of the hand alone, or by the aid of instruments. It has already been explained, that the vertex or crown ofthe head, the presentation of which constitutes the first order of natu- ral labours, is recognised by the presence of a round solid tumour, of greater or lesser size, upon which we can trace several sutures and fontanelles. But even when the vertex presents, the sutures and fontanelles do not always answer to the same point; which has induced prac- titioners of midwifery to distinguish the different positions of the vertex, accordhig to the manner in which, tbis part presents at the 582 bupcrior strait, and which we determine by the relative situation of the fontanelles, and the direction of the sutures. Although there is no point of the pelvis to which the posterior fontanelle, which we should always take for our guide, may not correspond, we may nevertheless confine the number of positions to six principal ones. Indeed, a sufficiently accurate idea might be given of natural parturition, by describing a lesser number of positions. But it becomes necessary to admit them as above enu- merated, to explain fully those cases, where the intervention and aid of art becomes necessary. For properly to apply the forceps, and to act widi them advantageously, the accurate knowledge of these different relations of the foetal head with the pelvis, as well as its progress through the different stages of the labour, until de- livered, is supposed to be well understood. More clearly to comprehend this part of our subject, we may consider the circumference of the pelvis as divided into two seg- ments, or semi-circumferences, one anterior and the other posterior. In the three first positions, [which have already been briefly enu- merated in a note to Chapter 1st of the 2d Book, and which we shall presently more fully explain] the posterior fontanelle answers to one, of what we may venture to term the cardinal points of the anterior semi-circumference ; in the three last, the same posterior fontanelle answers to one of the diametrically opposite points of the posterior semi-circumference. If we observe the direction that tho head pursues in each of these positions, when it is expelled by the efforts of nature alone, we shall find, that in each of them, it offers some peculiarities, which it is of importance to understand. The mechanism of these different species of labour, ought to be studied with the greater at- tention, as it is this knowledge, which is to guide the practitioner in all his operations, in those cases of labour, where malposition of the head occurs. Vide Chap. IV. Book II. First Position. In this position, the posterior fontanelle answers to the left acetabulum. The back of the infant is situated towards the anterior and left lateral portion of the uterus and pelvis. The face and the breast answering to their posterior and right lateral portions. The feet and breech are towards the fundus uteri. 583 At the commencement of labour it is frequently only the middle portion of the sagittal suture which presents at the centre of the su~ perior strait. Whilst both the fontanelles remain as yet out of the reach ofthe finger in the common examination; we cannot,there- fore, at this period, accurately determine the precise position of the head. For although we may ascertain that the sagittal suture is directed from the left acetabulum to the right sacro-iliac symphy- sis, we are as yet ignorant whether the posterior fontanelle is situ- ated in the anterior or posterior segment of the pelvis, and of con- sequence, whether the vertex presents in the first or the fourth po- sition. The same difficulty presents in discriminating between the 2d and the 5th position, and between the 3d and the 6th, whilst we can merely reach the sagittal suture. In the first period of labour, it is commonly one of the parietal' bones which presents. As the labour advances, the middle portion of the sagittal suture retires from the centre of the pelvis, to give place to one of the fontanelles; and it is the posterior fontanelle that most frequently presents. When the waters have been discharged, the first contractions of the uterus tend, in the natural progress of labour, to bend the head upon the breast. Whilst this is taking place, the posterior fontanelle approaches nearer and nearer to the centre of the pelvis. The head thus bent, continues to progress through the ca- vity, by passing from before backwards, in order to accommodate itself to the axis of the superior strait. It continues to descend,. until checked by the sacrum, the coccyx, and the perinaeum. Whilst the head descends into the cavity of the pelvis in a dia- gonal direction, one of the parietal protuberances passes before the left sacro-iliac symphysis, and the other behind the right ace- tabulum. In this position, it is the right parietal bone which answers to the arch ofthe pubis. One of the branches ofthe lambdoidal su- ture answers to the left limb ofthe pubis, and the other branch is' directed towards the left ischiatic notch. This has been often mis- taken for the