ARMED FORCES MEDICAL LIBRARY Washington, D. C. OUTLINE0 f / r' t^ATPT^ -— O F T H E THEORY and PRACTICE O F MIDWIFERY. B Y ALEXANDER HAMILTON, M. D. F. R. S. Edin." PROFESSOR OF MIDWIFERY IN THE UNIVERSITY, AND MEMBER OF THE ROYAL COLLEGE OF SURGEONS, EDINBURGH. ARTE NON VI. A NEW EDITION. P If I L A D E L P H I A; Printed bt THOMAS DOBSON, Bookseller and Sta- tioner, AT THE STONE HOUSE IN SECOND STREET. MjDCC,XC. ~- '-............ - — - ^ J ADVERTISEMENT; OINCE the publication of the Elements of Mid- ^ wifery'm 1775, continual refleaion, and con- ftant praaice, have produced many changes in dif- ferent parts of them. The firft rude proddaion of an-author unufed to publication, requires frequent revifal and copious alterations; but, in another view, this Work is t materially different. In the earlier ftages, the Author imagined, that Midwifery was in a great meafure Empirical ; and that its principles were few, vague, and uncertain. His opinions were not peculiar; and if he erred, he erred with the greateft and moft fuccefsful praaitioners. But he has fince- found, that, though in many refpeas uncertain, the Theory of Midwifery deferved his attention, as it might of- ten direcl: the Praaice; and that its imperfeaions were not greater than thofe of the Theory of Me- dicine in general, which have not been thought of fufficient confequence to preclude the attention of phyficians. With thefe views, he has endeavoured to give at leaft the rudiments of a complete fyftera; and, as. the iv ADVERTISEMENT. the Work was therefore materially changed, it was common juftice to the world and to himfelf to give fome information of this change. But, independent of this principle, the former Title would not now have exprefTed the prefent objea and defign ; fo that a work different in matter ought alfo to differ in form. Edin. Aup;. 7 ' CON- CONTENTS. PART I. Anatomy and Physiology. Pag. Chap. I. Of the Pelvis - - 25 Sea. I. Of the Parts feparately - 26 Sea. II. Shape and Dimenftons - 32 Sea. III. Diflorted Pelvis - - 35 Sed. IV. General Obfervations - ■ 4.0 Chap. II. Female Parts of Generation - 43 Chap. III. Of the Menfes 50 Chap. IV. Of the Gravid Uterus - 57 Sea. I. Of Conception - - ib. Sea. II. Structure of the Ovum in early Gefla- tion 60 Sea. 111. Evolution of the Foetus - 64 Sea. IV. Contents of the Uterus in advanced Gef- tat ion - - -67 Sea. V. Changes of the Uterine Syflem from Im- pregnation 75 Sea. VI. Manner f Circulation between the Mo- ther and Foetus. - ■:-.';/*i.- 82 Sea. VII. Circulation in the Foetus "rx* 83 Sea. VIII. P of tion of the Foetus in utero " 85 Sed. IX. Peculiarities of the Foetus - 86 A StcT vi CONTENTS, Pag. " Sea. X. Some fubjeRs conneftadwith Geflation 88 I. Superfcetation - - ib. 2. Ventral Conception - &9 . 3. Monfers - - 9° PART II. Pathology. ^Chap. I. Pathology of Generation - 92 Sea. I. Topical Difeafes of the Genital Organs ib. Seft. II. Irregularities of the Menfrua - 103 Sea. III. Difeafes fometimes mifotkett for Gef- tation - - - 115 Chap. II. Pathology ef Parturition - 117 Sea. I. Difeafes of early pregnancy - 118 Sea. II. Difeafes of advanced Pregnancy 123 Sea. III. Some srdinary Difeafes which re~ quire peculiar Treatment when they occur du- ring Pregnancy - - -'' 135 Sea. IV. Of Floodings and abortion - 138 Sea. V. Management during Pregnancy 148 PART III. Labours. Introduction. § 1. General Obfervations - - 150 § 2. Divifton of Labours - - jpg § 3. Management of Labours - 160 Chap. C O NT ENTS. vii :; Pag. Chap. L Method of treating Natural Labours 161 Sea. I. Expeditious and eafy Labours - ib. i/? Stage. Dilatation of the Orifcium Uteri ib. id Stage. Delivery of the Child - 162 yl Stage. Separjiin and Expulfion of the Pla- centa andSecundines - - 164 Management of the Placenta - - ib. I. Method of removing the Placenta when the. Cord is ruptured - - 169 2. Method of removing the Placenta in Cafes of Flooding - - - 170 3. Management of the Placenta in Cafes of Spaf- modic ContraSlion of the Uterus - 171 4. Management in Cafes of Morbid Adhefion. of the Cake - - x73 Sea, II. Tedious and Lingering Labours 175 C H A P. 11. Of Difficult or fir icily Laborious La- bours - - 200 Sea. I. Laborious Cafes requiring the Hand alone - - - 201 Sea. II. Inflrumental Delivery - 202 § 1. Cafes where the Child is intended to be extracted without injuring it or the Mo- ther - .. ,.. £03 § 2. Cafes where the Child muf be defray- ed by diminifhing its Bulk, with a view to preferve the Mother s Life - 2T4 § 3. Co- * INTRODUCTION. How few are the modern inftruments, in compa- rifon of thofe employed by the ancients! How fun- pie is their cemftruaion ! And how feldom is recourfe had to them ! Of late a true fpirit of obfervation has arifen, and been direaed to the molt important ob- jeas ; every difeafe his been accurately diftinguilhed from thofe which it more nearly refembles ; and it may with truth be affirmed, that more light has been thrown on his fubjea, wi thin thefe fewyears, than for above a century preceding. The late publicati- ons of Dr Smellie, Dr Manning, Dr Hulme, Dr Leak, Mr White, Mr Moss, Dr Denman, Dr Osburne, and others, and the elegant plates of Dr Hunter, may be confidered as valuable acquifitions to the praaice of midwifery. With regard to the plan of the following work, the f une method has been obferved which the author ' ptirfues in his courf=: of leaures. As this plan has Tome peculiarities, it will perhaps be neceffary to premife thofe refkaions which firft gave occafion to it -^ and as they arife from the nature of the fubjeft itfclf, they will form no unfuitable introduaion. Nothing is more conducive to the proper method of teaching an art, than to confider its principle ob- ject, as well as its immediate relations to thofe that are molt infnn.itdy connected with it. By this means a diftihdion can be mad- between thofe parts to which I N T R 0 C U C TT O Ni xi which attention ought to be chiefly direaecj, and others which would rather embarrafs than affift our reftarches. If, for inftance, the feveral parts of medicine be confidered, their ends will be found to be effentially different; and, of confequence, the means by which thefeends are accompliflied will be frequently oppofite. This is particularly illuflrated by a little refkaion on two different branches of the fcience, viz. the praaice? ofphyfic, and of furgery, ftriaiy fo called. In the firft, the nature of the difeafe can only be colieded from fymptoms ; which, as the famefymptams pro- ceed from different and even oppofite dates of the body, muff fometimes unavoidably lead into error; and even the fymptoms themfelves are often fo con- tradiaory, that nothing can be colkaed from them ; fo that the phyfician is obliged to proceed on fome very vague and diftant analogy. Though thefe difficulties be furmounted, the effeas of reme- dies are ftill uncertain? the real effeas of many are not known; and, as they operate, not on-an inanimate machine, but on a fyftem, in which, from any change, motions are excited frequently op- pofite to thofe expeaed, it is not furprifing that the exoeaations of the phyfician are often baffled. Thus the praaice of phytic cannot be regulated by certain rules; it depends much on the ftate of the body xii INTRODUCTI-O Nd body in health, and the very different changes introdu- ced by difeafe: To ftudy it properly, all thefe ought to be confidered ; and it is this part which is com- monly called the Theory of Medicine. In a fubjea fo difficult and obfeure as the ani- mal oeconomy, it is not furprifingthat the praaitioner fhould be often embarralTed ; and that inflead of certainty, he fhould fometimes be obliged to de- termine his condua by probability, or by a loofe and uncertain analogy. But the views of the furgeon are lefs obfeure ; he is often confined to cafes where manual dexterity only is neceffary, and has, very generally, the objeas of confideration fubjeaed to his fenfes; and, where they are out of the reach of fenfe, the fymptoms are more plain, the induaions fewer, and the conclufiorrs more certain. In this part, then, theory is lefs * neceffary, and only ufeful as it feems to connea the feveral faas : Praaice is particularly proper to ac- quire that firmnefs and conftancy of mind, and that manual dexterity, fo efTential to the fuccefs andcha- raaer of a furgeon. Midwifery, which may be defined " The art of f V C T'I'O -N. xiii learned by$raaice. But; taken in a more' enlarged fenfe, Midwifery may be defined, " The art of " facilitating the birth of children, and of managing " pregnant and puerperal women." A part of it, therefore, has ftill a relation to the praaice of phytic ; and, as fuch, mull: be involved in the fame difficulties and obfcurities. In this view, then, two objeas are chiefly to be attended to : I. The operation itfelf, with every thing relative to it. II. The ftate of the woman after delivery. To obtain a proper knowledge of the firft of theft?, it is neceffary that the ftruaure and funaions of the parts themfelves, the feveral changes which they un- dergo, and the caufes which may prevent or retard either conception, or a proper delivery, fhouM be known. The two firft of thefe comprehend the Phy- fiology of Midwifery ; the lafl, what maybe called the Pathology. An attention to the ftruaure of a machine on which we operate, is certainly a point of the greateft corv- fbquenGe ; and it is particularly fo in the obftetrical art, as much of the praaice depends on a proper knowledge of the parts; And it is not only the ana- tomical confideration of every part, but the" relations of one part to another, their ddtances and their incli- nations xiv IN T R 6 D U C TION. a.'d-- i-n .-• '-.: ' ■ , . • ■■<--. -..■-"•:' nations, both with refpea to each other, and to other parts of the body, that are abfolutely neceffary to be attended to. The confideration of their feveral func- tions is not foeffential, as it contains only hypothefes, which, though fanaified by the authority of great names, are often trifling, generally infufflcient and unfatisfadtory. Thefe, however, as they are imme- diately conneaed with the fubjea, have not been o- mitted. Several opinions with regard to the Theo- ries of Generation and Conception, have been con- cifely mentioned. This maybe called the Phyfiology of Midwifery ; for if no difeafe comes on, a natural delivery at full time may reafonably be expeaed. But there are many Topical Affeaions of the parts in the impregnated ftate, which will influence deli- very, either by inducing it prematurely, or preventing it altogether. Many difeafes may alfo fupervene in the impregnated ftate, which will have the fame effea ; thefe, therefore, mufl be confidered, and the mod approved method of relieving them pointed out. Having thus laid a proper foundation, the Operation itfelf, with all its material variations, comes next to be explained. This finifhes the firft, and not the leaft important part of Midwi fery, and. concludes the prefent work. The fecond part, or the management of lying-in women, and alfo of new born children, fhould fall next to be confidered. The INTRODUCTION. xv The management of puerperal women, from the late labours of fome ingenious accoucheurs already re- ferred to, may now be conduaed on a more certain footing; the different difeafes, for inftance, may be diftinguilhed with greater accuracy, which is a chief point in conduaing the cure. The management, where there is no particular difeafe, is now directed by an attention to nature, unencumbered by refine- ments built on fallacious and uncertain theory. This part the author propofed for the fubjea of a fecorid volume i but the late publications, already menti- oned, have in fome meafure anticipitated the inten- tion. ELEMENTS O F MIDWIFERY. PART I. ANATOMY and PHYSIOLOGY. CHAP. I. Of the Pelvis. THE human fkeleton is divided into the Head, Trunk, and extremities. The Head includes the Cranium and Face. The Trunk confilts of the Spine, Thorax, and Bones of the Pelvis. The latter, which include alfo part of the Spine, are the more immediate objecfs of the Accoucheur's atten- tion. The Pelvis is an irreguhr cavity, more nearly ap- proaching to a cylindrical than any other figure; and is chiefly compofed of the Offa Innominata, the B Os 26 Of the Pelvis. Chap. I. Os Sacrum, and OJfa Coccygis. The two offa inno- minata conftitute the lateral and anterior parts; the os facrum, and fmall range of bones called the coccyx, form the pofterior part. This bony circumference includes a fpace which reprefents the figure of a ba- fon, from whence the name Pelvis is derived. To have an accurate knowledge of the Pelvis, it is neceffary, firft, to defcribs feparately the different parts of which it confilts, and then to confider it when thefe parts are united. SECTION I. Of the Parts of the Pelvis feparately. HT^HE Offa innominata are two large expanded A bones, which form the fides and fore-parts of the pelvis, and inferior lateral parts of the abdo- men. In infancy and childhood, each of thefe bones is divided into three diftinft parts by interme- diate cartilages; and iho' afterwards the bones be- come united, and every appearance of former ft pa- ration is nearly oblittiattd, the names by which they were diftinguilhed in younger years are ftill re- tained. i. The Os Ilium, or Haunch-bone, is the fuperi- or and l.irgeft portion of the innominatum. It ex- tends from the femicircular ridge at the fuperior, part, Sea. I. Of the Parts feparately. 27 part, downwards and backwards as a tranfverfe feai- on of two-fifths of the acetabulum or cavity which re- ceives the round head of the thigh-bone, and for- wards to a little below the projeaion or ridge which forms the brim of the pelvis. Hence a fmall por- tion of the ilium, only, belongs to the pelvis, the expanded part being placed entirely without the brim. The different parts of the ilium are, the/uperior fe- micircular ridge or fpine, giving rife to feveral ine- qualities or prominences, termedfpinalproceffes ; two broad furfaces, improperly named dorfum and cofla; the fmall irregular furface by which it is joined to the facrum pofteriorly ; the lower, thick, narrow part of the acetabulum; and, the ridge or projeaion at the inferior anterior part. 2. The Os Ifchium, or Seat-bone, called alfo Huc- kle or Hip-bone, is the inferior lateral portion of the os innominatum. Its figure is very irregular, and its extent may be marked by a line drawn through near the middle of the acetabulum' The feveral parts of this bone are, the Body, Tu- berofity, and Ramus. The Body forms the lowefl and greateft part of the acetabulum ; the fmall branch, or Ramus, makes up four-fifths of the great hole com- mon to this bone and the Pubis, catted foramen ovale or thyroides; and the inferior bump, flattened by preffure, is the Tuberofity which fupports us in a fitting pofture. The tuber is nearly cartilaginous at birth, and afterwards becomes an epiphyfe, 3. The 28 Of the P e l v i s. Chap. I. 3. The Os Pubis, or Share-bone, which makes the anterior middle part of the pelvis, is the fmalleft portion of the os innominatum. Its feveral parts are, theBody, Angle, and Ramus. The body is the fuperior outer part, by which it is joined to the os ilium : on this is a remarkable crifta, which forms part of the brim of the pelvis. The Angle runs downwards and forwards; and has a rough unequal furface, for the firm adhefion of the thick ligamentous cartilage that conneas the bones of the pubes, which is confiderably thicker and of a fofter texture in females than in males. This arti- culaticnis called fymphyf.s pubis. The deficiency of bone below, or fpace between the two rami, is termed arch of the pubes. The three portions of bone jufl now defcribed, compofe the os innominatum of each fide; which *rc connected posteriorly at the facro-iliac fymphyfis, .md anteriorly at the fymphyfis pubis, by thick car- tilaginous agglutinations. Thefe are ftrengthened in a very particular manner by ftrong ligaments at the 1 oflerior fymphyfis, and a double capfular aponeuro- fis anteriorly *, which feem to render them incapa- ble of feparation, or of any confiderable relaxation by the impulfe o flabour. The bones and cartilages are, however, liable to be foftened by difeafe, and the •* Viite'Dr. Hunter's defcription of the Articulation of the Pubes, London Medical Obfervations and Inquiries, vol. ii. p. 223. Sea. I. Of the Parts feparately. 29 the ligaments relaxed, viz. from ricketty difpofi- tion, rheumatifm, and from debility in confequence of fevers and other difordcrs. The bones may alfo be fraaured, or the articulations forced by mechani- cal injury, as from falls, brnifes, &c. and fuppura- tions may enfue from internal caufes as well as acci- dents. The pofterior part of the pelvis is made up of the Os Sacrum, or Rump-bone, and its extremity the Coccyx. The Os facrum called alfo Os Bafilare by the anci- ent, from its ufe in fupporting the trunk, is, in young fubjeas, compofed of five or fix peices, with intermediate cartilages. It has two furfaces, an ex- ternal and internal : the former is rough and convex ; the latter more fmooth and concave, marked with fe- veral tranfverfe lines, the remains of the intermedi- ate cartilages which formerly conneaed the feveral pieces of bone. The flat fide is bent, firft downwards and a little backwards, then confiderably forwards. The facrum is of a fpongy cellular texture; and, in proportion to its fize, the lighted bone of the body. Its figure is triangular, having the fuperior part for the bafe, with the apex dwonwards, gradually becom- ing narrower terminates in its appendage the Coccyx. The fuperior part, or bafe, -anteriorly, has a fharp ridge, which makes the pofterior part of the brim of the peh is. Through the holes by which this bone is perforated, many nerves are tranfmitted. Thofe C 2 of 3» Of the P e l v i s. Chap. I- of the anterior fuperior part admit fome of the lar- geft of the whole fyftem. The facrum is articulated above to the laft vertebra of the loins, in the fame manner with the true vertebrae. Laterally, it is join- ed to the offa innominata by a deep irregular furface, where it forms the facroiliac fymphyfis, which makes an immoveable fynchondrofis ; and below, it is con- xieaed with the coccyx by means of ftrong ligaments. It is fecurely guarded from external injuries, by the thick mufcles that cover it behind, and by the ftrong ligamentous membranes which clofely adhere to it. The Os Coccygis, which is placed at the extremity of the facrum, form0 the lower pofterior part of the pelvis, and inferior terminting point of the fpine. Its figure refembles an inverted pyramid. Like the facrum, it is bent downwards and forwards ; having an external convex, and internal concave, furface. It confitls, generally, of four pieces of bones, with intermediate cartilages which admit of confiderable motion of the bones, in a direaion moft commocli- ovifly adapted for the enlargmei.t of the inferior ca- pacity of the pelvis. In children, the coccyx is almofl wholly cartilage ; towards the decline of life, the interpofed cartilages bcs;in to ofnfy : and at length the feparate pieces are united, znd become one bone with the facrum. The immobility of the coccyx is not, however, the only rcafon whv women advanced in life have commonly difficult and laborious births : various reafons alfo con- cur, Sea. I. Of the Parts"feparately. 