sagittal suture, and in consequence of its direction, which is from before backwards, it has been supposed that the head had already performed its movement of rotation, by which 584» \j the posterior fontanelle is ultimately brought under the arch of the pubis. The head having arrived at the bottom of the pelvis, cannot any longer follow its first direction, because it is checked by the sa- crum and coccyx. The contractions of the uterus continuing to act upon it, force the occiput, as it were, to revolve from behind forwards upon the inclined plane, which the left side of the pelvis offers, in order to advance towards the symphysis of the pubis; whilst at the same time,, the face turns into the hollow of the sa- crum, as it were revolving from before backwards upon the inclin- ed plane, which the other side of the pelvis presents. If the fin- gers are placed upon the posterior fontanelle, whilst the head re- tains it lateral position, it may sometimes be perceived to perform this movement on its axis during a strong pain. Whilst the occiput approaches the arch of the pubis, the trunk remains without motion in the uterus. This pivot-like motion of the occiput, depends solely upon the twisting of the neck. Tim rotation being performed, the posterior fontanelle is situated to- wards the centre ofthe arch of the pubis, and the anterior towards the sacrum. The sagittal suture is parallel to the great diameter of the inferior strait. The branches of the lambdoidal suture an- swer to each side of the pelvis. The chin, which, until this period, had remained constantly, ap- plied to the breast, begins to recede from it. The occiput dilates the external parts, and engages under the arch of the pubis, under which it revolves, in rising and approaching towards the abdomen of the mother. Whilst the occiput thus progresses, the nape of the neck, which may be considered as the centre of motion, re- volves under the inferior edge of the arch of the pubis. In this motion, the occiput passes over but a small space, whilst the chin, in describing a curve, progresses from the sacrum to the inferior commissure ofthe labia. The expulsive forces bear upon the fore- head and upon the face, during this period of labour, and oblige ihe chin to recede from the breast. The neck is sufficiently Ion"- to allow the head to be delivered without the trunk's advancing If the head in its passage does not accommodate itself to this curve line, above described, but descends directly in the direction of the 585 axis of the superior strait, every effort bears upon the perinaeum, which is then in danger of rupturing in its centre. If we do not succeed in obliging the head to follow the direction above des* cribed, by applying pressure from behind forwards, and from the perinaeum upwards, the only means which remains to prevent the laceration of this part is to apply the forceps, in order to direct the head forward, and thus oblige the chin to recede from the breast. Scarcely is the head delivered, when the face turns towards the right thigh of the woman, to which it answered in the com- mencement of labour; for it only turns into the hollow of the sa- crum, in consequence of the twisting of the neck, and resumes its first position, as soon as the neck is restored to its former situa- tion. When the head is completely delivered, the shoulders, which had entered the superior strait diagonally, as well as the head, turn t)ne towards the pubis, and the other towards the sacrum. The left shoulder, which is towards the sacrum, approaches the vulva, and begins to be engaged there, whilst the right shoulder remains applied behind the symphysis of the pubis, until the other appears externally; which indicates, that when it is proper to assist in ex- tricating the shoulders, we should act principally upon that which is placed posteriorly. Such Is the progress of nature in this species of parturition, as every one may convince himself, if he will trace it step by step, through the course of the labour. And in observing it, he will be able to distinguish three different movements. In the first period, the head bends itself towards the breast, and progresses through the cavity of the pelvis. In the second it performs a motion, which brings its long diameter in the direction of pubis and sacrum. In the third, the chin quits the breast, and the occiput turns back- wards, in disengaging itself from under the pubis. The head ought to present its greatest diameters to the greatest diameters of the straits; but as it regards the superior strait, it does not present as is commonly supposed, its smallest diameter to the smallest of that strait. Its smallest diameter is directed from one sacro-iliac symphysis, to the opposite acetabulum. The 7« 586 portion of the head which passess between the pubis and the sa- crum, is still narrower than that which is termed its small diameter. - This species of labour would always be the most advantageous, if the laws of nature were invariably carried into effect, but in pro- portion as nature varies from the line that has been