31 cur, as well as the drinefs and rigidity of thofe parts that are fofter and more pliable in younger years. The parts common to the Pelvis are, the Acetabu- lum Offis Femoris, Foramen Ovale, great Sacro-fciatic Notch, and the Brim. In the recent fubjea, this cavity is lined with the periofeum, with cartilages, tendons, membranes, mufcles, and cellular fubftance. Internally it is co- vered chiefly with the iliacus internus, the pfoas, and the obturatores mufcles; externally, by the glutcei, tricipital and pyramidal: the abodominal mufcles, with the peritoneum and common integuments, defend it before ; and the bottom is fhut by the mufculi coccy- geei, the facro-fciatic ligaments, the inferior part of the reaum, its fphindter, and the integuments of the perineum. Thefe parts are chiefly fupplied with nerves by the anterior and pofterior crural, the obturator, and thofe of the facrum ; with blood-veffelsr by the iliacs. The pelvis is articulated with thefpineat the fupe- rior pofterior part, and with the offa femorum below. Its principal ufes are, to defend thofe parts contain- ed in it from external injury, to fupport the uterus during geflation, and to give paffage to the child at birth. It alfo fupports the trunk and inferior parts of the body, forming the intermediate conneaion bet- ween them ; and is the great centre of motion of die whole machine. SEC- 32 Of the P E l v i s. Chap. I. SECTION II. Of the Shape and Dimenfions of the Pelvis. r I "'HE cavity of the pelvis, or fpace included with- ■*- in the bones, is of different fhapes in different fubjeas; and has been fuppofed by different authors to approach more or lefs to an oval, elliptic, trian- gular, or circular form. Its circumference ought to be fomewhat between an oval and a circle, and to meafure nearly one-fourth of the height of the body. The leffer or true pelvis may be diftinguifhed by the brim, or fuperior aperture ; and the bottom, outlet, or inferior aperture. Confidered in this point of view, the diameters of its brim and bottom, the width, depth, and form of its cavity, muft be carefully at- tended to. At the brim, the largeft diameter of the pelvis is lateral, the next to it diagonal, and the fmalleft from pubes to facrum. A well-formed pelvis ought to meafure nearly five inches and one-fourth laterally ; four inches and one-half, or four and three-fourths, diagonally ; and four inches and one-fourth from the top of the pubes to that of the facrum. Thefe pro- portions are reverfed at its inferior aperture, where the pelvis is nearly an inch wider from the lower part of the arch of the pubes to the point of the coccyx, when that Sea. II. Shape and Dimenfons. 33 that bone is on the ftretch, than it is from fide to fide : For the diflance between the tuberofities of the ifchia is about four inches, or four and one-fourth only; and from the arch of the pubes to the extremity of the coccyx when ftretched out, five inches, or five and one-fourth. The pelvis at the fides is nearly twice as deep as at the fore-part, and almoft three times deeper be- hind ; viz. from the top of the facrum to the point of the coccyx, when extended, fix inches, four at the fides, and two only at the pubes. The upper and lateral parts of the pelvis, at the brim, are nearly perpendicular: but the anterior part is fhallow ; and the lateral openings in the recent fubjea are covered with membranous, mufcular, and ligamentous parts, which yield with the coccyx to the preffure of the child's head, and form a concave nearly equal to that of the facrum.—From this conftruaion, added tothe curve and concavity of the facrum, and mobility of the coccyx, the bottom is confiderably more capacious, and fomewhat more circular than the brim. A line from the fymphyfis of the pubes, to the junction of the two laft vertebra; of the facrum, is horizontal. And a line that bifeas this horizontal line, as well as the two diameters of the brim, makes the axis of the pelvis ; and, if produced, will pafs through the umbilicus in an erea pofture ; but, if in a reclining pofture, the line that paffes through the umbilicus will be at right angles to the diameter of the 34 Of the P f l v i s. Chap. I. the brim: and, in general, whatever is faid of the angle which the axis makes with the diameter, is to be underftood of the diameter of the brim, when the woman is erea ; and of the horizontal line when re- clined. But, towards the end of pregnancy, aline to pafs through the centre of the pelvis muft fall half- way between the navel and fcrobiculus cordis. The axes of the different parts of the pelvis, form- ed by a diagonal, fhow the curved line of direc- tion which the child's head defcribes in parting ; and if thefe axes are fuppofed to be prolonged, they give the displacement of the child's body. The female pelvis differs from the male chiefly in the following particulars: The angle which the vertebrae lumborum make with the facrum is more obtufe, the ilia are more expanded, the concavity of the facrum and coccyx is larger, the conneaion of the coccyx with the facrum is loofer, the tuberofities of the ifchia are placed at a greater diftance, the fym- phyfis of the pubes is thicker, the arch of the pubes and tjie lateral openings are more confiderable, and the pelvis is wider in all its Jimenlions. SEC- Sea. III. Diflorted Pelvis. 35 SECTION III. Dif or ted pelvis. THE figure and proportions of the pelvis vary in fome degree indifferent women ; for the depth and form may be fo affeaed by different degrees of diftortion, as not only greatly to diminifh its cavity,' and occafion lefs or more difficulty and danger in de- livery, but in fome inftances to fuch a degree as to render the birth of a living child altogether im- poflible. As the proportions above defcribed con- ftitute what is called zfandard pelvis, if it come fhort of thefe dimenfions, the pelvis becomes faulty or difeafed. There are different kinds, as well as degrees, of narrow pelves. Sometimes the cavity of the pelvis is conftitutionally fmall, without any deformity. Sometimes there is a narrownefs confined to the brim ; fometimes to the inferior aperture. Sometimes the diftortion is general over all the pelvis: And fome- times the capacity is retrenched by an intrufionof the vertebrae lumborum over the facrum ; which may be fo confiderable, as to reduce the diameter of the brim to the fpace only of two or three inches, or even lefs: and this is the fpecies of diftortion moft fre- quently obferved in praaice. The vertebrae of the facrum may be alfo, from preffure while in a morbid ftate, 36 Of the P e l v i s. Chap. I. ftate, fo deformed and protruded, as to render that bone quite ftraight, and from the fame cfaufe often convex inftead of concave. The caufes of narrow pelvifes are chiefly ricketty affeaions in infancy , alfo external violence; fuch as fraaures and diflocation of the bones, &c. The bones alfo become foftened by difeafe in the adult ftate ; and are then liable to narrownefs and diftor- tion, even in women who have formerly had eafy labours*; but fuch cafes are rare. If the pelvis fhould not meafure above two inches and a half from pubes to facrum, and not above three laterally, it would be impoffible to fave the child at full growth, in any other manner than by enlarging the capacity of the pelvis by an incifion of the fymphyfis pubes. It is often extremely difficult to difcover a narrow pelvis, efpecially if the narrownefs be confined to the brim. We may fnfpe& the diftortion, from the make and fhape of the woman. The direaion in which the fpine is diftorted frequently determines it. But the pelvis is not always affected by a morbid cur- vature of the fpine : if that extend, however, to the lumber vertebrae, the pelvis very feldom efcapes : though the moft certain and infallible diagnoftic is the diftortion of the inferior extremities* along with a twilled fpine. Worn en who are well proportioned in the * Vide Vol. V. of the London Medical Obfervations and In- quiries, cafe of Caef. Op. by Dr Cooper. Sea. III. Diftortion or Narrownefs. 37 the lower extremities, have generally good pelvifes. When thefe are ill proportioned or crooked, efpe- cially the thigh bones, along with other fufpicious appearances, the pelvis is very generally, though not univerfally, deformed. We can generally, by the touch, difcover any fpecies of diftortion in the pelvis, below the brim, from the tuberofities of the ifchia approaching too near each other, from the convexity of the facrum, from the difference of fhape in the arch of the pubes, Sec. When the deformity is at, or above, the brim, and the woman otherwife well fhaped, it is often impoffible to afcertain the narrownefs till the labour be confiderably advanced, and the child's head pre- fenting in a conical from, with the bones protruding over one another, which are pretty certain marks of a narrow pelvis, or of a very large head. But in order to underftand the dimenfions of the pelvis, it will be proper to coidider the ftruaure and form of the head of the foetus ; which, being com- pounded of different pieces, is admirably well adapted for accommodating itfelf to the figure and " diameters of the pelvis. The figure of the head is fpheroidd, being com- pofed of two ovals a little depreiled on each other ; one of which is fuperior, called {.he cranium, the bones of which are fmooth and uniform, with iiiterveni»g D fpac**, 38 Of the P E L v I S. Chap. I. fpaces, c&Wedfutures, that on preffure allow the bones to yield and Aide on each other ; whereas the bones of the face, which make the anterior oval, are more folid, rough, and uneven, and muft therefore give confiderable refiftance in Palling through the pelvis. Eight bones compofe the Cranium, fix of which are proper, viz. the Os Frontis and Occiput, two Offa Parietalia, two Offa Temporum, and two com- mon to Cranium and face, the Ethmoid and Sphenoid. The bones are conneaed to each other by the coronal lambdoidal, fagittal, and fquamous futures. The head is broader behind than before, and the face is broader above than below. On the upper part of the cranium, where the Tagittal and coronal futures crofs'each other, is a membranous fpace called thafontanella or open of the head. The point from which the hair diverges is called -the vertex. The head, like the pelvis, has different diameters. The ordinary dimeniions at birth are as follows : From the os frontis to the occiput, between 4 and 4} inches ; or, according to Dr Burton, 4.-^ inches. Laterally, from temple to temple, 3 inches. Laterally, at the pofterior part, 3!. inches. From the top of the head to the nape of the, neck, 3-, ~ inches *. The *See Dr Burton's N. S of Midwifery, table 1. fig. 3. and 4. Sea. III. Dimenftons, &c. 39 The length of the face from the chin to the fore- head, is about 51 inches. The length of the whole head from chin to vertex, about 5} inches ; and when the vertex is ftretched out in laborious births, about 6 or 7 inches. The total circumference of the head, between 12 and 14 inches, or fomewhat more. The breadth of the body at the fhoulders, is about 5 or 6 inches. The breadth of the body at the breech, about 5 inches. The circumference of the body at fhoulders and breech, from 15 to 18 inches. The length of the whole body, 20 or 21 inches. Confidering the ftruaure, form, and diameters of the pelvis and child's head, the application, in regard to the mechanical defcent of the head through the pelvis, is fufficiently obvious; but, as the bulk and diameter of the one is not always mathematically adapted to the capacity of the other, difficulties muff: fometimes arife. Hence the advantage of this pe- culiar ftruaure and mechanifm of the cranium : for if the child's head were one firm offified body, whofe dimenfions at any time exceeded thofe of the cylin- drical cavity through which it fhould pafs, however mechanically and with whatever force it defcended, the delivery could not be accompHfhed without ex- traordinary 4p Of the P r r. V I s. Chap. I. tr2fvdinarv affif'ance ; aid the confequences would alvv:;ys prove :atal eitlser To mother or child. The fh'nrdirs are alfo capable of confiderable dni.iriTnn by ^/ediire , and the feparation of .the offa irui'ninata in the foetus may contribute, fome- wf.it, to facilitate th<: paflage in birth. For living cl i-drcn are often brought into the word without artificial affdance, the bulk of whofe bodiescon- fiderably exceeds the largeft diameter of the pelvis. SECTION IV. General Obfervstions. i.rT^HouGH the cartilaginous fymphyfes at the -"- anterior and pofterior parts may be, in fome degree, relaxed in time of labour, it appears fuffici- cntly obvious, from a fuperficial view of the ftruaure and articulation, that the bones are incapable of fe- paration fufficient to enlarge, in any fenfible extent, the capacity of the pelvis, but in confequence ofdif- tafe, or from violence. In that ftate the bones may be forced by the throes of labour ; but the woman becomes lame, and generally continues fo for life. 2. Such a feparation may, however, be procured by incificn at the fymphyfis pubis, in general, though not always with fafety to the mother ; and a child, ■rddch would otherwife infallibly be deftroved; may by Sect. IV. General Obfervatlons. 41 by that means be extraaed alive. The fuccefs of this operation, fince firft performed by Monf. Sigaulr, is not yet fufficiently eftablifhed to enable us to fpeak of it in a decifive manner, nor to point out the parti- cular circumftances in which it may be attempted with propriety. But we may here obferve, that it cannot, in cafes of difficulty and danger, be perfor- med with an abfolute certainty of preferving either the mother or child, from the difficulty of afcertain- ing the real dimenfions of the pelvis, and of the in- creafed fpace to be gained by the operation. 3. The fhape and conftruaion of the child's head, which admits of confiderable diminution by preffure, fufficiently compenfate for the want of motion of the bones of the pelvis : for the head is of an oval or fpheroidal figure, and the membranous futures permit a free play of the cranial bones by the force of labour. But in different fubjeas it varies in fhape, ftruaure, and folidity. Hence, in palling through the capacity of the pelvis, it will not always be com- modioully modelled to fuffer that diminution of its bulk, from preffure, which may be neceffary. If, therefore, the volume of the child's head be difpro- portiom-d to the diameters of the brim or outlet of the pelvis, or if the long axis of the one be applied in an improper direaion to the other difficulties will occur that will require extraordinary afihunec. 4. It is therefore of the utmoft confequence to know the figure, ftruaure, mode of pofition of the D 2 child's 42 Of the P f l v i s. Chap. 1. child's head, and the fhape and proportions of the different openings of the pelvis; and to remember, that thefe proportions are revcrfed in the ovals of the pofterior and inferior apertures; that the depth of the fuperior part is to the anterior as three to one, and to the fides as three to two. 5. Thefe proportions are, however, liable to confiderable variation in different fubjeas; and the whole pelvis may become fo affeaed, as to have its brim, depth and inferior aperture, confiderably re- trenched and diminifhed, either from an original mal-conformation, from bruifes, poftures, &c. or from difeafe. 6. Thofe women who appear, from fome di- ftortions, to have been fubjea to rickets, have pro- bably a contraaed pelvis ; and the probability is great- ly ftrengthened if the lower extremities have fuf- iered. 7. Deformities of the fpine from the other caufes • do not generally influence the pelvis ; fo that every woman apparently crooked, has not always a labori- ous and difficult birth. 8. All the different diftortions of the pelvis may be accounted for from the preffure of the body on the bones previoufly foftened by difeafe, viz. by the preffure of the upper parts on the fpine, and by that of the whole body on the offa ifchia and pubis. CHAP. M Chap. II. Fumale Parts of Generation. 43 CHAP. II. ■ Female Parts ^Generation. nf^HE organs of generation, fo called from their ufe -*■ in propagating and increafing the fpecies, are divided into external and internal. The external parts are, the mons veneris, the labia externa, the labia interna ale minores or nymphe, the clitoris with ks glans and praeputium, the orifice of the urethra, the os externum, membranous expanfion cal- led hymen, caruncule myrtiformes, fphinffer vagina, and glands of the parts. The internal parts are, the vagina; the uterus, with the ligaments, ovaria, and Fallopian tubes ; and the blood-vetfels and nerves of the parts. The contiguous parts are, externally, the anus, fphincler ani, and perineum ; internally, the bladder, urethra and re£ium. The mons veneris is nothing more than the fkin raifcd by a quantity of adipofe fubftance colleaed under it, that cufnions it up externally in the form of a tumor. From the lower part of which the great labia begin, and run downwards, till they are boun- -ded by the perinaeum, or by what the French call fturchette. In their ftructure they are cellular, but more ligamentous than the mons veneris. Their inner furface is villous and glandular, feparatinc a febacious 44 Female Parts of Generation. Chap. IL febacious kind of liquor analogous to that about the corona glandis of the male. Upon feparating the labia externa, a red projeaing body appears, called clitoris, compofed of two crura, which arife from the lower part of the offa pubis, approach one another, and form the body of the cli- toris, whofe extremity is its glans, covered with a loofe doubling of the fkin, called preputium. The nymphe are placed immediately within the external labia, and are continued downwards and forwards on the anterior fymphyfis pubis nearly as far as the orifice of the urethra. They are pro- ductions or folds of the integuments lefembling fraena, and very vafcular. When the labia externa are open, they will devaricate; and when fhut, come into contaa. Downwards from between die nymphae runs a fmooth foffa ; at the bottom of which is a promin- ence in the centre of which is the orifice of the ure- thra. Its ufual fituation is nearly oppofite to the inferior extermities of the nymphze. Below the ur-thra is the aperture into the vagina, called os externum ; which has round its orifice the caruncule myrtiformes, fuppofed to be the remains of the ruptured hymen (a membrane peculiar to infancy,. that furrounds the entry of the vagina in form of a crefcentj: but many anatomiits deny that thefe car- unculas are formed from the lacerated hymen, and maintain that they exift previous to its rupture. The A Chap. II. Female Parts of Generation. 45 The fphincler vagine is a flat mufcle, coming out infenfibly from'the perinaeum, and is loft chiefly in the crura clitoridis. In very mufcular fubjeas, its fibres run quite round the vagina. There is a plexus of nerves and blood-vetfels, called plexus reteformis, that goes up on the infide of this mufcle, and com- municates with the clitoris ; which, of confequence, will be comprelfal between it and the penis in coition. The glands of thefe parts arc fituated in fuch a manner, that, tupon preffure, a confiderable quantity of vifcus humour is thrown out in time of coition; fo that by many this liquor was thought to be the ■femen femineum. The ftruaure of thefe parts renders them all cal- culated for nearly the fame purpofe, viz. to give titillation in coitu. The clitoris is fituated in the part where it is moftcxpofed to friaion by the introduced penis: its ufe, therefore, chiefly, is to render the fenfation in coitu more exquifite. Thefe parts, in proportion to their fenfibility, are exceedingly irri- table, and fubjea to confiderable inflammation and tumefaaion even in the eafieft labours. Hence the impropriety and hazard of officious touching in the beginning of labours, while the pretending part of the child is at a diftance, while the paifage is narrow and tight, and not yet fufficiently relaxed by the lubri- cating mucus which is afterwards fo plentifully thrown 46 Female Parts of Generation. Chap. II. thrown out for. the purpofe. The orifices of thefe parts, obferving the direaion of the facrum and peri- naeum, do not run ftraight out, but downwards and forwards; by which the vagina, uterus, and reaum, are in lefs danger of protrufion. In the in- troduaion of the catheter, the point fhould there- fore be direaed, firft a little downwards and back- wards, then gently raifed forwards and upwards rather. than quite ftraight. The vagina, or paffage to the womb, lies immedi- ately under the bladder, and upon the reaum. It is commonly in length about four or five inches: but this differs in different fubjeas, and at different ages: as alfo its diameter, which is narrow and contr»aed in young women, but capable of very confiderable 'dilation ; for in virgins it is full of rugae, but fmooth- er in married women and thofe who vdio- have born children. It is compofed of a plexus of mufcular fi- bres, and a rugous membrane ; and its dructure is al- fo nervous and glandular. Its internal coat is conti- nued upwards, and makes the inner covering of the uterus. The vagina and body of the uterus are conneaed with the bladder, a good deal higher up than with the reaum. The vagina leads to the os uteri, which projeas a a little into that cavity, and advances rather more for ward in the lower pofterior that in the upper anterior part. * The Chap. II. Female Parts of Generation. 