delineated, the labour becomes more and more difficult, and often indeed im- possible, without the aid of art. Second Position. In this position the posterior fontanelle is placed behind the right acetabulum, and the anterior is situated before the left sacro-iliac symphysis, so that the back of the child answers to the anterior and right lateral portion of the uterus, and of the pelvis; whilst the face, the breast, and the knees, are situ- ated towards their posterior and left lateral portions. The mechanism of labour in this position, is perfectly similar to that of the preceding. As in that, if the expulsive forces are di- rected in such a manner, as to apply the chin of the infant more and more to the breast, the occiput progresses during the first period through the depth of the cavity. In the second period, the occi- put slides from behind forwards upon the inclined plane, which is presented by the right, side of the pelvis, in order to place itself under the arch of the pubis; whilst at the same time, the face turns into the hollow of the sacrum. In the third period, the ex- pulsive forces oblige the chin to recede from the breast; the oc- ciput dilates the vulva as it turns upwards towards the pubis. This movement of the occiput is but inconsiderable ; it does no- thing but turn itself, whilst the nape of the neck revolves under the superior part of the arch. In order that this revolving of the head backwards, which facilitates its expulsion may take place, il is necessary that the face should pass over a curve which mea- sures in extent the whole length of the sacrum, to the anterior edge of the perinaeum. As soon as the head is delivered, the face turns towards the left thigh, to which it primarily answered. The left shoulder turns towards the pubis, and the right towards the sacrum. This latter alone advances until it appears at the vulva. The relative proportions of the diameters of the child, with those of the pelvis, are really the same in this position as in the former. The occiput and the face have not a larger space to 587 traverse to arrive, the one at the symphysis pubis, and the other in the hollow of the sacrum, in the position where the posterior fontanelle is situated towards the right acetabulum, than • in that where it is placed behind the left. Hence it would _$tfppear,that one of these positions ought to be as favourable a*.'s the othr to the expulsion of the child. But there are, notwithstanding, g'ater difficulties experienced in that where the occiput is U.^ the igbt; because the rectum, which is placed on the left side of &-be scrum, prevents the forehead from turning so readily into the hcilow of that bone. Practitioners have supposed that it more frequendy happens in this position, than in the preceding, that the direction of the ex- pulsive powers, instead of advancing the occiput, as in the natural order, tends to throw it back upon the shoulders. What truth there is in this supposition, we shall not here stop to investigate. , Third Position. In this position the posterior fontanelle is behind the symphysis pubis, and the anterior before the projection of the sa- crum. The back of the infant is towards the anterior, and its abdo- men towards the posterior portion ofthe uterus. For a long time this was considered as the most common and the most advantageous po- sition, but both of these suppositions are incorrect; for experience on the contrary proves, that it is very rare; so much so indeed, that many practitioners who have never met with it, have absolutely called its existence in question. Those who have imagined that the occi- put constantly answered to the pubis from the commencement of labour, have only thought so, because they observed it disengage itself in this direction from the inferior strait. A regular examina- tion through the whole process, would have taught them, that al- though the occiput is expelled from under the pubis, it nevertheless enters the superior strait diagonally. When the occiput passes through the superior strait directly behind the symphysis pubis, the long diameter of the head is opposed to the small diameter of this strait. The difficulty which is experienced by the head in its passage must be greater, as the friction must be more consider- able. If no obliquity exists, parturition may nevertheless be ac- complished with a sufficient degree of ease; because in a well formed pelvis, the short diameter of the strait is four inches, and the long diameter of the head is no greater. If the head engages 588 favourably, it only presents its height, or its perpendicular diame- ter, because the chin rises towards the breast of the infant, which faciiifa *es the expulsion of the head. There jvc but two periods to be taken notice of in the progress of tls specie^ °f labour; the face remains towards the perinaeum for sme timre after the delivery of the head; it does not turn to one o0ther* ofthe thighs, until after the shoulders, which had en- tered le tf superior strait diagonally, have presented at the inferior strait, one being towards the pubis, and