47 The uterus lies in the middle of the pelvis, loofely between the re&um and bladder ; but its pofition is liable to variation at different periods of life, and is affeaed by various other circumftances. It is tri- angular, of the figure of a pear or fmall powder-flafk, and generally about three inches long, fomewhat con- vex on its fuperior part and, by preffure, a little flattened below. It is divided into its cervix or collum, and fundus. On being cut open, it appears of a compaafolid fub- ftance, broader at its upper part, and narrower at the neck: its cavity is very inconfiderable in the unim- pregnated ftate, for the fides of the plane almoft come in contaa. Though its ftruaure is mufcular, its mufcular fibres can with difficulty be traced: They appear to be moftly circular; but are very difficult to unravel. Its veffels proceed from the fpermatics aud hypogaftrics. The arteries are very fmall in proportion to the veins ; which, in time of the gefla- tion, are fo much dilated, as to have obtained the name offnufes. Its nerves come from very fmall fi- laments : and ?.re chiefly furnifliedfrom the intercofl- als, thofe of the facrum, and the fympathetici maxi- mi. It is alfo fupplied with lymphatic veffels. The uterine tgements are of two kinds ; theligamen- ia latdand the ligamenta rotunda. T lie former are no more than part of the peritonaeum, which, alter gi- ving a coat to the uterus, goes out laterally to form thefe ligaments and are therefore only doublings of that 48 Female Parts of Generation. Chap. II that membrane, like the mefentery to the inteftine. Through thefe doublings the veffels of the uterus run. they have two folds in their upper part: The ante- rior contains the Fallopian tubes ; the pofterior, the ovaria. Each of the ligamenta rotunda is a little plexus of of mufcular fibres, nerves, and veffels, enveloped in a common membrane, in the form of a cord or liga- ment, coming down before the Fallopian tubes, and going out at the rings of the abdominal mufcles to be loft in the groin. In the anterior plica of the broad ligaments the Tube Fullopiane are contained. They have one extre- mity fixed to the fundus uteri, where the perforation is fo fmall it will hardly admit of a hog's brittle ; but the diameter gradually enlarges, becoming wider and wider like a trumpet, till it terminates .in a loofc floating extremity called Morfus Diaboli. This cavi- ty is not ftraight, but convoluted : When inflated, it feems to be ftrung upon the broad ligament, as the the inteftines are upon the mefentery. The ovaria are two flattened oblong bodies, not very unlike the male teftes, fituated at the fides of the uterus, .on the pofterior part of the ligamenta lata. Their fhape and fize are different in different women : Their outer furface is divided by a nfimber of chops but is fmoother and more uniform in virgins than in married women who have had children. There is lit tie to be obfervcd in their texture, except a number of Chap. II. Female Parts of Generation. 49 of veffels, and fomething like veficulaeor water-bags; thefe were fuppofed to be the ova, remarkable in the ovaria of quadrupeds. When a woman dies with child, one particular cavity is obferved, which was thought to be the calyx from whence the ovum had dropped, and is called corpus luteum: but later phyfio- logifts think that thefe corpora lutea are glands, con- taining the female femen, which in the time of coi- tion burft and throw out their contents into the tube in form of a liquid ; which, when mixed or blended with the feminal fluid of the male, is fuppofed to be conveyed through the tube into the uterus, to be- come the rudiments of the future foetus. Moftofthe phenomena of impregnation correfpond with this theory. Fcetufes have been found in the cavity of the abdomen, where there has been no rupture of the uterus ; and bones have made their way through the belly, while the uterus has been found perfeaiy found. Contiguous to the genital parts are, externally, the anus and perineum ; internally, the reclum, urethra, and bladder of urine. The anus is the orifice of the reaum, which is the centre of axis of the pelvis. It is contraaed into ru- gae by a plexus of mufcular fibres cA\ed fphinfter ani, which anfwers nearly the fame purpofe as it does in the male, and is loft in the perinaeum, inftead of the bulb ofthe urethra. E The 50 Of the Menfes. Chap. III. The reclum runs in a line, not quite ftraight, be- hind the vagina and uterus, in the hcdlow part of the facrum, through the capacity of the pelvis, and is fup- ported upon the coccyx and mufcles below, as in the male. The urethra is about an inch and a half long ; has no regular proftate, like the male ; but is fuppli- ed with a number of fmall glandular bodies, placed along the whole interior furface. The bladder is fituated over the vagina and uterus immediately behind the pubes : and is fuppofed to be larger and more capacious than in the other fex. As the vagina and urethra lie between the reaum and bladder, anv diforders in the one will readily bring the other into fympathy. The perineum is the feptum or fpace between the os externum vaginae and the anus. It is chiefly made up of the fphinaer ani and vagisae mufcles, the common integuments, and cellular fubftance. In its n.i'u tt , ^ .. fmall * See Dr Harper's Tables, Pl.xxxiv. fig. 3. Uf 6. Std. II- Ovum in early Geflation. 63 fmall bag, or white fpeck, is then obferved on the amnion, near the infertion of the umbilical cord. It is filled with a white liquor, of a thick milky con- Gftance; and is called vejicula umbilicalus, veftcula aU ba qs.la&fa : it cpm.mHnicaies with the umbilical '^ord^y.a fmall funis, which is made up of an artery flfldyein. This veficle,, and dua or tube leading Jjtom it, are only confpicuous in the early months ; ^d afterwards become tranfparent, and of confe- rence invifible *.. Their ufe is not yet underftood. Thpugh l;l)e bag, or external parts of the concep;- jion, at firil. Iqrrn a large proportion of the ovpm in comparifon pf tjie embryo or foetus,, in advanced ge- ftation the proportions are reverfed. An ovqm be- tween the eighth and ninth week after conceptiqn, is fpearly, about the fize of a hen's egg, while the embjiyo fiercely exceeds the weight of a fcruple: 'at ; three rnonths, the former increafes beyond the mag- nitude of a gopfefs egg, the weight above eight oun- ces,.; but foe, foetus does not then amount to tl\ree ,ounce,?; at fix months, the foetus weighs twelve or .thutejen,. ounces, and the placenta and membranes i ,only feyen, or eight: at eight months, the fbejtus i generally weighs fpmeiwhat more than five pounds, i theTccundines little more than one pound: at birth, the foetus weighs from fix or, feven to nine pound?, ' ...... which * Vldt Dr Hunter's elegant Plates of the Gravid Uterus, Pi, Mitiv. fig. 2. ©4 Gravid Uteru*. Chap. IV. which it rarely exceeds*; but the plaqenta. fe^dorn in- creafes much in bulk from between the,feventh* and eighth month. ^ :, Having defcribed the ovum in early ge&rtiqn, we {ball next take a view of the germ i trace the pra- :grefe of the embryo and foetus; then fefame the fob- jea of the ovum, to explain the ftru&ureof the membranes, placenta, &c. in advanced geftation, and point out the moft remarkable changes which the uterus fufrers during impregnation. SECTION III. r . Evolution of the Foetus. THere can be little doubt that all the. parts of an animal exift completely in the germ, though their extreme minutenefs and fluidity for fome time conceal them from our fight. In a ftate, of pro, greftion, fome of them are much earlier confpicuous than others. "'•' The embryo, in its original ftate, is probably en- tirely fibrous and nervous ; and thefe primary parts feem to contain, in a fmall fcale,all the others which "are afterwards to be progreflively evolved. Of the iormef trie heart and liver, of the latter the brain and fpinal * Natura fibi femper conftans manet, confuetum maturorum foe- tuum pondus effc inter 6 et 7 libras civiles midium ; rarius 9 libras excedere.—Henr. Aug. Wriibergii Obf. Anatomies, &c. Goettin- Sea. III. Evtlution of the Foetus. 05 fpinal medulla, firft become confpicuous : for the fpine or carina of the embryo is formed fome time before any veftige of extremities begin to fprout. The encephalon, or head, and its appendages, firft appear ; then the thoracic vifcera ; next, the ab- dominal : at length the extremities gradually fhoot out; the fuperior firft, then the inferior : and, by flow and infenfible gradation, the beautiful and ad- mirable ftruaure of the whole complicated fyftem is evolved. As foon as the embryo has acquired fufncient con- fiftence to be the fubjea.^ of any obfervation, a little moving point, which is the heart, difcovers itfelf. Nothing, however, but general circumftances rela- ting to the particular order and progrefs of the fuc- ceflive germination or evolution of the vifcera, ex- tremities-, vafcular fyftem, and other pa/ts of the human fcetus, can be afcertained, as it is beyond the power of anatomical inve(ligation. It is alfo exceedingly difficult to determine the age or proportional growth of the foetus. The judgment we form will be liable to confiderable variation : 3ft, From the uncertainty of fixing the period of pregnancy \ adly, From the difference of a foetus of the fame age in different women, and in the fame woman in different pregnancies ; and, laftly, Becaufe the foetus is often retained in utero for fome. time after the extinaion of its Ij|~e. F: * The 66 Gravid Ut«r«s. Chap. IV. The progrefs of the foetus appears to fee much quicker in the early than latter months: but the proportional increafe is attended with difficulty in the calculation ; for this, among other reafons, that we have not an opportunity of knowing the magnitude or weight of the tame foetus in different months. It will alfo, probably, be materially influenced by the health, conftitution, and mode of life, of the pa- rent. A foetus of four weeks, is near the fize of a com- mon fly ; it is Toft, mucilaginous, feems to hang by its belly, and its bowels are only covered by a tranf- parent membrane. At fix weeks, the confiftence is itill gelatinous, the fize about that of a fmall bee, the head larger than the reft of the body, and the extre- mities then begin to fhoot out. At twelve weeks, it is near 3 inches long, and its formation pretty diftina *. At four months, the foetus meafures a-. bbve 5 inches ; at five months, between 6 and 7 in- ches ; at fix months, the fostus is perfea in all its external parts, and commonly in length about 8, or between 8 and 9 inches ; at feven months, it is be- tween ii and 12 inches ; at eight months, about 14 or 15 inches-; and at full time, from 18 to 11 or 23 inches. But thefe calculations, for the above rea<- fons, muft be very uncertain. S E C- • y,de Dr Hunter's elegant Plates of the Gravid Uterus, the Vf6rM$ of Dr Harvey, De Granf, Malpighi, Haller, &c. Seel. IV^ In advanced Gtftklion. &] 5 ECT ION IV, Contents of the Gravid Uterus in advanced Gefiaiion. THESE eonfift of the Foetus, Umbilical Cord, Placenta, Membranes, and Contained Fluid. .We have already traced the progrefs of the fcetus; and fhall proceed to defcribe the other parts of the ovum in advanced geftation, as juft now enu- merated. Umbilical Cord. The fcetus is connected to the placenta by the umbilical cord, or navel-ftring; which may be defin- ed, " a long vafcular rope, compofed of two arteries and a vein, covered with coats derived from the .membranes, and diftended with a quantity of vifcid gelatinous fubftance to which the bulk of the cpidls chiefly owing.'' The cord always arifes from the centre ©f the child's belly, but its point of infer tion in the cake is .variable. Its fhape is feldom quite cylindrical ; and •its veffels are fometimes twifted or coiled, fometimes iformed into longitudinal fulti. Its diameter is com- monly about the thicknefs of an ordinary finger, 'and its length fufficient 10 admit the birth of the child with fafety, though-the placenta fhould adhere at the fundus, uteri. In. length and thicknefs, however, it is liable to confiderable variation. The extremity next 68 Gravid Uterus. Chap. IV. next the fcetus is generally ftrongeft ; and is fome- what weaker and more flender next the placenta, ac- cording to its place of infertion ; which, though commonly not far from the centre, is fometimes towards the very edge. This fuggefts an important advice to praaitioners, to be cautious of pulling the rope to extraa the placenta when they feel the fen- fation of its fplitting as it were into two divifions, which will proportionally weaken its refiftance, and render it liable to be ruptured with a very flight de- gree of force in pulling.—The ufe of the cord is to- connea the foetus to the cake, to convey the nutri- tious fluid from the mother to the child, and to return what is not employed. Placenta. The Placenta, Cake, or After-birth, is a thick, foft, vafcular mafs, conneaed to the fcetus by the funis umbilicalis, and to the uterus by means of the fpongy chorion, as already explained; It differs in fhape and fize, it is thickeft at the centre, and gra*- dually becomes thinner towards the edges* where the membranes go off all round, making-a complete bag- or involucrum to furround the waters, funis, and child. Its fubftance is chiefly vafcularj and probably in fome degree glandular. The ramifications of the veffels are very minute, which are unravelled by ma- ceration, ararVwhen injected,, exhibit a mod beauti- ful % A S4Ri lit. In-cmayKk^Gffailtn. 6g fat appearance refewghling the bufhy tops' ef> a tree. It has af» externa)1 convex,, and an internal concave, furface. The former Ts divided into a nuftibe? of fmall lobes and fiflures, by means of which its adhe- flon to the uterus is more firmly fecured. This loi bulated appearance is moft remarkable when the cake has beea rafhly feparated from the uferws ;' for the membrana • decidua, or conne^ing membrane 'be- tween it and the uteruis, being then torn, the moft vio- len* and aJaraning haemasr/hagies frequently; enfue. The iotewiat concave fwfface of the placenta is loo&fy covered udtb the awwdan, and by the chorion more immediately and intimately. From thisf-ini. ternat furface arife innumerable ramifications of Veins and arteries, which inofculate and anaftomofe with one another ; and at laft the different branches unite, and fortm the funis umbilicalis. . • .j-v .; .. Thea&er,4>irth adheres to every part of tfeMftfernal furface of tjhe uterus, as at the pofterior and anterior fuperior parts, laterally; and fometirnes, -thpugh mpre rearly, part of the cake extends over the orifi- c'mm uteri; from whence, when theorifice beginsto dilate, the moft frightful ,and dangerous . floorings ^ rife. But the moft common place of attachment of; the cake is fijom the fuperipr pairjt of the cervi^ tpjthe fundijs, , ■-',.,..!. Twins, triplets, fyc. have their placenta;fomedtpes feparate and fometimes adhering together. nWhe.n. the ?0 GKvid'Urtms.^ CMfaVtt. the placentae adhere, they have generally the thoribti iri common; but each fcetus-nas its difiin&' amnion. They are commonly joined tdgethef, either by. an in* tervening membrane, or by the furfaces bemg con- tiguous to one another : and fometimes the veflfels^f the one cake anaftomofe with thofeof the other, ■',- The human placenta, according to Dr Hunter, is fimiiar in ftruaure to that of quadrupeds.- and feems to be compofed of two diflina fyftems of parts, a fpongy or cellular, and a vafcular fubftance.. It ha* of confequence two diftinft: fets of veffels. The fpon- gy or cellular part, formed by the decidua, is derived from the mother; and, if filled with injection, will increafe the placenta to nearly twice its ordinary! thicknefs; the more internal vafcular part belongs entirely to the foetus, and can only be inje&ed. froq* the cord, as the fpongy part by the filling the veffels of the uterus. This will be better underftood when the mode of circulation between the parent and child is explained. , Membranes. These confift, externally, of two layers of the fpongy chorion, called decidua and decidua refexa; in- ternally, of the true chorion and the amnion. They form a pretty ftrong bag, commencing at the edge of the cake, going round the whole circumference, and? lining the internal furface of the womb. When feparated from the uterus, this membranous bag ia 1 ■' (lender 9s$. IV; i In efdvettfal Geftation. ft Header and yielding, and its texture readily .deftfcoyed by theimpulfcpf the contained fluid, the preffure; pf the/child, or of the finger in touching; but in its natural itafe* while it lines the womb, and is in clofe contaftwlth its furface, the membranous bag is fo tough and ftrong as to'give a confiderable degree* of ief«ftancfei It is alfo ftrengthened in propdrtion to -the-different layers of which it is compofed, whofe ftru&ure we (hall proceed to explain more particularly. i. The Mfpibrana Decidua, or that lamella of the fpongy falfe chorion which is in immediate contract with the.uterus,/is originally very thick and'fpongy, and exceedingly vafcular, particularly where it ap- proaches the placenta, At firft it is loofely, as it Were, fpread over the ovum ; and the intervening fpace is filled with a quantity of gelatinous fubftance. It gradually becomes more and more attenuated by "J^'tching, and approaches nearer to the interior la- mella of the decidua, called decidua reflexa\ and about the fifth month the two layers come in contact, and adhere fo as to become apparently one mem- brane *, 2. Decidua Reflexa. In its ftruaure and appear- ance it is fimilar to the former, being rough, fleecy, tand vafcular, on its external furface; internally, fmopther, and' perforated with a number of fmall ..,„.,, i dram in a ,'* Fide Br. Hunter's Tables, PI. xxvii. fig. 2. PI. xxix. f5jj. 1, 2. 4- J. PI. XX3». fig. I %, &C. 72 •Gravid Uterus. CbapiTV, foramina, which: are t>hc orifices pf veffels that open into this internal fufface. In advanced geftation, it adheres 'intimately to the focmer membrane, and is with difficulty feparated when the double decidua comes off entire; but it he outer lamella more com- monly -adheres to the uterus after the placenta and other membranes are expelled, and is afterwaMk caft off with the cleanfings. The decidua reflexa becomes thicker and more vaf- cular as it approaches the placenta, and is then blended with .its fubftance, conftituting the cellular or mater- nal part of the cake, as it is termed by Dr Hunter. The other or more internal part belongs to the foetus, and fe ftyled thefcetal part of the placenta. The double decidua is opake in comparifon of the bther membranes ; the blood-vefiels are derived from the uterus, and can be readily traced into it. Dr Hunter fuppofes that the double decidua lines the uterus nearly in the fame manner as the peritonaeum does the cavity of the abdomen, and that the ovum is inclofed within its duplicative as within a double nii^htcap. On this fuppofition the ovum muft be placed on the outfide of this membrane, which is not Very readily to be comprehended ; unlefs we adopt Signor'Scarpa's opinion already mentioned, and fup- pofe it to be originally entirely compofed of "an infpi(fated coagulable lymph." 3. Tilt true Chorion, or that conneaed with the amnion, Se'&\ IV. In advanced Geflation. 73 amnion; is the firmeft, fmootheft, and moft trans- parent of all the membranes, except the amnios; and, when feparated from it, has a confiderable de- gree of tranfparency. It adheres pretty clofely to the internal furface of the cake, which it covers imme- diately under the amnios, and gives alfo a coat to the umbilical cord. It is conneded to the amnion by means of a gelatinous fubftance, and is eafily feparated from it. 4. The Amnion, or internal membrane, forms the external coat of the umbilical cord. This internal lamella of the membranous bag is by much the moft thin, attenuated, and tranfparent of the whole ; and its veffels are fo delicate, that they can hardly be dif- covered ; their diameters are fo fmall, as to be inca- pable in their natural ftate of admitting globules of red blood. It is, however, firmer and ftronger than the chorion, and gives thegreateft refiftance in the breaking of the membranes. The fmall bag, called veficula umbilicalis, formerly defcribed, and only confpicuous in the early months from its fituation, is placed between the amnion and chorion, near the the attachment of the cord ; and, from the colour of its contents, has been miftaken for the urachus : but there is no allantois in the hu- man fubjea. The allantois in quadrupeds is an oblong mem- branous fac, or pouch, placed between the chorion G zr.d 74 Gravid Uterus. Chap. IV. and amnion. This membrane communicates with the urachus, which in brutes is open, and tranfmits the urine from the bladder to the allantois. 5. The Waters are contained within the amnion, and are called the liquor amnii. They are pureft, cleareft, and moft limped in the firft months ;acequi- ring a colour and fomewhat ropy, towards the latter end. They vary in different fubjeas, both in regard to confiftence and quantity ; and, after a certain pe- riod, they proportionally diminifh as the woman advances in her pregnancy. This liquor does not, in any refpea, refemble the white of an egg; it is generally faltifh, and therefore unfit for the nutrition of the child: fome of it may perhaps be abforbed by the foetus, but the child is chiefly nourifh- ed by the navel-ftring. In the early months, the organs are not fit for fwallowing ; and monfters are fometimes born alive, where fuch organs are altoge- ther wanting. Water is fometimes colleaed between the chorion and amnion, or between the lamellae of the chorion. This is called the falfe water : It is generally in much fmaller quantity than the true water; and, wi- thout detriment to the woman, may flow at any time of pregnancy. Having defcribed the contents of the gravid ute- rus, let us confider the changes which that organ fuffers during he progrefs of geftation, and explain the man- ner of circulation between the parent and fcetus, and - d See"?. V. Changes from Impregnation 75 and within the body of the fcetus : we fhall then enumerate the moft remarkable peculiarities of the non-natus ; and couclude the fubjea with a few obfer- vations on Superfcetation, extra-uterine Conception, and the Generation of monfters. SECTION V. Changes of the Uterine Syfemfrom Impregnation. THouoh the uterus gradually encreafes in fize from the moment of conception till full time, and although its diftention is proportioned to that of the ovum, with regard to its contents, it is ftriaiy fpeaking, never completely diftended : for, in early geftation, they are entirely confined to the fundus; and, at full time, the finger can be paffed for fome Way within the orificium uteri without touching any part of the membranes*. Again, though the capacity of the uterus increafes, yet it is not mechani- cally ftretched, for the thicknefs of its fides does not diminifh. The increafed fize feems, therefore, to depend on a proportional quantity of fluids fent to that part, nearly in the fame way the fkin of a child, though it fuffers f o great diftention, does not become thinner, but preftrves it ufual thicknefs. • Sec Dr Hunter** Tables, PI. XXXi. fig. 1. This 7& Gravid Uterus. Chap. IV. This is proved from feveral inftances of extra- uterine foetufes, where the uterus, though there were no contents, was nearly of the fame fize, from the additional quantity of fluids tranfmitted, as if the ovum had been contained within its cavity. Boehme- rus* relates the fame circumftance, without attemp- ting to explain it, in the hiftory of a cafe of extra- uterine conception in the fifth month. The uterus is painted of a confiderable fize, though the foetus was contained in the ovarium. The gravid uterus is of different fize in different women ; and will vary according to the bulk of the fcetus and involucra. The fituation alfo varies ac- cording to the increafe of its contents, and the pofi- UQn of the body. For the firft two or three months, the cavity of the fundus is triangular as before im- pregnation ; but as the uterus ftretches, it gradually "^•--esamore rounded form. In general, the ute- rus never rifes directly upwards, but inclines a little obliquely ; moft commonly to the right fide +: its pofition is never, however, fo oblique as to prove the fole caufe either of preventing or retarding delivery. Though confiderable changes are occafioned by the gradual diftention of the uterus, it is difficult to judge * Vidt Boehmeri Obf. Anatom. Rarior. Fafciculus ttotabflf circa uterum human. Obfervatio de Conceptione ovaria, tabula prima. f See Dr. Hunter's Tables, PI. i. iii. and iv. Sea. V. ' Changes from Impregnation. 77 judge of pregnancy from appearances in the early months. For the firft three months, the os tincae feels fmooth and even, and its orifice is nearly as fmall as in the virgin ftate. When any difference can be perceived, it will confift in the increafed length of the projecting tubercle of the uterus, and and the fhortening of the vagina from the defcent of the fundus uteri through the pelvis. This change in the pofition of the uterus, by which the projeaing tubercle appears to be lengthened, and the vagina pro- portionally ihortened, chiefly happens from the third to the fifth month. From this period the cervix begins to ftretch and be diftended, firft at the upper part; and then the os tincae begins alfo to fuffer confider- able changes in its figure and appearance. The tu-* bercle fhortens, and the orifice expands: but, during the whole term of geftation, the mouth of the uterus is ftrongly cemented with a ropy mucus, which lines it and the cervix, and begins to be difcharged on the approach of labour. In the laft weeks, when the cervix uteri is compledydiftended, the uterine orifice begins to form an eliptical tube, inftead of a fiffure ; and fometimes, efpecially when the parietes of the abdomen are relaxed by repeated pregnancy, difap- pears entirely, and is without the reach of the finger in touching. Hence the os uteri is not placed in the direaion of the axis of the womb, as has gene- rally been fuppofed. G 2 The 78 Gravid Uterus. Chap. IV. The progreffive increafe of the abdominal tumor, from the ftretching of the fundus, affords a more de- cifive mark of the exiftence and period of pregnancy than any others; and the progrefs is nearly as fol- lows. About the fourth, or between the fourth and fifth month, the fundus uteri begins to rife above the pubes or brim of the pelvis, and the cervix to be fomewhat diftended. In the fifth month, the belly fwells like a ball with the fkin tenfe, the fundus extends about half way between pubes and navel, and the neck is fenfibly fhortened. In the feventh month, the fundus, or fuperior part of the uterine tumor, advan- ces as far as the umbilicus; and the the cervix is then nearly three-fourths diftended. In the eighth, it reaches midway between the navel aud fcrobiculus cordis ; and, in the ninth, to the fcrobiculus itfelf, the neck then being entirely diftended ; which, with the os tincae, become theweakeft parts of the ute- rus. Thus at full time the uterus occupies all the umbilical and hypogaftric regions: its fhape is al- moft pyriform, that is, more rounded above than below, and having a ftriaure on that part which is: furrounded by the brim of the pelvis*.' During the progrefs of diftention, the fubftance of the uterus becomes much loofer, of a fofter texture,. and more vafcular than before conception ; and the diameter of its veins is fo much enlarged that they have * FideDr Hunter's Tables, PI. xvi. A Seft. V. Changes from Geflation. 79 have acquired the name offmufts. They obferve a rriore direa courfe than the arteries, which run in a Terpentine manner through its whole fubftance*, and anaftomofe with one another, particularly at that part where the placenta is attached: It is in this part alfo that the vafcular ftruaure is moft confpicuous. The artepies pafs from the uterus thro' the deciduaj and open into the fubftance of the placenta in an oblique direaion. The veins, alfo open into the placenta; and by injeaing thefe Veins from the uterus with wax, the whole fpongy or maternal part of the placenta will be filled *. The mufcular ftructure of the graviduterus is ex-* tremely difficult to be traced with any exaanefs; In the wombs of women who die in labour, or foon after delivery, fibres running in various direaions ar© obfervable more or lefs circular. ■' ■ ■ , Thefe feem to arife from three diftina origins/ viz. from the plac» where the placenta adheres, and, from the aperture or orifice of each of the tubes ; hub it is almoft impoffible to demonftrate regular plans of fibres continued any length without interrupt ton. • The appendages of the uterus fuffer alfb. IV, rifes higher than infubfequent impregnations, the ligamenta rotunda are confiderably ftretched ; and to this caufe thofe pains are probably owing which ftrike from the belly downwards in the direaion of thefe vafcular ropes, which are often very painful and dif- treffiag towards the latter end of geftation. Again, as the uterus, which is chiefly enlarged towards the fundus, at full time ftretches into the cavity of the abdomen without any fupport, leaving the broad li- gaments below thf; moft bulky part, we can readily fee, that by pulling at the umbilical cord to deliver the placenta, before the uterus is fufficiently con- traaed, the fundus may be pulled down through the mouth of the womb, even though no great violence be employed. This is fly led the mverfiw of the uterus; and is a very dreadful, and generally fatal accident. It is the confequence only of ignorance or temerity ;. and can fcarcely happen but from violence, or from an officious intrufion on the work of nature, by pul- ling at the rope while the woman is faint or languid, and the uterus in a. ftate of atony. In fome rare inftances, the force of labour which propels the child where the-cord is fhort naturally, or rendered fo by circuuav&lqtions round the body of the child, may, when the placenta adheres to the fundus uteri, bring it down fa-near the os tincae, that little force would afterwards be fuflkient to complete the inverfion. This fuggefts a precaution, that in the above Seft. V. Changes from Geftatm. 8t above circumftances, if ftrong labour-pains fhould continue, or a conftant bearing down enfue, after the delivery of the child, the praftice of pulling by the cord fhould be carefully avoided, and the hand of the operator be prudently conduaed within the uterus, to feparate the adhefion of the cake, and guard againft the hazard of inverfion *. The ovaria alfo fuffer fome change from pre- gnancy. A roundifh figure of a yellow colour appears in one of them, called by anatomifts the corpus luteum ; and in cafes of twins, a corpus luteum often appears in each ovarium. It was imagined to be the calyx ovi ; and is obferved to be a gland from whence the female fluid or germ is ejeaed. In early geftation this cicatrix is moft, confpicuous, when a cavity is ob- vious, which afterwards collapfes. If the ovarium be injeaed in the latter month, the corpus luteum will appear to be compofed chiefc ly of veffels. A portion of it, however, in the cen- tre, will not be filled ; from which it is, with fome reafon, fufpeaed that it is a cavity, or that it con- tains a fubftance not yet organifed t. S E C- * Of feven unhappy cafes of inverted uterui where I have been. called vrithin feveral years, the confequence of ignorance or temerity of the practitioner, in one fingle inftance only the wo- man furvived the fliocking accident. The other women had g&> n«rally expired before any attempt could be made to relieve them,* f Vide Dr. Hunter's Tables, PL v.; PL xv. fig. J.; PL xxis. fig. 3.; and Tl. xxxi. fig. 3. 8a Gravid Uterus. Chap. IV*. SECT ION VI. Manner of Circulation between the Mother and Foetus* A Fter many difputes on this fubjea, it is now ■*• •** generally allowed, that the communication between the parent and child is carried on entirely by means of the placenta, whofe fpongy furface ad- heres to the internal furface of the womb, and re- ceives the finer part of the arterial blood of the mo- ther by abforption. No anaftomofes of blood-veffeis between them have yet been clearly fhown by the experiments of any phyfiologift; nor has any colour- ed injeaion been pufhed from the uterus into the in- terior vafcular part of the cake, nor from the foetus or umbilical veffels into the cellular part, except by the force of extravafation, This cellular part of the placenta is probably derived from the decidua ; and- is not a fpongy inorganic fubftance, merely intended' for the attachment of the cake ; but probably a regu- larly conftruaed and organifed part belonging to the mother. The cells, therefore, cannot be filled by injeaion from the umbilical veffels, though an injec- tion will readily pafs from the veffels of the uterus. We find the fame ftruaure obtain in cows, where, the cellular can be eafily feparated from the vafcular part* and the diftina property of each afcertained. As the ftruaure of the cellular part of the placen- ta,. J Sea. VII. Circulation in the Foetus. 83 ta is fomewhat fimilar to that of the more fimple glands, it may be reafonably inferred, that it is inten- ded for other purpofes befides merely abforbing blood and conveying it to the umbilical veffels of the child. It feems probable, therefore, that an operation fimi- lar to fecretion is carried in the placenta ; that the veins and arteries of the fcetus, in the vafcular part of the cake, are continuous ; and that abforbents arife in the follicles, which foon terminate in veins. From this view it appears, that the placenta is not only the conneaing medium between the mother and child, intended for conveying and returning nutritious fluid from the one to the other, but alfo changes and prepares it, in a particular manner, for circulating through the minute vefiels of the delicate foetus. This mode of circulation is admirably well contrU ved for the prefervation of the child from difeafes which would otherwife be communicated from the mother, if the mutual communication were kept up by continuous veffels, the fcetus would conftant-p ly be in danger of fuffering when the mother's circu- lation was accelerated or otherwife difturbed. SECTION VII. Circulation in the Fat us. :.\\' THE finer part of the arterial blood of the mother tranfmititd, in the manner juft now mention- ed, from the uterus to the placenta and conveyed a- long 84 Gravid Uterus. Chap. VI. lohg the umbilical cord to the fcetus for its fupport and increafe circulates in the fyftem of the non-natui in the fallowing manner. The blood panes direflly from the placenta into the umbilical vein ; which running along the funis, perforates the belly of the fcetus, and enters under the liver, where it divides into two branches, nearly at half a right angle. One of thefe branches, called the duclus venofus, carries part of this liquor immediate- ly to the lower vena cava. The other carries the reft to the vena portarum ; where, after circulating through the liver, it alfo gets into the vena cava, and fo to the heart: but the circulation here is carried on without any neceffity for the lungs being dilated. For foetufes have an oval hole open between the two auricles of the heart, and a large communicating canal, called canalis arteriofus, going between the pulmonary artery and aorta ; which two paffages al- low the reft of this circulating fluid, that returns by the cava fuperior, to be tranfmitted to the aorta, with- out paffing thro' the lungs. The blood is returned from the foetus by the arleriat umbilicales, which take their rife fometimes from the trunk of the aorta, and fometimes from the iliac arteries of the foetus ; and, running by the external fides of the bladder, afcend to go out at the navel. Thus there are three circulations belonging to the foetus, viz. one between the uterus and placenta, by abforption ; one between the placenta and foetus, by A Sea. VIII. Pofttion of the Fcetus. S5 jy a continuation of veffels through the cord ; and one within the fcetus itfelf. SECTION VIII. Pofttion of the Fcetus in utero. THE foetus is commodioufly adapted to the cavity of the uterus, and dcfcribes an oblolfg or oval figure; its feveral parts being colleaed together in fuch a manner as to occupy the leaft poffible fpace. The fpine is rounded, the head reclines forward to- wards the knees, which are drawn up to the belly, while the heels are drawn backwards towards the breech, and the hands and arms are folded round the knees and legs. The head of the child is generally downwards. This does not proceed, as was com- monly alleged, from the funis not being exaaiy in the middle of the child's body, fcr it is not fufpended by the funis :* the reafon is, becaufe the fuperior parts*are much larger and heavier in proportion than the inferior. When other parts prefent, it feems owing to. the motion of the child altering its figure when'the waters are much diminifhed in quantity, or to circumvolutions of the cord : when the pofition is once altered, it becpms confined or locked m in the uterus, and cannot eafily refume its- original po- fture. As thefigure of the fcetus is oval, and the head na- H . naturalljr 36 Gravid Uterus. Chap. IV. turally falls to the moft depending part of the uterus, the vertex generally points to the os tincae, with the ears diagonally in the pelvis between the pubes and facrum. The foetus is mechanically difpofed to af- fume this pofition from its peculiar figure and con- flru£tion, particularly by the bulk of the head and articulation with the neck, by the aaion of its muf- cles, and by the fhape and conftruaion of the cavity in which it is contained. SECTION IX. Peculiarities of the Fcetus. THE foetus, both in external figure and internal ftruaure, differs materially, in many ftrikingcir- -cumftances, from the adult, it is fufficient for our prefent purpofe to mention a few particulars. The head is very large in proportion to the reft of the f/ody ; the cranial bones are foft and yielding, arid the futures not yet united ; fo that the bulk of the head may be diminifhed in every direaion, and its paffage confequently be rendered more commo- dious. The bones of the trunk and extremities, and all the articulations, are alfo remarkably flexible. AH the apophyfes are epiphyfes; even the heads and condyles and brims of cavities,, inftead of bone, are of a foft cartilaginous confiftence. The brain, fpin;i: marrow, and whole glandular as well Sea. IX. Peculiarities of the Fcetus. 