the other towards the sa- crum ; but they turn indifferently to one or the other part of the pelvis, because the head has not been obliged to perform the pivot-like motion. Of course, it is not in our power previously to designate, which shoulder will turn towards the pubis. Fourth Position. In this position the anterior fontanelle is be- hind the left acetabulum, and the posterior before the right sacro- iliac symphysis, and the course ofthe sagittal suture is obliquely, from the former to the latter point. The back of the infant is to the right posterior portion, and its breast, &c. towards the left anterior portion of the uterus. Although at the commencement of labour, the posterior fonta- nelle is placed towards the right sacro-iliac symphysis, the face does not always come out under the arch of the pubis. We some- times observe, that the occiput approaches the right acetabulum, in proportion as the head advances in the pelvis. When this sponta- neous conversion of the fourth to the second position takes place, it is to be considered as extremely favourable for the patient. From hence an inference has been drawn, that when the practitioner meets with this position, he ought at the commencement of labour to facilitate its progress, and lessen the sufferings ofthe female, when the face is turned towards the symphysis of the pubis, by making an effort to disengage it from that part, and bring the occiput during the pains, rather forward towards the pubis, than towards the sa- crum. If the membranes have not been ruptured, it is impossible to touch the head during the existence of a pain. This conversion cannot be accomplished without risk, except we act at the instant of the discharge of the waters. When nature spontaneously pro- duces this conversion in the fourth and fifth positions, the same change of relative situation takes place in the trunk. We ought not, 589 therefore, to attempt producing it by art, unless the child is suffi- ciently moveable, to permit the trunk to undergo the same changes in situation as the occiput; unless this were the case, the neck would suffer a twisting, which would amount to the third of a circle. It may be important to recollect the possibility of this conversion, in those cases in which we are obliged to apply the forceps, because the mode of proceeding will be different if that has taken place. We should, therefore, before applying the forceps, endeavour to ascer- tain whether or no the face is towards the pubis. If the change of position, of which we have just spoken, has not taken place, the delivery of the head becomes more difficult, be- cause, in the second period, the face turns towards the symphysis of the pubis. This part is disengaged with more difficulty from under the arch of the pubis, than the occiput; for the arch has less breadth in its superior part, than the forehead and the face of the infant. The form of the occiput, on the contrary, accommodates itself very well to the arch ofthe pubis, under which it turns, whilst the face disengages itself behind. If in this position, the contractions of the uterus are directed in such a manner, as to bear upon the occiput, it descends into the pelvis, passing before the right sacro-iliac symphysis. When the head reaches the sacrum, it can no longer follow its first direction. The contractions of the uterus oblige it to perform a pivot-like mo- tion, which turns the occiput into the hollow of the sacrum, de- scending along the inclined plane of the right side; whilst at the same time, the forehead places itself under the pubis, sliding along the inclined plane, which the left side of the pelvis offers. At the end of this second period, the anterior fontanelle is situated behind the pubis, and the posterior towards the sacrum. In the last period, the forehead cannot engage under the arch of the pubis, as the occiput does in the three preceding positions; it is obliged to ascend behind the symphysis, to the internal surface of which it remains applied, whilst the posterior fontanelle passes over the length of the sacrum, the coccyx and the perinaeum, to arrive at the bottom of the vulva. At this moment the edge of the peri- naeum is considerably stretched, and runs a greater risk of lacera- tion than in the preceding positions. The perinaeum not being ca- pable of remaining stationary upon the inclined plane which the 590 occiput offers, retires suddenly towards the base of the neck of the infant. The posterior edge of the perinaeum becomes then the point of support, or axis, upon which the nape of the neck revolves, whilst the occiput turns backwards towards the anus of the woman In proportion as the head turns backwards upon the perinaeum, the face disengages from under the pubis. We observe successively appear the forehead, the orbits, the nose, the mouth and the chin. As soon as the chin appears externally, the face turns towards the left thigh, to which it primarily answered. The left shoulder pre- sents afterwards towards the pubis, and the right towards the sa- crum. That which is posterior, disengages the first, the other re- maining stationary at that time. Fifth Position. In this position the anterior fontanelle is behind Hie right acetabulum, and the posterior before the left sacro-iliac symphysis. The back of the infant is towards the left and posterior part of the uterus, its breast and abdomen is towards the right and anterior part. It is not unfrequently the case, that the efforts of nature alone are competent to convert this position into the first, the occiput gradually approaching towards the left acetabulum, hi proportion as it descends into the pelvis. All the observations that have been made on the preceding position, with respect to attempt- ing, by the aid of art, what nature herself sometimes performs, are equally applicable to this position. The relations of the dimensions of the head of the child with those of the pelvis, are absolutely the same in this position, as in the preceding; the face turns equally upwards. Hence the mecha- nism of this species of labour, is in every respect similar to that of the preceding position. If every thing is in the natural order, the occiput descends into the pelvis, passing before the left sacro-iliac symphysis. In the second period it turns towards the sacrum, at the same time that the forehead turns towards the symphysis pubis. The presence of the rectum on the left side ofthe pelvis, renders this rotation more difficult, by preventing the occiput from turning freely into the hollow of the sacrum. This position is one of those, in which it is most essential to evacuate the rectum by an enema. As soon as the face is disengaged from under the pubis, it turns to the right groin. The right shoulder is afterwards directed towards 591 the pubis, and the left towards the sacrum. The latter alone ad- vances until it appears at the vulva. Sixth Position. In this position the anterior fontanelle is behind the pubis. The sagittal suture is parallel to the smallest diameter of the superior strait. The occiput and the back of the infant is towards the sacrum. This position is the least favourable of all those which the occi- put can take. Not only does the head present its length to the smallest diameter of die superior strait, but also the face is anterior, as it regards the pelvis, as in the two preceding positions. Hap- pily it is the most rare of all. The rounded form of the head, with difficulty permits it to remain fixed during labour against the projection of the sacrum, so that even supposing it should answer to this part of the sacrum at the commencement of the labour, it would soon turn to one of its sides, which would be better accom- modated to its figure. When we happen to see the face disengage itself from under the pubis towards the end of labour, we are not thence to suppose, that the head engaged in that way in the supe- rior strait. Although in the two preceding positions, the head tra- verses this strait in a diagonal situation, the face, which in the first period, was placed toward one or other of the acetabula, turns by a pivot-like motion towards the arch of the pubis, from under which it is delivered. We can distinguish but two periods in this position. If the ex- pulsive forces of the uterus act upon the occiput as occurs in the natural order, it progresses through the peh/is before the sacrum. Whilst the forehead is applied against the internal surface of the symphysis of the pubis, the occiput, which ought to be delivered first, considerably distends the perinaeum, passing over a curve line which extends from the hollow of the sacrum to the lower edge of the vulva. At this instant the perinaeum retires backwards, and. passes under the nape of the neck, which revolves above it, whilst the occiput turns backwards towards the anus of the woman. As soon as the occiput begins to turn backwards, the different parts of the face, which until then had been retained in the interior of the pelvis, successively disengage themselves from under the pubis, in the order which has already been pointed out; 595 When the chin appears externally, the face remains sometimes stationary; afterwards it turns towards one of the woman's groins, but only at the same instant that one of the shoulders presents to- wards the pubis, and the other towards the sacrum. This position", also, is one of those in which it is allowable to be ignorant which of the shoulders may present towards the pubis ; for it is uncer- tain which ; and when the change of position is procured by the aid of art, it is indifferent which we bring there. These divisions of the presentations of the vertex or crown of the head, originated as we believe, with the experienced Baude- locque, and on this subject he very judiciously observes, that the head may without doubt present at the superior strait, in a manner different from those described. The posterior fontanelle, which as we have before observed, we should always take for our guide, may sometimes correspond to the intermediate spaces between these six points ; so that we might perhaps distinguish six other positions, which might be again