87 well as nervous and fanguiferous fyftems, are confi- derably larger in proportion in the fcetus than in the adult. It has a gland fituated in the fore-part of the cheft between the laminae of the mediaftinum, called the thymus. The liver and kidneys are much larger in proportion ; and the latter are divided into a num- ber of fmall lobes, as in the brute. The foetus alfo differs in feveral circumftances from a child who has breathed. The cavity of the thorax is lefs in proportion than after refpiration. The lungs are fmaller, more compaa, of a red colour like the liver, and will fink in water; but putrefaaion, and a particular emphy- ferna; as in difeafes of cattle, and blowing into them, will make them fwim: which fhould prevent us from haftily determining, from this circnmftance, whether a child has breathed or not; which we are often called on to do. Neither does their finking prove that the child never breathed ; for a child may die, or be ftrangled in the birth, or immediately after, before the lungs are fully inflated. The arterial and venous fyftems are alfo different from that of the child. Hence the difference in the manner of circulation already taken notice of. S E C- 83 Gravid Uterus. Chap. IV. SECTION X. Some Subjects connefted with Geflation I. Super-Foetation. QOON after impregnation takes place, the cervix ^-* and orificium uteri become entirely clofed up by means of a thick vifcid gluten : the internal cavity is alfo lined by the external membrane of the ovum, which attaches itfelf to the whole internal furface of the fundus uteri: the Fallopian tubes alfo become flaccid ; and are, as geflation advances, fuppofed to be removed at fo great a diftance, that they cannot reach the ovaria to receive or convey another ovum into the uterus. For thefe and other reafons, the doadr.e of fuper-foetation, or the poiTibility of one conception foon after fupervening another in the fame womsn, is now pretty generally exploded :—A doc- trine that feems to have an fen from the cafe of a double or triple conception ; where, fome time after their formation and progreffive evolution in utero, one . forms Iins been expelled, and another has remained j rr, after the extinaion of life at an early period, one cr more may ftill be retained, and thrown off in a fmall and purtrid ftate, after the birth of a full-grown child. HPU r " ' . ,| . . ., ^, - ' -~!. ; j. uC mtins ui unites is divided info wrrrrrTTrTCli> J and their oVa do not attach themfelves to the uterus fo Sea. IX. Saper-Foetation. 89 fo early as in the human fubjea, but are fuppofed to receive their nourifhment for fome time by abforp- tion. Hence the os uteri does not clofe immediately after conception ; for a bitch will admit a variety of dogs while fhe is in feafon, and will bring forth pup- pies of thefe different fpecies.—Thus it is common for a gre-hound to have, in the fame litter, one of the gre-hound kind; a pointer; and a third, or more, different from both: Another circumftance that has given rife to fuper-fcetation in the human fubjea, which can only happen when there is a double fet of parts ; inftances of which are very rare. II. Extra-uterine Foetuses, or Ventral Conception. The impregnated ovum, or rudiments of the foetus, is not always received from the ovarium by the tuba Fallopiana, to be thence conveyed into the cavity of the uterus. For there are inftances where the foetus fometimes remains in the ovarium, and fometimes even in the tube ; or where-it- drops cut of the ovarium, miffes the tube, falls into the cavity of the abdomen, takes root in the neighbouring parts, and is thereby nouriihed: But they are always lefs than the uterine foetufes ; they either do not receive fo much nourifhment as in the fucculent uterus, or they generally come to their full growth long before their - common term. Ha Some f* yo Gravid Uterus. Chap. IV. Some-of thefe burft in the abdomen; others form abfceffes, and are thereby difcharged ; others fhrivel, appear bony, and are retained during life, or dif- charged by ftool, abfceffes, &c *. III. Monsters. Every confiderable deviation in the ftruaure of a foetus from the common order of nature is confidered as monftrous, whether fuch deviation be confiftent with life or not; and the produaion is commonly termed a monfier. This idea of a monfter will, however, comprehend all the variety that has been obferved; and thefe we fhall endeavour to reduce under four ge- neral heads. i. Thofe produaions which have fupernumerary parts. Thefe include all the variety, from the famous in- ftance of the Bohemian fitters, who were joi ned together by the glutei mufcles and the inteftinal canal, to thofe foetufes which have only an additional finger or toe. 2. Thofe whofe parts are defeaive ; which has hap- pened with refpea to every part of the animal body. 3. Thofe who have any remarkable diftribution of any of the veffels, nerves, or excretory organs, whether externally vifible or not. 4. The produaions of animals of different fpccies, exemplified * Vid. Memoires de 1' Acad, de Sciences; Philofophical Tranf- ai^ions; Manget. Biblioth. Anat.; Med Efiays; and Smellk'.; Cafes. Sea. IX. ■Monflers. 9* exemplified in the mule produced by the mixed gene- ration of an afs and mare. It is very difficult to give an explanation of thefe deviations, nor indeed is it to be expeaed, while the procefsof generation is itfelf fo great amyftery. If we allow with Bonnet, &c. that a germ or embryo of the future produaion exifts in the female previous to the impregnation, many of thefe deviations muft to it be referred. Though this, however removes the difficulty, it by no means folves it. Supernumerary parts may be more readily accounted for; for if two ova become contiguous in their gelatinous ftate, they may eafily unite : and this contiguity and union will prevent the evolution of many of the parts, and the produaion will appear as one. This we can fay with fome certainty has been often the cafe, as in the Bo- hemian fifters mentioned under the firft fpecies ; and1 the union in the different monfters has at various times been feen gradually more and more complete, fo that moft fupcrnumerary parts evidently proceed from this caufe. Thecaufesof the other deviations are more obfeure, and we can find no view which we can purfue with fufficient probability to be here mentioned. BART* PART II. PATHOLOGY. HAVING concifely defcribed the feveral parts, and pointed out their ufes, we fhould next pro- ceed to the Operation ; but we muft firft corifider thofe complaints which may prevent conception, and may be ftiled the Pathology of Generation ; fecondly, thofe which impede or retard delivery, or the Patho- logy of Parturition. CHAP. I. Pathology ^Generation. r I TIE difeafes included under this divifion are,. ■** Topical affeaions of the parts, Irregularities of of the periodical Evacuation, and difeafes which are fometimes miftaken for Geftation. SECTION I. Topical Difeafes of the Genital Organs. r I'^HE mons veneris and labia pudendorum are liable , -*- both tooedematous and inflammatory fwellings, and ■ to tumors, chiefly of the featomatous kind. The latter fometimes, from fmall beginnings, gradually en - large- Sea. I. Topical Difeafes 93 large to an enormous fize : but as they commonly adhere by a fmall peduncle, their excifion is a fim- ple operation, and feldom followed wiih confiderable haemorrhage ; they leave but flight marks behind them, and for the moft part eafily heal. Oedematous fwellings are of two kinds ; general or local. The firft are the attendants of an univerfal leucophlegmafia, the confequence of adropfical habit; and the treatment muft then be conduaed on gene- ral principles, with a view to cofrea the fault in the habit. The latter arife from venous plethora, and, the preffure of the bulky uterus interrupting the re- turning blood from the lower extremities ; hence the ferous part is extravafated, and forms a local oedema. The fwelling at firft appears on the feet and legs, and gradually extends to the thighs and labia. . Though fometimes formidable, it is entirely fymptomatjc of pregnancy ; and for the moft part, entirely fubfides foon after delivery. The labia, when inflamed or abraded ; from what- evercaufe, (as from the involuntary difcharge of a- crid urine, or any other acrimonious difcharge which excoriates the parts), may grow together if not pre- vented by frequent bathing ; fhouldjhis happen, they muft be feparated with a fcalpel, and the like acci- dent by proper care in future prevented. The clitoris fometimes becomes enlarged greatly"' ^ beyond the ordinary fize. When incommodioufty;*' elongated 94 Pathology of Generation. Chap. I. elongated, amputation may be performed with fafe- ty. The enlargement of the nympha alfo requires the fame treatment. Extirpation of the carunculce myrliformes fometimes alfo becomes requifite; but fungous excrefcences of - thefe parts may generally be removed by cauftic, or any mose gentle efcharotic application. The urethra, too, is fubjea to diforders and ac- cidents ; fuch as fungous excrefcences, contufion, laceration, inflammation, gangrene, and the ftone. The firft of thefe may, when large, be cut out with the fciffars, or deftroyed by the application of the bougie. All the others, as now enumerated, may be the confequence of a ftone ftickin'g in the paffage: when the expulfion cannot be forwarded by the femicupium, the ftone muft be extraaed,. either by dilating the urethra itfelf, or cutting upon - it through the vagina. The fymptoms of a ftone in the female bladder, towards its neck, or in the ure- thra, are nearly fimilar to thofe which occur in the ■ male, and the treatment and operation are loo well known to require a defcription. The imperforated hymen in fome fubjeas fhuts up the os externum entirely, and is expanded even to th» meatus urinariouf. It is feldom attended with in- convenience till the age of puberty, when the men- fes fhould appear; at which time a fuelling or tumor h formed, by the confinement of the accumulating menftrual Sea. I. topical Difeafes. 95 menftrual blood. The quantity increafes at every fucceeding period ; and, by the diftention of the parts, excites the moft troublefome and painful complaints. The cure confifts in dividing the membrane by inci- fion. The opening fhould be fufficiently large, that the whole contents may be freely evacuated : In fome cafes the thicknefs is fo great, as to require the ufe of a trocar*. The re-union of the lips of the wound muft, by proper dreffings, be carefully guar- ded againft. Narrowness of the Vagina fometimes oc- curs. This may be either natural, from original conformation ; or accidental, in confequence of dif- eafe. Cicatrices may be formed from a laceration af- ter fevere labour; in confequence of ulceration, erofion, &c. Preternatural conftriaions may like- wife be induced, from the ufe of ftyptic applications, -or fumigations. The cure may be attempted by emol- lient fomentations ; as by the fteams of warm water direaed to the parts ; and by introducing a fmall tent of compreffed fponge, which hath been previoufly moiftened and kept tight bound with tape till dry. This by imbibing the moifture, will fwell and ex- pand ; and thus the aperture will be gradually ftrech- ed. The tent muft be withdrawn every day, by means of a thread fixed through its middle, and a lar- * Vid Edinburgh Med. Commentaries, Vol. II. part % Seel, ii. Cafe iv. 96 Pathology of Generative. Chap. I. a larger one introduced in its ftead. The fponge fhould be fmooth, and lubricated with pomatum. This procefs muft be continued, till the paffage be- comes fufficiently enlarged. If thefe methods fail, rccourfc muft then be had to the knife ; though, in the fimple contraaion of the cavity of the vagina this expedient: is feldom neceffa- ry, and the attempt is often attended with the utmoft danger ; therefore fhould never be determined on till every other method has failed. The dilation, which previous to impregnation feemed -impraaicable, has very often been accompliftied by labour-pains. Sometimes there is a natural defea in the genital parts', from an original mal-conforrnation ;fo that the vagina is either imperforated altogether, or a foramen only remains fufficient to tranfmit the menftrual blood. If, from coalition of the parictes of the vagina, the paf- fage be entirely fhut up, an attempt to force it would be vain. tThe orifice in the latter cafe will afford a pro- per direaion for the knife ; but the operator muft be cautious not to miftake the urethra for the paffage into the vagina. 'When the vagina is impjfvious altogether, the u- terds has been fometimes wanting*. The perineum, from the diftention it fuffers in time of labour, or fro pa mechanical violence in delivery • * Vid. Morgagni, de caufis et fedilms morborum, gpiftol. XLVI. •» Sea. I. Topical Difeafes. 9/ delivery, is fubjea to inflammation, tumefaaion, la- ceration, and their confequences; and thefe, in fome cafes, are not confined to the perinaeum only, but even extend to the vagina, reaum, and bladder. If thefe complaints refill the common means of relief, fuch as frequent bathing, fomentations, cataplafms, &c. and terminate in gangrene, leaving behind them fiftulous fores with callous lips, unlefs a cure be effeaed by time, they generally continue in a fiftu- lous ftate, without a poflibility of remedy. The uterus, like other parts, may alfo be affeaed vdth various diforders : Thefe are chiefly inflammation and its confequences ; farcomatous, fungous, and po- lypous tumors ; flroney concretions, dropfy4 tympa- nites, fcirrhous and cancerous tumors. When the os tince is fhut up, either originally, or by cicatrix in confequence of fuppuration, daceration, ulceration, or the like, the cafe is generally incur- able ; except the menftrual blood by its weight force a paffage, or point out the manner of procuring it: if that fails, a future fterility is the unavoidable con- fequence. Original conformations of this kind feldom admit of any treatment, for this reafon : Becaufe, befides the impervioufnefs of the os tincae, the utertis itfelf fometimes appears a folid body without any cavity in the centre. Sarcomatous, fungous, or polypous Tu- I H°$s> c;8 Pathology of Generation. Chap. I. mors, arife from all parts of the vagina and uterus. They happen to women at every period of life, but moft frequently towards the decline. They gene- rally proceed from an obftruaion of the fmall glands of the parts, and are lefs or more difficult to difcover or remove, as their origin is low or high in the va- fdna or uterus. Their texture or confidence is very different ; fometimes they are tender and muci- laginous, like thofe in the nofe ; at other times firm and folid, like a wen. Their exiftence is difcovered by a careful inquiry into the circumftances of the cafe, and by an examination of the parts ; fometimes their bafis is very confiderable ; though they generally adhere by a fmall neck. They fometimes, like fcir- ahi, continue indolent for many years ; and are alfo liable to degenerate into fcirrhus and cancer. In their mildefl ftate, they are attended with perpetual ftillicidium from the vagina, and fometimes with profufe and dangerous floodings. They muft be carefully diftinguilhed from hernie, prolapfus uteri, and other tumors. Polypi, when curable by an ope- ration, may generally be removed by ligature; a fafer method than cutting with the fcalpel, as they are often fupplied with large blood-veifels, from which there may be danger of a fatal haemorrhagy. For fixing the ligature, the fingers of the operator will be fometimes fufficient. When this method fails, Dr Hunter's needle, or M. Levret's dou- ble Sea. I. - Topical Difeafes. 99 ble canula for applying and fixing the ligature over the tumor, are the moft fimple and fuccefsful expe- dients. M. Levret's inftrument is nothing more than a piece of flexible gold or filver v/ire, paffed through a double hollow probe in the form of a noofe: This is to be conveyed into the vagina, and carried over the tumor till it reach the bafe ; the ends of the wire muft be gently drawn, or it muft be twifted round as tight as the patient can eafily bear ; the canula muft afterwards be fixed to the thigh, and the wire tightened every day as it flackens. By this means the circulation in the tumor is flopped, and in two or three days the polypus will drop off. In fixing the ligature, the operator muft be cautious not to miftake the tubercle of the os tincae for the po- lypous tumor; a blunder which would prove of fatal confequence to the patient. Stoney Concretions, and even Worms, it is faid, have been fometimes found within the uterus *. Calcular concretions have indeed been difcovered al- moft in every cavity of the human body ; but fuch appearances rarely occur in the human uterus. There feems lefs probability ofdhe exiftence of worms, except in cafes of fuppuration or cancer. A Collection of Water, called Hydrops Uteri, is fometimes formed in this cavity ; a dif- eafe * Vide Mifcellania Curiof. Acad. Naturx. Mem. de 1' Acad. Rovai des Scicnc. Vol. II. &c ioo Pathology of Gene rati 6n. Chap. I. eafe which has been often miftaken for pregnancy, as the menfes are generally obftruaed. When the difeafe is afcertained by a fluauation fenfibly felt in the part, and if there fhould be no fufpicion of real geftation, the water may be evacuated by intro- ducing a finger, or the catheter, through the os uteri; if this feems impraaicable, the conftriaed parts muft be relaxed by warm baths and fomentations. Af- ter the evacation of the water, the cure may be completed by fuitable regimen, ftrengthening me- dicines, and proper exercife. Tympanites Uteri, or wind pent up in this cavity, is always paifed involuntarily, and frequently with confiderable noife. The only cure is by the fpontaneous contraaion of the uterus, and by re- moving the difcharge which may give rife to it; fur this uncommon diforder is often conneaed with a morbid difcharge from the vagina*. Scirrhous Tumors are feldom difcovered till the difeafe has made confiderable progrefs. An un- eafy weight and bearing down, fupprefllon of urine, fluor albus, uterine pain, and fometimes flooding, are the ufual fymptoms; but the touch of the enlaro-ed indurated cervix or fundus uteri, in fufpicious cafes, will afford the moft infallible criterion. Thefe tumors, like fimilar complaints in other parts, tho' they may long remain in an indolent ftate, feldom admit Qi * VtJe Sauvage. Sea. I. Topical Difeafes. 101 of relief from medicine, and generally at length de- generate into cancer. Nor is any good to be expea~ ed from Peruvian bark, farfaparilla, or even the fo- much extolled cicuta. The general health muft then, in a very particular manner, be attended to, and the moft urgent fymptoms muft be palliated. For this purpofe, a cooling regimen, the moderate ufe of gentle laxatives, occafional bleedings, and opiates are the chief means. A foetid bloody difcharge, along with an increafe of pain, heat, and itching, mark the ulcerated or cancerous ftate of the difeafe. The progrefs is then rapid ; and the ftench becomes intolerable even to the attendants as well as to the patient. The rava- ges of the difeafe are fhocking; for ftools, urine, blood, and matter, are fometimes difcharged from one orifice. In thefe unhappy circumftances, lit- tle can be attempted by way of treatment, but to amufe the patient, by palliating the painful fymptoms with opiates, and keeping the fores clean by injec- tions, till death brings the only relief. Procidentia or Prolapsus Uteri. The uterus fometimes changes its place, and falls down into the vigina, frequently protruding through the os externum. The caufe may either be general de- bility, or topical relaxation of the conneaing parts, particularly of the vagina. The cure confifts in the reduaionand retention of the urolspfed part. When I a, , peffaries ro2 Pathology of Generation. Chap. I- peffaries are difagreeable, the uterus may be fufpended by a bit of fponge: Gently reftringent injeaions fometimes prove ufeful; but a long-continued ufe of them will as certainly be hurtful, fo that they fhould always be employed with caution. The ge- neral conftitution fhould be ftrengthened by a proper regimen, bark, mineral waters, and the cold bath. The ovaria, in common with other glandular parts, are fubjea to difeafe, fuch as fcirrhous, ftea- tomatous, and dropfical fwellings ; by which they be- come fo much enlarged, as to occupy the whole abdomen. Such cafes generally prove incurable. Tumors of the ovaria at length generally terminate in dropfy : the fymptoms are analogous to thofe of the afcites ; from which, however, they fometimes differ in feveral particulars. In the beginning, the enlarged ovarium may be eafily diftinguifhed from the afcites, by the Pwelling and pain being circumfcribed, and confined to one fide ; in the progrefs, by the advances being more flow and gradual; in it* advanced ftages, by fomecedema- tous fwellings of the leg and thigh on the fide affeaed, and by one being able to feel it from the vagina. The cure differs in nothing very material from that of the true hydrops afcites*'. When the tumor points outwardly, the contents, whether water or pus, muft be evacuated by a free opening; when gelati- nous * Vide Dr Monro's Treatife on the Dropfy. Sea. II. Irregularities of the Menfirua. 103 nous or purulent, a conftant drain, by means of a feton, may, in fome cafes, be employed with advan- tage. The patient muft afterwards be treated in the ufual manner. The extirpation of the ovarium, in a difeafed ftate, has been by fome authors propofed : but when the tumor is very much enlarged, and per- haps adhefions to the neighbouring parts are already formed, the excifion would at leaft prove a difficult, if not a very hazardous operation. The Fallopian tubes are alfo liable to difeafe. Wa- ter is fometimes colleaed in them, and either floats through the whole cavity of the tube or each end coa- lefces in confequence of fome inflammation, and the water appears to be contained in a cyft. It is difficult to be diftinguilhed from the.difeafed ovarium, with which it is often complicated, and requires a fimilar method of treatment. Foetufes or Bones of Foetufesare fometimes found in the tubes or ovaria ; but they feldom make confidera- ble progrefs, and ought never to be cut upon andex- traaed, unlefs when they point outwardly, or form abfceffes. SECT IO N II. Irregularities of the Menfirua. THese comprehend Amenorrhea, Mc?njrrhagiat and Leucurrhoea ; and each diftina genus a confiderable variety of fpecies, I. Am- 104 Pathology of Generation. CKap. I. I. Am^enorrhoe a confifts of two fpecies. i. The retention or abfence of the menfes beyond their ufual period of appearance, called emanfto menfi- um. 2. An interruption in the periodical revolution, af- ter the law of habit is eftablifhed, ftyled fuppreffion or obflru£iion. i.] The Retention of the Menfes proceeds from dif- ferent caufes; and may be referred to general debility of the fyftem , which impairs the aaion of the heart and arteries: or to fome fault in the uterus itfelf, as torpor or rigidity of the veffels. The firft produces fymptoms of debility, which are generally ftyled chlo- rotic : and the indications of cure are, to ftrenghen the ftomach and fyftem ; which is chiefly effbaed by bark, chalybeats, regimen, and the-cold bath. Tor- por and rigidity of the uterine veffels may be fometimes removed by the means ufually employed for relaxing torpor and rigidity of the whole fyftem : or by pro- moting the action of the uterine veffels, more parti- cularly by ftimulating the neighbouringorgans. Thisis chiefly to be attempted in thofe cafes where nature makes an effort; but, from debility or fome other cir- cumftance, is unable to accomplilh it. She is then to be gently affifted, not forced. Aloetic purges, tinau- ra melampodii, fmall dofes of calomel, or elearicity, are the ufual remedies ; but they ought to be cauti- oufly and prudently ufed. Tinaura fuliginis, or an extract . Sea. II. Irregularities of the Memflrua. 105 extraa prepared from it, and given in the dofe ^j twice or thrice a day, is a more fafe, and often moft efficacious medicine in the latter cafe, along with the foetid gums. But the warm bath, or a change of climate, are the moft powerful antifpafmodics, and may be often fuccefsfully employed when other reme- dies^ fail. Though we are in general able to diftinguifh thefe two caufes of debility and torpor, yet it muft be allowed, that retention of the menfes, from every caufe, foon induces a debility, which, without fome attention, may be miftaken for the original defea. 2.] SuppreJJion of the menfes. The evacuation may be defficient in periods or quantity. The firft is more properly termed fuppreffion, or, in vulgar lan- guage, obflruclions ; the latter fparing or painfulmen- fruation 1. Suppreffton. The menfes are rarely fuppreffed in confequence of weaknefs : though it muft be ob- ferved, that they are readily affeaed by any general dif- order in the habit ; and, in that view, the deviation is to be confidered merely as fymptomatic : and the cure will depend on correaing the fault in the conftitution. Spafm, or rigidity of the uterine veffels, is, per- haps, a more frequent caufe than any other, occafi- oned, more remotely, by cold, irregular paffions, plethora, &c. The cure muft then be directed with a view 106 Pathology of Generation. Chap. I. ] view to remove the conftriaion of the uterine g veffels, and adapted to particular conftitutions and fymptoms. Venaefeaion, the warm bath, and em- menagogues, fuited to the peculiar circumftances of the cafe, are the proper remedies. Medicines under the name of emmenagogue are not, however, to be re- lied on ; and the means employed for reftoring" the evacuation are moft fuccefsfully exhibited when our efforts concur with thefe of nature. Violent uterine emmenagogues, fo far as they may have any tenden- cy to affea the general health, are always improper and frequently hurtful. In a fimple fuppreffion, it is often fufficient to keep the patient quiet; to avoid cold, and irregularities of diet ; with the ufe ofthe- warm bath, femicupium, cr fleams of water direaed to the uterus, when the expeaed period approaches. When the fuppreffion is more cbftinate, aloetic purges, eleflricity, and the moft powerful relaxants and antifpafmodics, muft be employed. 2. Difmaenorrhoca, fparing, difficult or painful menflruation. Some women menftruate with difficulty, the ute- rine efforts to throw out blood are painful and im- perfea, the difcharge is fcanty ; but the appearance continues for many days : during which the irritati- on is communicated from the uterus to the neigh- bouring parts, and, by fympathy, all over the fyf- tem ; very generally producing pains about the arti- culation of the facrum, from thence to the ilia and down Sea. II. Irregulariteis of th^ Menfirua. 107 down the thighs ; and not unfrcquently attended with ficknefs and retching, nervous fymptoms, or a flight degree of hyfteria. Thefe fymptoms are beft relieved, by avoiding cold and irregularities for feveral days preceding the ac- c.uftomed period ; by ufing aaual warmth then, and more particularly during the time of menftrua- tion ; by drinking, every night before bed-time, and in fmaller quantities through the day, any mild, dilu- ting, tepid drinks; by frequent reft on a bed or fo- fa ; and, occafionally, by the ufe of opiates. II. Menorrhagia.—The menfes are only to be confidered as exceffive, when the periods recur fo I often, the duration is fo long, or the quantity eva- cuated fo great, as to induce debility, with its ufual fymptoms. In all thefe cafes, Leucorrhcea is a fre- quent attendant. The caufes may be aaive or paf- five, in common with other preternatural haemor- rhagies. Of the former are. Plethora, univerfal or local; increafed aaion of the veffels from fever ; ex- ceffive exercife, paffions; ftimuli applied to the ute- rus, or neighbouring parts ; and every caufe which determines the blood more forcibly to the uterus. Of the latter, Relaxation, univerfal or local. To diftin- guifh sclive from paffive maenorrhagia, is of the ut- moft confequence in direaing the treatment. In the firfl cafe, which is generally preceded with headach, oppretfed breathing, attended with heat, *o8 Pathology of Generation. Chap.T. heat, thirft, quick full pulfe, and other febrile fymp- toms, fhe muft be exceedingly cautious of giving a fudden check to the flow, till the veffels have been fufficiently emptied, naturally from the difcharge, or by the prudent ufe of venaefeaion. A fpare cool- ing diet, cool air, open belly, and the ftriaeft anfi- phlogiftic regimen, are then effentially neceffary. Heat, violent agitations and exercife, and every cor- poreal and mental exertion, fhould be avoided . In pajfive maenorrhagia, the difcharge, muft be- moderated by ftyptics and opiates given internally; by cold wet applications to the pubes and' external parts; by confinement to a horizontal pofture on a firm bed, with hair matrefs, and few bed cloaths; by giving cold aftringent drinks; and by avoiding e- very caufe of irritation. The vis vitae muft be duly fupported by nourifhing diet; but while the flow continues, every thing of the ftimulating kind under the name of cordial muft be very cautioufly ufed. When the haemorrhagy hath entirely ceafed, the interval muft be improved to ufe the proper means for reftoring the conftitution. Of thefe, ftrengtheningdiet, the moderate ufe of cordials, gentle exercife, the Pe- ruvian bark, and chalybeates, are principally to be relied on. In fome paffive cafes, the flow is almoft conftant cordials and tonics are then particularly in- dicated : and gentle exercife in a carriage has been often known to moderate or fupprefs the flow. Under J Sea. II. Irregularities of the Menfirua. 109 Under this article of Maenorrhagia may alfo be mentioned, Irregularities towards the ceffatim of the menfrua. The menfes generally become irregular towards their final ceffation. This critical period in the fe- male conftitution iscommonly announced by irregular interruptions, unexpeaed returns, or immoderate difcharges ; in many inftances, by exceffive, long con- tinued, or frequent and alarming floodings. The fymptoms affume a variety of appearance, as influen- ced by conftitution, habit, manner of life, and the ftate of the uterine fyftem. They are rather to be confidered as the confequence of a general change in the conftitution, which terminates the age of child- bearing, than merely the effeas of an accidental inter- ruption, or excefs of the periodical evacuation. Every important change which the confiitutda fuffcrs, is introduced by flow and infenfible degrees : the alarming fymptoms which at this period occur, proceed from the decline of life ftriaiy fpeaking, a difeafed ftate of the uterus, or may be afcribed to mif- taken management. In fome women, the menfes take their leave more abruptly ; in other, more flow- ly; and no material inconvenience is perceived in ei- ther cafe. Women who never had children, nor en- joyed good regular health, or whofe conftitution is impaired by frequent labours or mifcarriage, the ner- K vous no Pathology of Generation. Chap. I. vous and delicate, are more commonly the fubjeas of complaint towards this period. The particular fymptoms and conftitution, the age of the patient, her manner of lifs, and other circum- ftances formerly mentioned, will direa the proper treatment. If no obvious inconvenience arifes from the ab- fence of the menfes, it would furely be abfurd to in- jure the conftitution by a fudden change of manner of living, by abftemious diet and debilitating eva- cuations. On the contrary, if the fymptom'S indi- cate a full habit and plethoric diathefis, venaefeaion, purgatives, and fparc diet, will then be'neceffary. Frequent or immoderate floodings, attended with fymptoms of debility, muft be treated as already di- rected. In relaxed weakly women, the confequences are always to be lefs or more dreaded : the flux muft be checked by cold wet applications ; the painful fymptoms relieved by opiates ; and the conftitution afterwards ftrengthened by nutritious diet, bitters, -&c. Shooting pains about the region of the uterus, the pubes, and breads, along with frequent floodings, or leucorrhcea, indicate fufpicion of fcirrhous or cance- rous difpofition, and are generally preludes of difeafe which foon ends fatally, or renders the remains of fife uncomfortable. Floodings, fecmingly alarming and hazardous from A Seel. II. Irregularities of the Menfirua. in from their cxeefs or frequency, are never to be dread- ed, while no quantity of clots or concretions are void- ed, while they are unaccompanied with violent pain in the hypogaftric region or other fymptoms of mor- bid predifpofition. They may generally be modera- ted by fome of the means formerly recommended in menorrhagia ; and if the ftrengthbe kept up, though the haemorrhagy may occafionally recur at vague and irregular periods, even for two or three years, I have never, in the courfe a long praaice, known it to end fatally in a fingle inftance : a complete recove- ry is generally at laft accomplilhed, and the confti- lution reftored, with the profpea of a ftate of good health for a confiderable time after. III. Leucorrhoea, Fluor Albus, or Whites, is a difcharge of ferous cr mucous matter of a whitifh colour, from the vagina. Its fource is chiefly fup- pofed to be from the veffels which pour out the mem- ftrual blood ; and the difcharge is therefore confidered as a mere depravity, or morbid ftate, of the catame- nia : but it probably often proceeds from the glands at the cervix uteri, and not unfrequently from the lacunae of thofe of the vagina ; for many women fub- jea to leucorrhoea have the difcharge nearly of the ufual appearance and quantity during pregnancy, and it is more feldom obferved to be periodical. Its co- lour and confiftence vary according to the nature and duration of the difeafe, the conftitution, feafon, cli- mate, 112 Pathology of Generation. Chap. I. mate, and other circumftances. It is probably mild and ferous when firft poured out ; afterwards, by ftagnaiing, becomes more thick and acrid, varying alfo in colour and odour. Few women, fomewhat advanced in life, efpecialjy thofe who have had children, who have been fubjea to mifcarriage, or irregularities of menfirua, are en- tirely free from it. The inaaive and fedentary; full, jolly, or flabby women ; and the relaxed and weakly ; are tfpecially liable to it. Pain and weaknefs of deback and loins, difpepfia, and the other fymptoms of debility and indigeftion, fuppofed to be its almoft conftant attendants, only occur when the difcharge is exceffive or very long continued. From quantity, or acrimony, efpecially in warm weather, in grofs habits, or from neglea to keep the parts clean, painful excoriations are fre- quently occafioned : in that ftate it may be readily confounded with gonorrhoea. The Cure muft be regulated by particular circum- ftances. Grofs habits, and thofe who have been ac- cuftomed to full rich diet, with little excercife, re- quire frequent purging, along with a mild fpare diet and cooling regimen. In weakly relaxed confu- tations the indications are, To reftore the tone and Vigour of the fyftem, by proper regimen ; bark, mineral waters, with ftcel and alum, and the cold bath. /!"'" In Seia.II. Irregularities ef the Menfirua. 113 In either cafe, the parts fhould be kept clean by frequent cold bathing. Any gently aftringent wafh, after general evacuations, may be freely ufed in the former cafe: and in the latter, injeaions of alum- water, tinaura rofarum, or balf. traumatic, in a very dilute ftate, or wafhing the parts with a fponge foaked in the ftyptic liquor, often fenfibly diminifh the difcharge ; and, in recent cafes, entirely remove it. Gellies of hartfhorn, or ichthyocolla, balf. capivi, and topical aftringent injeaions and wafhes, are the beft palliatives. Leucorrhoea may be diftinguilhed into local and ge- neral ; a morbid affbaion of the parts, or a weaknefs of the fyftem, In the former cafe, aftringent wafhes or injeaions ; in the latter, tonics, as bark or bitters, with lime-water, have the beft effeas. It is fup- pofed that abforbents aa by neutralizing the fuper- abundant acid in the ftomachs of fuch patients, and fo removing one debilitating caufe. Furor Uterinus. There is a fpecies of fluor albus, defcribed by many authors under the name of furor uterinus. But even the exiftence of that difeafe is as confidently denied: We can at leaft with confi- dence afierr, that the real nympho-mania is rarely known in this country. Nothing farther is probably meant by it, than an increafed acrimony of the fluor albus, occafioning heat, pain, itching, and of con- K 2 fequence- ui% Pathology of Generation. Chap. I* jequence irritation in thefe parts. The cure muft therefore be conduaed nearly in the fame manner as in the former difeafe: The parts fhould be Conftantly kept clean by frequent bathing, or injeaions; of thefe a dilute folution of facch. faturni in rofe-water has been generally found to prove the moft fuccefs- ful; a cooling regimen muft alfo be enjoined, and occafional caufes counteraaed. Sometimes the cen- tre of this irritation has been difcovered within the urethra, when the bougie has proved the cure. Sterility. From moft of the preceding com- plaints, and from various other difeafes incident to thofe parts, the uterus may be unfit to receive or re- tain the male feed; or the tubes may be too fhort, ©r may have loft their creaive power: in thefe cafes, no conceprion can take place. Or, cither from uni- verfal debility and relaxation, or a local one of the genital fyftem, the tone and contraaile power of thefe parts may be deftroyed, fo that the femen is thrown off immediately pcfl coilum; which will in like manner occafion ftcrility. Thefe caufes of bar- rennefs are obvious; for where the aperture of the vagina, or of the uterus was impervious, there is not one inftance of conception to be found in the records of medicine. The fame effeas generally follow f-orn imperforation of the tubes, or difeafed o varia. There are, however, many olher.caufes of fterility ; but Sea. III. Spurious Gefatton. 115 but thefe, while the manner of generation is a my- ftery, are beyond the power of phifiological invefti- gation.