subdivided into as many more. This distinction, he remarks, would not only be useless and super- fluous, but might confuse the ideas. There is not in fact any of these middle positions, which may not be referred to one of the six first; and each of them ought, therefore, properly to be desig- nated by the name of that to which it approaches the nearest, as the mechanism of delivery in it is exactly the same. These intermediate positions, therefore, ought to be referred to the three first, as often as the posterior fontanelle answ ers to any point of the anterior semi-circumference of the pelvis ; because that fontanelle turns gradually towards the symphysis of the pubis, under which the occiput is ultimately situated. The head, continues Baudelocque, sometimes follows this direc- tion, even though the fontanelle in question, be placed opposite one of the sacro-iliac symphyses at the commencement of labour; but when it is more backward, and answers to some point in the posterior third of the superior strait, all those positions ought to be referred to the three latter, that is to say, to the fourth, fifth or sixth ; because the occiput constantly turns in descending, towards the sacrum, and the forehead under the pubis. A TABLE of the Various Presentations at the period of Parturition, which indispensably require that the Child be turned and delivered by the Feet. [According to BAUDELOCQUE.] on. r * f .v, v nf -1,5*1, r 1 «t The lowdr part of the Face on the Pubes ; the upper part of the Breast on the projection of the Sacrum... Either the right or left fcand of the practitioner, indifferently, to be introduced to turn the Child. g /The fore part of tho \ Of which C 1st. The !^^^J[^^^ ^^uco towards the Sacrum........................................................... The right hand to be introduced when the Face is on the right side ofthe vertebral column, and vic6 versa. I | / Neck,orthe Throat, f there are 5 2d. The ^^^^^..JJ^JS l^^tto Breast on the right Ilium................................. The left hand to be introduced to reach the feet and turn the Child, &c. <3 2 | „, presenting k y. m • anterior Dart of the rieht Ilium, and the Breast on the left........................................ The right hand to be introduced, &c. &c. V The Breast ) Of which C 1st. ^ ^K J to SS^rto^f^sl^, and the Abdomen over the Pubes...................... The right hand to be introduced when the face is on the right side of the vertebral column, and vic6 versa. £3 1 presenting x in < 3d" The Neciand Head resting on the left Ilium, and the Abdomen on the right Ilium............................... The left hand to be introduced, &c. &c. — 0tS 1 A!?6. S ■*• ' •„ f A*u Tho NppI and Head resting on the riffht Ilium, and the Abdomen on the left........................................ The right hand to be introduced, &c. &c. 1* ° J °S™e"; I ^Sfwhich M^Se St aoove tt^^^^^^ ........I-................................. The ri|ht or left hand may be introduced indifferently &c. 6 &|/ ^SlT ) Sfereare S 2d Thl££t above the Sacrum ; the inferior Extremities above the Pubes..........*................................. The right or left hand, indifferently, may be introduced .SSoS P Ttthe & £ IV i3d. The BeJst resting on the left Ilium; the Thighs and Knees on the right Ilium................................... The lefthand to be introducedtowards the right side o/^ Uterus. S S • 1 Os Uteri > positions, viz. f 4A. The Breast resting on the right Ilium; the Thighs and Knees on the left .....V--"""p"i......;;""/ The right hand to be introduced towards the left side of the Uterus. «« - JThe fore oart of the -v ,- 1st. The Kn^es above, or on one side of the projection of the Sacrum; the Abdomen above the Pubes ; the ( Tho right oj. ]eft hand> indiffer6ntly> may be introduced. ^°i Thiffhs # Of which i Breast and Face to the anterior portion of the Uterus. S ' a 8 / and the Pelvis, f there are 1 2d. The Knees over the anterior brim of the Pelvis ; the Breast and Face to the posterior portion ot the / Tfae right or left ]mndj indifferently) may be introduced. '■g'Sf or the Sexual Parts, ? IV. "S Uterujs. „„„•*_ „f tu- r:_ut T1:nm . fnp Brpast to the left Ilium......................••••. The left hand to be introduced towards the right side of the Uterus. l\ atfhTofuLi. )P°^~7&K^££S^........................... The right hand to be introduced towards the feft side of the Uterus. T, B , ft, , Of which r 1st The Occiput over the margin of the Pubes; the Back above the Sacrum..........|.................................. Either the right or left hand, indifferently, to fee introduced, &c. °Ji / Th6 BN«i°f ) to ire S 2d The Occiput oTone side of the projection of the Sacrum ; the back above the Pubes............................ Either the right or left hand, indifferently, to be introduced. tU( PrSng th^e. | ? tir^StStaSi:..............::::3-r-r-:=:::r::::::::: ? Sittttt1^^ --"111 ^TL^r ^°rw\Vh1Z-r .