—Hence medical treatment can only avail in cafes arifing from univerfal and topical debility; in correaing irregularities of the menftrual flux, one of the moft common caufes of barrennefs; and in removing tumors, cicatrices, or conftriaions of the paffages, by the art of furgery. SECTION III. Difeafes fometimes mifdken for Geflation. VARIOUS difeafes incident to the uterine fyftem? and other morbid affeaions of the abdominal vifcera,. frequently excite the fymptoms, and affume the appearance, of uterine geftation*. Complaints arifing from a fimple obftruaion, are fometimes mi- ftaken for thofe of breeding ; and difeafed tumors any where in the pelvis, or about the region of the ute- rus, fo nearly, in fome inftances, refemble pregnancy in their fymptoms, that the ignorant patient is often deceived, and even an experienced phyfican impofed on. , Scirrhous, Polypous, or SarcomatousTu- MORS, in or about the Uterus or Pelvis; Dropfy or Tympanites of the Uterus or Tubes ; Steatoma or Dropfy of the Ovaria, and Ventral Concep- tion, * Vid Mdrgpgni de caufo ct fed. Mori). Ep. xlviii. MO Pathology of Generation. Chap. I. tion, are the common caufes of thefe falacious ap- pearances. In many of thefe cafes, the menfes dif- appear ; naufea, retchings, and other fymptoms of breeding enfue. Flatus in the bowels is miftaken for the motion of the child ; and in the advanced ftages of the difeafe, from the preffure of the fwelling on ihe adjacent parts, tumefaaion and hardnefs of the mammae fupervene, and fometimes a vifcid ferous fluid di(tills from the nipple. Thefe circumftances ftrongly confirm the woman in her opinion ; till time, or the dreadful confequences that often enfue, convince her at laft of her fatal miftake. False Conception. Mola. Other kinds of fpurious geftation, lefs hazardous in their nature than any of the preceding, may under this article al- fo be claffed. When the fcetus is deprived of life, and diffolved in the early months while it is in a gelatinous ftate, , the placenta often remains for fome time in the ute- rus; its bulk is increafed by additional coagula, and its confiftence in confequence of abforption. When it is excluded in this ftate, it is called a falfe conception. When it remains longer, and acquires the confiftence of a fcirrhus, without any traces of its ever having been an organic body, it is called a mola. Mere coagula of blood, retained in the uterus after delivery, or after immoderate floodings at any period of life, and fqueezed by the refiftance of the uterus, into Sea. HI. Spurious Geflation. i±"j into a fibrous or compaa form, conftitute another fpecies of mola, that more freqnently occurs than any of the former. Thefe, tho' they may affumc the ap- pearances of geftation, are generally expelled fpon- taneoufly, and are feldom followed with dangerous confequences. CHAP. II. Pathology of Parturition. HPHE changes introduced by conception, frequent- -*- ly prove the fource of diforders which affume a variety of appearance in different conftitutions, and at different periods of pregnancy. Thefe complaints are fometimes troublefome, but they feldom injure the conftitution ; their effeas are generally tempora- ry, their appearance and duration vague and irre- gular. Some women, foon after conception, fuffer the moft violent ficknefs and feverifh indifpofition, which harrafs and diftrefs them for feveral months; and, in fome inftances, continue during the whole term pf geftation. In others, the breeding fymtoms difap- pear after the early months. Many women feel no inconvenience but from the weight and preffure:of the bulky uterus in the advanced months; while p7 thers* Ii8 Pathology of Generation. \ Chap. IL thers enjoy a more than ufually good ftate of health and fpirits in thefe fituations. In the pregnant ftate, the courfes are generally flopped ; and confequently, th edetermination of the blood is altered: from this difference of determina- tion many of the fymtoms of pregnancy may be ac- counted for; particularly the appearance of gene- ral, and fometimes of a local, plethora. It muft be confefled, however, that many of the fymtoms ap- pear to be entirely of the nervous kind, and not rea- dily explicable in the prefent ftate of our Phyfiology : but they are fuch as the ftoppage of any accuftomed evacuation will often produce. In the advanced ftates of pregnancy, the preffure of the uterus on the furrounding parts produces many others, which we can with more certainty refer to their proper caufe. SECTION I. Difeafes of Pregnancy in the early Months. r I 1H E moft common fymptoms of breeding are, -*- ficknefs and loathing, vertigo and drovvfinefs, heartburn and diarrhoea, painful tention of the mam- ma;, nervous fits, deliquia, &c. Sickness and Loathing. A flight degree of feverifh indifpofition, naufeating ficknefs, or vo- miting, chiefly in the morning and after food, are in, Se&. I. Difeafes of early Pregnancy. "319 in fome inftances almoft coeval with conception; and the appetite is fo whimfical and capricious, that the moft extravagant and unaccountable fubftances are anxioufly wifhed for. The ficknefs from breeding is fometimes fo fevere as to refemble fea-ficknefs, and it is often as little in our power to relieve it. Thefe early fymtoms have been generally afcribed to the ftoppage of the menfes, altho' they commence often before the obftruaion occurs. In manyconftitutions, however, particular- ly in the young and healthy, a certain degree of ple- thoric difpofition, even in the more early periods of pregnancy, feems to prevail; fmall bleedings, there- fore, where the ficknefs is attended with flufhings, dry parched mouth and fauces, vertigo, or any other fymtoms of fever,. are fafe and beneficial, and often give all the relief in our power to afford. Although a rafh, indifcriminate, or frequent ufe of vensefeaion is to be guarded againft as a hazardous expedient; on the contrary, if prudently employed, it may often be the means of preventing abortion. It may be fafely ' performed at any time of geftation, and repeated ac- cording to the urgency of tire fymtoms. But fmall bleedings are always to be preferred to copious eva- cuations ; which, in every period of pregnancy, ef- pecially in the early months, when the hazard of mif- carriage isgreateft, fhould be avoided. When the ftomach appears affeaed, along with con- ftant 12© Pathology of Parturition. Chap. II. ftant loathing, or frequent retchings, the offenfive matter fhould be difcharged by gentle vomits of ipecacuan, or of infufions of chamomile flowers or of carduus. The violent efforts of natural vo. uniting, which threaten the moft difagreeable confe- quences, and fometimes aaually throw off the con- ception, are in fome inftances entirely removed, in many cafes greatly diminiflied, after the operation of a gentle emetic. Small dofes of rhubarb fhould be given to keep the body moderately open : the patient fhould alfo be put on a courfe of light, aromatic, and ftrengthening bitters ; and her diet, air, exercife, and amufement fhould be properly regulated. In conftitutions of the nervous irritable kind, opi- ates fometimes procure a temporary relief from fick- nefs and vomiting, when every other remedy fails. Vertigo and Drowsiness.—Thefe prooceed from fullnefs and plethora, conneaed with a parti- , cular ftate of the nervous fyftem. Small bleedings when very troublefome, gentle exercife, an abftemi- ous temperate diet, and every means of obviating ple- thora, and diverting the attention by promoting a cheerful ftate of mind, are the beft remedies. Heartburn, Diarrhoea, &c. are common fymptoms of brecding-ficknefs, and muft be treaied nearly in the fame manner as fimilar complaints from other caufes. They chiefly depend on the ftate of the i Sea. I. Difeafes of early Pregnancy. 121 the ftomach, peculiarly influenced by that of the uterus. The afcefcent tendency of the ftomach mould be obviated, and the digeftive faculty reftored. Tumefaction, Tension, and Pains in the Mammae.—If tight lacing be only avoided, and the breafts be permitted to expand, no material in- convenience will arife from their enlargement. Thefe ''fymptoms are the natural confequence of a natural caufe, and feldom require medical treatment. If they fhould be very troublefome and uneafy, bathing with oil, or anointing with pomatum, and covering them with foft flannel or fur, will in moft cafes tleffenthe painful tenfion. In plethoric habits, where painful hardnefs and fwelling are excefSve, and do not readily yield to more fimpie remedies, venaefeition and gentle purging may be neceffary. Deliquia, Nervous or IIysteric Fits—- Lowlinefs and depreffion of fpirits are incident to the early ftages of pregnancy, and are merely the effeas of uterine irritability communicated to the nervous fyftem ; for the mind, as well as the body, is then pecularly fufceptible of irritation. Faintings more feldom occur, but about the term of quickening. They feem to arife fro.n the fudden change of pofttion of the u'crus emerging from its more clofe confinement within the bony pa- rietes of the pelvis, and from the irritation communi- cated by the child's motion. They are commonly L fight 122 Pathology of Parturition. Chap. IL flight and tranfient, and leave no bad effeas behind them. Deliquia, which are occafioned by falls, frights and paflions of the mind, are of more ferious con- fequence, and the fhock is frequently fatal to the child. The complaints which occur in the early months require a variety of treatment in different circum- ftances. When fymptoms of fullnefs appear in young women, formerly healthy and accuftomed to live well, indicated by pain or giddinefs of the head, flufhings in the face and palms; or when the ficknefs is conftant or exceffive ; venaefeaion, an open belly, with abftemious diet, and every other means to obviate plethoric difpofition, muft be ufed. But, in oppofite circumftances, where there is ap- pearance of nervous delicacy, along with fymptomi of dyfpepfia and confequent debility, bleeding muft be avoided with the ftriaeft care. Nourifhing diet given in fmall quantities and often repeated, the moderate ufe of cordials, good air, cheerful fociety, eafy exercife, variation of fcene, fuited to the peculi- ar circumftances of the patient, and, in a word, thofe means adapted to footh or diminifh fenfibility and irri- tability of the fyftem, and keep up the^general health, are the moft proper. SEC- Seit. II. Difeafes of advanced Pregnancy. 123 SECTION II. Difeafes of advanced Pregnancy. HTTHE difordcrs which attend the advanced months •*■ of geftation, are more fudden in their occur- rence, more painful in their fymptoms, and more dangerous in their confequences, than thofe of the early months. The lofs of the child, and a tempo- rary weaknefs, from which the mother, under proper management, foon recovers, are the worft confe- quences to be dreaded from the latter: But, from the compreffion of the bulky uterus on the contiguous vifcera, their important funaions are impaired, the circulation in the vafcular fyftem, and nervous in- fluence, are materially interrupted, and the moft fatal event is fometimes produced. The diforders incident to advanced geftation chiefly are,—fuppreffion or difficulty of palling urine, retro- verted uterus, coftivenefs, piles, cedematous fwel- lings, varices, coiic, cramps, pains in the back or loins, cough, difpncea, vomitings, ftrangury, or in- continence of urine, convulfions, &c. Ischuria and frequent Micturition. Thefe fymptoms are occafioned by the preffure of the uterus on the neck of the bladder, before the fundus uteri rifes above the brim of the pelvis. The reten- tion of a fmall quantity of urine then is a powerful ftimulus 124 Pall :l:yy of Parturition. Chap. II. flimufis to void it. If that is negleaed, and the bladder becomes diftended, painful ifchuria enfues. Women under thefe circumftances fhould be cau- tioned to avoid crowded places, and every- fituation which expofes them to difagreeable rciiriaionsv A flight degree of fuppreffion, if early attended to, will feldom prove troublefome or hazardous. It only requires a c'onftant attention to cbey the diaates of nature, \\ hen the call to evacuate the urine is urgent; to keep the belly regular ; to lie down on a bed or fufa from time to time, when pained or uneafy ; and carefdiy to guard agdidt fadgue, and confinement in a crowded place, till the uterus be fo much en- laiged, as to be fupported by retting on the expanded bones of the ilia. RET HO VERT ED UTERUS. As the gravid uterus enlarge*, it finks downwards, till it becomes to bulky too be longer confined'within the bony cavity : but if, from the uncommon capa- city of the pdvis, any extraordinary exertions, vio- ''■■nt fsdgr.e, obftinate coftivenefs, rr the diftention of the bladder with urine, the uterus fhould be pre- ye:-tttd from emerging above the brim of die pelvis, die fundus will fink lower and lower, fid ling back- wards into die inferior p;i*-.rior part of the pelvis; the os tincae will then be drawn upwards towards the pubes Sea. II. Difeafes of advanced Pregnancf. 125 pubes, making the fuperior part, and the fundus for- ming the moft depending part of the tumor. This refkaed ftate of the prolapfed gravid uterus is ftyled retroverfion; and is readily known by the fymptoms, and from the period of pregnancy in which it occurs. It chiefly occurs between the third and the end of the fifth month of pregnancy. The fymptoms are, an increafe of thofe ufually oocafioned by painful dif- tention of the bladder with urine, conftant weight, and uterine pain and preffure, tenefmus and other fymptoms fometimes refembling the fevereft throes of labour. A tumor will be alfo felt to the touch be- tween the vagina and reaum, which occupies the whole inferior capacity of the pelvis, prevents the finger from palling into the vagina, and preffes againft the perinaeum and anus, like the child's head in time of labour. In the beginning of the difeafe, the urine is voided with difficulty ; in the progrefs, ftools and urine are totally retained. As the bladder diftends, it draws the cervix uteri up with it; the uterus, growing big- ger and bigger, finks lower, fpreads out beyond the inferior circumference of the pelvis, and occafions conftant (training and preffing. The throes at laft become fo violent, that the uterus feems ready to be protruded without the vulva. The inferior lateral openings of the pelvis yielding to the diitending caufe, JL a as 126 Pathology of Parturition. Chap. IS. as they do in real labour, the tumor becomes fo bul- ky, as, in fome inftances, to elude the poffibility of reduaion *. Laceration of the coats of the bladder, inflammation communicating to the vifcera, delirium or convulfions, and the moft- fatal event, foon enfue, if the means of relief are negleaed or prove inef- feaual. The cure confifh in reftoring the uterus to its pro- per pofition, and guarding againf. the hazard of relapfe. Previous to attempting the reduction of the uterus, the counteraaing obftacles muft be removed. With this view, repeated venaefeaion may be neceffary; fomentations or the femicupium, fhould be ufed to diminifh fwelling and inflammation ; the catheter fhould be paifed to evacuate the urine ; and the ree- it.m fhould be wafhed out with repeated glyfters. The reduaion of. the uterine tumor fhould then be attempted, by placing the patient on her knees and arms, with her head reclined and properly fupported, endeavouring, by every poffible means, to reftore the uterus to its proper pofition. The force employed fhould be gentle at fiiit, prefling backwards and up- wards in ciifirent direaions, (to dra t the os tincae down from the pubes), not by ftarts, but conftantly and * Vide Tit Huntci's Phtcs of the Gravid Uterus, Pi. siyj. London Medical Ol-i'c nations and Inquiries; Vol. IV. act. xxxvi Sea. II. Difeafes of advanced Pregnancy. 1-27 and equally, gradually increafing the exertions of force, as far as they can fafely be carried, till the end in view be obtained. After the reduaion the patient muft be confined moftly to bed, and the diftention of the bladder and reaum muft be carefully prevented, till the uterus rifes above the brim of the pelvis, when fhe will be fecured from future danger. But if the obftinacy of the difeafe fhould render every effort ineffcaual ei- ther to evacuate the urine or replace the uterus, it has been propofed to punaure the bladder at the pubes; and, if that fhould fail to facilitate the reduaion, to thruft a trocar into the fubftance of the uterus to pro- cure abortion ; or to enlarge the pelvis by incifion at the fymphyfis pubes, in order to accomplifh the re- duaion of the uterus.—The two firft propofals are fhocking and defperate : the laft gives a more reafon- able profpea of favingboth the mother and child.,. Costiveness. This fymptom is a common at- tendant of pregnancy. The occafional caufes are, the preffure of the gravid uterus, a difordered ftate of the ftomach, and fedentary life. It may be obviated or prevented, by attention t© diet, and the occafional wfe of gentle laxatives; of thefe ripe fruit, magnefia, cream of tartar, foluble tartar, lenitive ekauary, cl. ricini, or analoeticpill, when the patient is not fubjecl to any haemorrhoidal afft.aion, 12S Pathology of Parturition. Cbap. II. affeaion, or has been formerly accuftomed to it, are the moft proper. But in cafes of obftinate coftivenefs, to break down and remove indurated fcybili, emollient gly- fters, occafionally rendered moderately ftimulent with foap, or a fmall proportion of common fait, ought t» be repeatedly exhibited. Piles—are fmall tumors placed a little way within the redum, or protruding like varicous fwel- lings without the verge of the anus, attended with throbbing pain, heat itching; frequently with fever and reftleffnefs, and fometimes liable to frequent or exceffive haemorrhagies. Their occafional caufes chiefly are, coftivenefs, and venous plethroa from.. geftation. The treatment fhould be direaed nearly on the fame principles as fimilar cafes from other caufes with the precaution which pregnancy fuggefts. Cof- tivenefs muft be obviated by cooling laxatives : of which cream of tartar and flowers of fulphur are the beft. General or topical bleedings fhould be ufed, to leffon plethora or local inflammation ; and fomen- tations and cataplafms, emollient or faturnine appli- ed, to difperfe the.fwelling or promote fuppuration. For allaying the pain often attending piles when the inflammation is removed, pulv. gallarum and axung., pore, in the form of ointment, has been much re- commended... Sea. II. Difeafes of advanced Pregnancy. 129 ccsmmended. Balf. copivi is alfo an excellent remedy in piles, and keeps the belly moderately open. OeDuEMatous Swellings of the Legs, and fometimes extending to the thighs and labia, arife from the fame caufe with the precediwg complaint; viz. venous plethora from the preffure of the uterus. They are merely fymptomatic, and only attended with a temporary inconvenience ; as almoft in every inftance, where the conftitution is otherwife unim- paired, they fubfide immediately after delivery. The beft palliatives are—fmall bleedings and gen- tle purgatives, with alight fpare diet, if the patient be full and plethoric ; if otherwife, ftrengthening diet, the moderate ufe of cordials, an open belly, fre- quent reft on a bed or couch : and in either cafe, eafy exercife when fhe is able to bear it, and friaion with aflefh-brufh, applied to the l«gs evening and morning, to promote the circulation and abforption of the ftagnant fluids. Varicous Swellings are merely diftentions of the coats of the veins from venous plethora, occafi- oned by preffure of the gravid uterus. They are ge- nerally confined to the legs or thighs, and feldom proceed fo far as to burft and throw out their con- tents. When very large or painful, gentle eva- cuations may be neceffary ; and topical aftringent applications tafed, to remove local laxity ; as com- preffes foaked in any ftyptic dicuor, and retained by, the *30 Pathology (f Parturition. Chap. IF. the application of a bandage. A moderate preffure on the part by comprefs and bandage, when the ac- cumulation is confiderable, will, in moft cafes be fufficitui to remove any inconvenience occafioned by the fueling till delivery ; foon after which, they generall difapresr, or are confiderably leffened. Pain-in the Back or Loins, Colic, Cramp ■—are occa'oned by the ftretching of the uterus, or by its preffure on the neighbouring parts, particular- ly on the diaphragm. They are moft troublefome in a firft pregnancy, or when the diftention of the abdomen is enormous.