^^b^cte........... ^*&^*l.to^U^*»J*M«toV^ l£*»] ££ ) there are 1 2d The Lular Region over the Pubes ; the back of the Neck over the posterior margin of the Pelvis.......... The right hand, &c. &c. 6£&iJ PTtC £ IV >3d! ?Lo3utontrieft Ilium; the Lumbar Region on the right Ilium................................................. The right or eft hand, indifferendy, &c. &c. .8* S<~o\ OsUteri. S positions, viz. < 4?h. The Occfput to the right Ilium; the Lumbar Region on the left Ilium............................................... The ngh t 01rlefk h^ ^teyUy. *o. S STS 1 J The Lumber Region > Of which ( 1st. The Bacl/above the Pubes; the Thighs above the Sacrum ................................................. The gh hand to^be introduced, &c. •J3 ««S / „„♦;„» # thprparp 7 2d The Thighs and Feet above the Pubes ; the Back and head towards the Sacrum................................... l he right hand, &c. II* f PTthe g J IV i 3d The BaTon the left Ilium ; the Thighs and Feet on the right Ilium.................................................. The lefthand to be introduced towards the right Ilium. 15° V Os meri. ) position;, viz, ( 4th. The Bact on the right Ilium; the Thighs and Feet on the left Ilium.................................................. The right hand to be introduced towards the left Ilium. !/lst. The Ear and angle of the Lower Jaw to the Pubes; the Shoulder towards the Sacrum. The Face to- ) The right hand to be introduced when the right side ofthe Neck presents; the left hand when the left side, &e. ( wards the left side of the mother when the right side of the Neck presents, and vice versa. S Of which 1 2d. The Ear and angle of the Lower Jaw towards the Sacrum; the Shoulder towards the Pubes. The Face ( Tne ieft hand to be introduced when the right side of the Neck presents ; the right hand when the left side. there are J towards the rigijt side of the mother when the right side of the Neck presents, and vice versa. S IV. \ 3d. The sidotof the Head upon the left Ilium, and the Shoulder on the right Ilium. The Face towards the i The rf ht hand to be introduced when the right side of the Neck presents, &c. positions, viz. I Sacrum when the right side of the Neck presents; towards the Pubes when the left. \ f 4th. The sidelof the Head upon the right Ilium, and the Shoulder on the left Ilium. The Face towards the I The left hand to be introduced, &c. ^ Pubes when the right side of the Neck presents ; towards the Sacrum when the left. S SI t.( rn< -j n tL Mpck on the Pubes. and the Side over the Sacrum. The Breast towards the left Ilium ) ..«,,, . , *, , ., , r. ou u . O I ^TheShoulder, v / * when; theright^tulder or Arm Resents; and towards the right Ilium when the le^ J The right hand to be introduced when the right Shoulder; the left when the left Shoulder presents. orW' I °u which ) 2d. The sidebf the Neck over the Sacrum, and the Side over the Pubes. The Breast towards the right Ilium { The jeft hand to be introduced when the right Shoulder presents; the right hand when the left Shoulder, &c. Arm and Hand \ theJe.are < when the right Shoulder presents, and vice versa. ^ nresentinff ' / • • 1 3d The Neck and Head on the left Ilium; the Side and Hip on the right Ilium. The back to the fore part i The • ht hand to be introduced when the right Shoulder presents; the left hand when the left Shoulder, &c. at the 1 P0sltl0ns' V1Z' I of the Uterus when the right Shoulder presents, and to the back part when the left presents. S tj 02 / qs uteri. / \4th. The Neck and Head on the right Ilium ; the Side and Hip on the left Ilium. The Breast to the fore part / The rignt hand to be introduced when the right Shoulder presents; the left hand when the left Shoulder, &c. % -g / / of the Uterus when the right Shoulder and Arm present, and vice versa. S 0«\ ^ /lst# The Axijlla over the Pubes ; the Hip over the Sacrum. The Breast towards the left Ilium when the right ) The rignt hand to be introduced if the right Side presents; the left hand if the left Side presents. ■5 h> 1 One of the J i Side presents, and vice versa. 1 H " J Sides f Of which 1 2d. The Axilla over the Sacrum ; the Hip over the Pubes. The Breast towards the right Ilium when the \ The jeft hand to be introduced if the right Side presents; the right hand if the left Side presents. of the Child \ there are J right,Side presents, and vice versa. n presenting / IV. \ 3d. The Axilla on the left Ilium ; the Hip on the right Ilium. The Breast towards the back part of the Ute. ) The right hand to be introduced if the right side presents; the left hand if the left Side presents. 8 J at the i positions, viz. I rus when the right Side, and vice versa. ( Os Uteri. I I 4th. The Axilla on the right Ilium; the Hip on the left Ilium. The Breast towards; the fore part of the Ute- ) The right hand if right Side . the left hand if left Side. s V rus when the right Side presents, and vice versa. f /lst. The Thighs towards the Sacrum ; the Spine of the Ilium towards the Pubes. fThe Breast towards the i The right band to be introduced when the right Hip presents; the left hand whjen the left Hip, &c. One of the ^ ( left Side of the Uterus when the right Hip presents, and vice versa. ., - < Hips f Of which 1 2d. The Thighs towards the Pubes ; the Spine of the Ilium towards the Sacrum. The Breast towards the i The Ieft hand to be introduced when the right Hip presents ; the right hand when the left Hip, &c. of the Child [ there are / side of the Uterus when the right Hip presents, and vice versa. < a I tirescntinff / IV \ 3d The Thighs towards the right Side; the Spine ofthe Ilium towards the left Side. The Breast towards the ) The left hand to be introduced in both varieties of the position. "5\ at the I positions, viz. J posterior part of the Uterus when the right Hip presents, and vice versa. I Os Uteri. 1 I 4th. The Thighs towards the left Side ; the Spine of the Ilium towards tho right Side, the Breast towards i Tfae right hand to be jntroduced in both varieties of the position. / \ the anterior part of the Uterus when the right Hip presents, and vice versa. $ mte -It is to be observed that Baudelocque, and the French practitioners generally, in preternatural Labours, or where the operation of Turning, or the application of the Forceps becomes necessary, place the Woman in a Supine Position, with the Breech brought to the edge P fcS rf the bed, so that the Coccyx and Perineeum may be freS, the Thighslnd Legs half extended, the Feet resting on two chairs placed properly, or supported by assistants. No. 2. TABLE OF CASES OF LABOUR, Which occurred at VHospice de la Matemite in Paris, from the 10th December, 1797, to ie 31st July, 1806, inclusively, Infants born Women delivered ------ 12,605. One hundred and forty-two of these women had twins. Two only had triplets. Of these 12,751 infants, one hundred and eighteen were born before the admission of their mothers into th Hospital, or with such haste, that there was no time to ascertain the part which presented, or the real position. Many of this number were not beyond the term of four or five months, and some from five to six, which educes the number to 12,633, of those in whom could be accurately ascertained the part which presented to the orifice ofthe uterus, in the course of the labor and delivery, and the position ofthe particular nart. 12,751. part The Regions which Presented, the number of Times, and their Po'tions. The crown of the head or vertex The Breech or the thighs The feet The knees - The face The belly - The occipital region The back . The loins ... The right side of the head The left side of the head The right shoulder The left shoulder The right side of the thorax The left side The right hip The left hip Number of times. 12,183 - 198 - 147 3 42 3 1 3 3 1 4 20 18 2 1 3 1 12,633 First Position. 10,003 Second Position. 2,113 Third Position. Fourth Position. 40 Fifth Position. 22 Sixth Position. But four Positions of all the other Regions are admittd to exist 118 - 71 85 - 58 1 - 0 1 0 1 - 0 1 - 0 1 . 0 1 - 1 0 - 0 2 - 0 0 - 0 1 - 0 0 - 0 0 - 0 1 0 0 - 0 213 130 3 3 1 22 1 0 2 0 0 1 7 9 0 0 1 1 51 6 1 0 17 0 0 0 0 0 1 13 8 1 1 0 0 48 Positions not ascertained. No. CJPARATIVE Of the Labours which were accomplish by Nature alt we, with those in which the aid of Art was necessary. most ST^e *}TSand. seven hundred and fifty-one cases abour, 12,573 at east were accomplished naturally, and but one hundred and seventy-eight, a! i * ;« ii,„qUI !■ ass'stance of art; some by means of the 1 alone, others witl the forceps, or with the crotchet, after the perforation of the Cranium, which is> in the proportion of 1 to 71 2-3. head alone, eith lich render the 1; the whole, is as 1 co^nrrTt- ^u T™ necessary to give assistance bj conformation of the pelvis, or from accidental circumstanceJiich render the la|bour One hundred and thirty-two in all—which, in proportio Viz : The child presenting The face The shoulders - The crown ofthe health the umbilical The breech The feet The other parts sped in the table On account of convu is and floodings ord TJie forceps were applied in thirty-seven cases, which isk to 34- The child presenting face The crown ofthe Iiea Of these latter the forceps were applied. J seven on n. rpi , I two on acmt of the mal-con formation of pelvis. xne crotcnet was employed, or the cranium perforated in ne—which is in tl ie proportion of 1 to 1,416 2-3 Viz: 1 on account of hydrocephalus in thbild. 8 on account of great deformity of tl jelvis. H„mn j ™ ..olfe gastrotomy to extract an extra-ute e fcetus. nemartc.—vt 42 children in whom the face presented, 1( ere born without i iny assistance, 6 were brought to one ofthe positions ofthe vertex, after whirl they were delivered without assistance. I Of ]ll~WJiere tJe Jreech or thiShs Presented, 176 were irn without extra a id Of iJ^Tir JT Presented>136 ™* born in the sae way. vi iz,oi, tne cord tirst came out but 36 times, viz: 35 ties when the verte cpresented, and only once with the feet. P..,, u ,„_„ I Sex of the C hildren Children born 12,751. 6,524 Bovs. 6 227 G Is T£dSfdead 53°\ ^: ^ the pe"od of labour 412 during labour, or The ielat.ve proportion of chddren still-born, and of thosjwho survived but,. -rvrr • u j • ■_ . Weight of tki Children. v*Jfof b V :-^ A .'**** Hi .1 je>/- ■■■• y S ft' •• :b--^ a L»« *:1I4