—Small bleedings, gentla laxatives, a light fpare diet, and occafional opiates, are the beft palliatives. If the patient be of a full habit, and where a dif- pofition to inflammatory complaints prevails, any vio- lent fixed pain about the back or loins, along with fever, or in the abdominal vifcera, exciting fymptoms o! Colic, is highly alarming and dangerous in advan- ced geftation where the preffure is great. The threa- tening event can only be prevented by repeated venaefeaion, and the antiphlogiftic treatment. Cramps are fometimes very troublefome towards the latter end of geftation. They are chiefly confi- ned to the legs and thighs, more rarely they af- fea the belly, and are moft troublefome during the night. Their occafional caufes are, the ftretching of, the Sea. II. Di/eafes of advanced Pregnancy. 13* the womb, or its continued preffure on one particu- lar part.—-When frequent or violent, and the ha- bit is full or plethoric, bleeding is neceffary. The fudden expofure of the body to cold, or change of po- fture, as getting out of bed and walking about, may be often fufficient to give a temporary relief; and opiates may be ufeful to leffon nervous irritability. Cough, Disvnoea, Vomitings, Difficul- ty or Incontinency of Urine—The caufe in advanced geftation is fufficiently obvious. The for- mer of thefe fymptoms are chiefly to be alleviated by fmall bleedings, gentle laxatives, light fpare di- et, and opiates. The patient lhould be placed, when in bed, in an eafy pofture, with her head and fhoul- ders confiderably raifed, and the bed-room fhould be as large and airy as poffible. Bandages, advifed by many when the uterus rifes very high, are dangerous expedients for altering its direaion ; and ftriaure in drefs, with a view to hamper and confine the uterus, can never be employed with fafety. To prevent the confequences of frequent miauri- tion, or incontinency of urine, a fufpenfory and thick linen comprefs, or fponge.fhould be conftantly worn, and occafionally fhifted as it becomes damp. CONVULSIONS. The appearance of epileptic fits in pregnant wo- men is frightful; the fymptoms are alarming; and the event is always precarious, often fatal, The t-32 Pathology of Parturition. Chap. II. The paroxyfms generally come on without any obvious prelude. Headach intolerably violent, or in- tenfe pain or oppreffiori about the praecordia, are the moft common prefaging fymptoms. At whatever term of geftation, there is great dan- ger ; but, in the advanced months, the difeafe is more defperate. The danger is alfo to be judged of by the violence of the fymptoms, the duration and re- currence of the fits, conneaed with the occafional caufe and conftitutional temperament of the patient, and from her condition during their remiffion. The remote caufes are, Increafed irritability from pregnancy, particularly uterine irritability communi- cated by fympathy to the encephalon, in fome in- ftances probably originating from the ftruggles or convulfive motions of the fcetus, arifing from its aukward or hampered pofition ; and preffure of the gravid uterus interrupting the circulation through the abdominal vifcera, difturbing their funaions, and changing the determination both of the circula- ting fluid and nervous energy. They may alfo arife , from inanition, in confequence of prof ufe haemor- rhagies, or other debilitating evacuations; or be oc- cafioned by mechanical injury of the uterus, from violent bruifei, wounds, &c. and by paffions of the mind, and other occafional caufes, fufficient to bring on convulfions in the unempregnated ftate. Hyfteric or nervous fpafms are readily diftinguifhed from J Sea. II. Difeafes in advanced Pregnancy. 133 from convulfions. The former are milder than the? latter in their fymptoms; and much lefs frightful in appearance, by the abfence of foamings and diftor- tions : They have no fenfible effea in bringing on la- bour ; they are feldom followed with bad confequen- ces ; and yield to the common treatment. Women of vigorous conftitutions, rigid fibres, and plethoric habits, are more ufually the fubjeas of the latter : the delicate, the nervous, and irritable, of the for- mer. Convulfions, during pregnancy, may be referred to three diaina periods at which they may occur ; thofe of the early months, thofe of the latter, and >■ thofe that come on along with labour. 1. Thofe which appear in early geftation, chiefly happen to young women of a plethoric habit; and can only be obviated or palliated by a free ufe of the lancet, by gentle purging, cooling regimen, and low- diet. After fome evacuations in this way, if con- ftant naufeating ficknefs Jlrongly indicate a difordered ftomach, a mild emetic may be of ufe ; but it fhould be employed with the moft judicious and guarded caution. In oppofite circumftances, a different treatment muft be direaed. Opiates, or caftor and mufk given internally, emollient glyfters, warm fomentations applied to the legs, the femicupium, and every means to foothe nervous irritability and remove fpafmodic M ftriaure, 134 Pathology of Parturition. Chap. II. ftriaure, will then prove the moft effeaual remedies. When it cannot be received into or retained in the ftomach, opium, in large quantities, fhould be exhi- bited by way of glyfter. When the patient is totally infenfible and coma- tofe, ftimulating purgative glyfters fhould be given; and epifpaftic and ftimulating cataplafms, in order to roufeher, fhould be applied to the legs and hams. In defperate circumftances, the femicupium, or warm bath, fhould be frequently ufed, and long continued, with a view to relax and open the orifi- cium uteri, and bring on labour. In the intervals of the paroxyfms, or after they have ceafed, the patient, when languid or much re- duced, muft be fupported by nourifhing diet and fui- table cordials; and, when fhe is no longer able to fwallow, nourifhment muft be fupplied by way of glyfter. 2. In the advanced months, the attacks are more. fudden, the progrefs more rapid, and the event more fatal, than in early geftation : therefore the moft aaive and vigorous meafures are neceffary ; for, like appolexy, a fit or two then, in fome inftances, terminates the difeafe with the lofs of life. If any treatment can prevent the threatening cataftrophe, immediate and copious venaefeaion, occafionally repeated, may chiefly be relied on. Other means for leffening plethora, obviating the effeas Sea. III. Difeafes during Pregnancy. 135 effects of violent agitation, and rendering the fyftem lefs irritable, muft afterwards be employed, and the treatment otherwife dirc-aed according to particular circumftances. 3. Laftly. When convulfions come on along with with labour-pains, they muft be palliated by fome of the means already direaed, till the delivery can be fafely affifted by art. SECTION nr. Some ordinary Difeafes which require peculiar treatment when they occur during Pregnancy. BEsides thofe hitherto enumerated as more im- mediately deriving their origin from pregnancy, other diforders fometimes occur, which may then require fome variety from the ufual management. Thefe are chiefly, paralyfis, nephritis and calculi, lrerniae, dropfy, leucorrhoea, venereal complaints, fevers. Paralysis is generally local, and chiefly confined to the lower extremities, or may be traced by the courfe of the nerves to depend on the preffure of the uterus. The treatment can only be direaed with a view to palliate till delivery. Gentle exercife, mo- derate evacuations when the habit is full, otherwife ftrengthening diet and regimen, with warm applica- ions.and friaion, are the principal remedies. Nephritis 136 Pathology of Parturition. Chap. II. Nephritis and Calculi. The former muft be palliated by venaefeaion, diluent drinks, opiates. If the calculus flicks in the urethra, and the woman is near her time, it fhould, if poffible, be pufhed back into the bladder with the catheter : other- wife, when eafily come at, the ftone may be cut upon and extraaed. Hern i.e. Some of thefe are cured by pregnancy; others continue during the whole term of geftation. Bandages can feldom be ufed with fafety in the pregnant ftate; at leaft tight preffure by the com- mon umbilical bandage muft be avoided. In time of labour, they muft be carefully fupported with the hand during a pain; after delivery, future inflam- mation and its confequences muft be guarded againft; the ufual bandage muft again be applied, when the patient is fufficiently recovered to be able to ftay any time out of bed after delivery. The Hydrops Ascites—in pregnant women, fometimes alfo occurs ; and will, during that ftate, only admit of palliation. The belly muft be kept open; the evacuation of urine, as much as poflible, muft be promoted, by cream of tartar, dried fquills, and the like ; and gentle exercife muft be ufed. If, however, the abdomen be much diftended, the ref- piration difficult, and other fymptoms urgent, the water may be fafely drawn off by the operation of the paracentefis. The Sea. III. Difeafes during Pregnancy. 137 The Fluor Albus or Leucorrhoea—is fometimes cured, fometimes increafed, by geftation. Except the little variety which an attention to the gravid ftate requires, the cure is the fame as at other times. Gonorrhoea and Lues Venerea.— The cure of the former is to be conduaed inpretty much the ufual manner ; that is, by keeping the parts clean by frequent bathing by drinking freely of di- luent drinks, by an open belly and cooling diet. If complicated with ulcers and chancres within the la- bia, or any where about the vulva, the prudent ufe of mercury becomes requifite: It may either be gi- ven internally, or rubbed on the fkin by way of una i- on. In the confirmed lues, we can only, in general, propofe to ftop the progrefs of the difeafe, or palliate the feverity of the fymptoms. But, in early preg- nancy, when the conftitution is good, and the feafon favourable, if a mercurial courfe be regulated with prudence, both mother and child may obtain a radi- cal cure. The proper time for entering on fuch a courfe is between the third and fix months. When a radical cure is attempted, the fafeft method of ad- miniftring mercuryfeems to be in the way of unaion : As a palliative, the folution of corrofive fublimate is< the moft powerful preparation. To prevent di- arrhoea and colic complaints, opiates always mould,-.-, be conjoined. M2 Fevers 138 Pathology of Parturition. Chap. II. Fevers.—Women are lefs fubjea to febrile dif- orders during pregnancy than at other times. There is, however, an univerfal heat all over the body ; which with fome is a fymptom of conception, and with others continues during the whole term, that hardly deferves that name. The limits of the prefent work neither admit of of our entering into any difquifition on the nature of fever in general ; or the treatment of the variety ^of fpecies. All great evacuations muft then be avoi- ded, and whatever might excite any violent fhock to endanger abortion and its confequences. The treat- ment muft otherwife be direaed on the common principles, attending to the management neceffary to be obferved in circumftances fo peculiarly critical. SECTION IV. Of Floodings and Abortion. ABortion, and its common attendant Flood- ing, are neither confined to the early nor latter months; but happen indifcriminately to every peri- od of geftation. The one is a frequent confequence of the other, and the event is often hazardous. In the earlier months, when the child has little life, a con- fiderable difcharge of blood frequently precedes the expulfion of the ovum ; and, in the latter ftages, the tftufion is fometimes fo exeeflive as to endanger the mother's life. Their Sea IV. Floodings and Abortion. 139 Their more frequent terms of occurrence are, in early geftation, the fecond and third, in advanced pregnancy, the fifth and feventh months. I. FLOODING. The Menorrhagia Gravidarum may be defined, " A vague or irregular appearance of blood from the " uterus, fubjea to no periodical returns, but liable " to recur from very flight occafional caufes." The immediate caufe is, the feparation of fome portion of the fubftance of the placenta, or membra. na decidua from the uterus. The feparation may be more remotely produced' 1. By plethora. a. General plethora of the whole fyftem. b. Partial plethora of the uterus and neighbour- ing parts, occafioned by External accidents ; as, Blows, cold, &c. Internal caufes ; as, Tumors compreffing fome of the neigh- bouring arteries, Effeas of fuppreffed perforation from the depreffing paffions, &c. Effeas of conftipation, or the ftoppage of a- ny other neceffary difcharge. 2. Debility. 3. Direa affeaions of the uterus and placenta. 4. Stimuli communicated from an affeaion of o- ther parts. , Floodings 140 Pathology of Parturition. Chap. II. Floodings feldom prove fatal to the mother before the feventh month of geftation, but are afterwards proportionally more alarming and dangerous. In the early months, there is always hazard of the lofs of the foetus, even from an inconfiderable difcharge ; and from the increafed diameter of the blood-veffels in the more advanced periods, the difcharge is often fatal to the parent. To check the haemorrhagy, the indications are, I. To diminifh plethora, as well as the impetus> of the heart and arteries. II. To reftore a more equable circulation in the whole fyftem. III. To reftore the tone of the folids, and pro-- mote the conftriaion of the veffels. 1. To anfwer the firft intention, venaefeaion, a : free circulation of cool air, coollingdiet, drink, and, other refrigerants, are the principal.remedies. 2. The fecond indication is with difficulty fol- - lowed ; for the exertion which the feveral remedies that produce this effea occafion, will be often very v hurtful. Vomiting and purging, except with the moft cool- ing neutrals, are feldom admiffible ; and warmth, applied to the furface, is equivocal in its effeas. . The only means, therefore, which we can recom- mend with this view, is to keep the feet warm with flannels and gentle friaion, and the. body and mind Sea. IV. Floodings and Abortion. 141 in the moft perfea tranquillity. Opium, in the form of of Dover's powder, is alfo frequently effeaual in ren- dering the circulating more uniform and equable. Might not the opium and ipecacuan only, be kept mixed, and the powder given in thofe cafes, in frefh folution of nitre, in a full dofe ? Such a for- mula would probably be a powerful remedy for hae- morrhagies of all kinds. Some of the caufes which we have mentioned are evidently beyond our reach. Thefe indications are, however, chiefly ufeful in the early ftages : the eva- cuation itfelf foon takes off plethora, as well as the haemorrhagic effort of the heart and arteries; fo that the chief bufmefs of the praaitioner is, 3. To reftore the tone of the folids, and promote the conftriaion of the veffels. With this view, in- ternal aftringent?, and the application of cold, are the moft effeaual means. The ftyptics generally employed are, the vitriolic acid, alum, terra Japo- nica, and gum kino: but cold applications to the pudendum and neighbouring parts are chiefly to be trufted ; as thick linen compreffes wet with cold vi- negar and water, applied to the os externum, pubes, and loins, and often renewed left they fhould become warm. A bladder with cold water, in which fome crude fal ammoniac is diffolved, may be ufed for a topical application, and will retain the cold fluid lon- ger than any other comprefs. By 142 Pathology of Parturition. Chap. II,- By thus keeping the patient quiet and cool, by gi- ving internally cooling things and opiates, and by the application of cold to the organ affeaed, the haemor- rhagy may be reftrained, tho' threatening and alarm- ing ; and the woman, after feveral attacks, may, under proper management, be enabled to carry the- child to the full term of delivery. Debility and relaxation muft afterwards be remo- ved, by nourifhing diet and tonic remedies ; and, in relaxed habits, the hazard of relapfe guarded againtt by the ufe of the Peruvian bark, moderate exercife, and the other remedies ufually employed after cafes of profufe menorrhagia. In full habits, or where- there is an evident difpofition to plethora, gentle eva- cuations, cooling regimen, and an abftemious fpare diet, are the beft prophylaaics. In the latter end of pregnancy, when the haemor- rhagy proceeds from the feparation of a portion of the cake which adhered at the cervix, over the orifi- cium uteri, the deluge is fometimes fo impetuous at to kill the mother very fudden'y. The only method, then, in our power, for preferving both the parent and child, is by an expeditious delivery; 1 mean expe- ditious with refpea to the time it is attempted, for the operation of delivery fhould be flovvly perfor- med. In all cafes of flooding, when any portion of the- pappy iubftancc.of placenta can be felt by the finger to Sea. IV. Floodings and Abortion. 143 to prefent before the child, delivery fhould be perfor- med as foon as the orifice of the womb is fufficiently relaxed to admit of the introduction of the hand, after gently ftretching*: and if the repetition of floodings without pain be frequent, or the difcharge fo profufe as to bring on faintings, it may be necef- fary to deliver, even though there fhould be no fen- fible dilatation of the uterine orifice, and though no part of the placenta can be felt to the touch ; for, if the woman is previoufly much exhaufted, fhe can- not be faved by delivery. II. ABORTION. Abortion is, " The premature delivery of the foetus;" which comprehends every period before the evolution of its fyftem be fufficiently complete to enable the child to exift after the conneaion with the parent is diffolved. Some authors ftill make the following diftinaion. When the ovum is expelled in the early months, they call it an abortion ; and, if the fcetus be delive- red at any period between the fifth month and the full time, a mifcarriage. Abortion is commonly preceded by fome of the following fymptoms : Flooding, pains in the back or belly, uterine bearing-down pains with regular in- termiflions, the difcharge of a watery fluid. If, * See a valuable eflay on this fubjecl by Mr Rigby. 144 Pathology of Parturition. Chap. II. If, along with flooding, any portion of a vafcular fkinny fubftance, which is the membrana dicidua, fhould be difcharged, abortion for certain will enfue. None of the other fymptoms are infallible ; even the evacuation of a watery fluid is not neceffarily follow- ed with delivery, fince it may proceed from a col- leaion on the outfide of the ovum, between the lamellae of the membranes. In the early months exceffive floodings fometimes occur; and yet, by proper management, the woman is often enabled to retain the child. There is lefs fear of abortion while the blood eva- cuated is pure and without clots, unattended with uterine pain and preffure. But, in forming a judg- ment, the conftitution, occafional caufe, and term of geftation, muft be regarded. Abortions happen more frequently from the be- ginning of the fecond to the end of the third month, ; than at any other period. The immediate caufe of abortion is the fame with that of real labour. The more remote caufes are, I. Whatever interrupts the regular circulation be- tween the uterus and placenta; as, I. Difeafes of the uterus. 2. Impervioufnefs, or fpafmodic conftriaion, of the extremities of the uterine blood-veffels. 3. The feparation of any portion of the cake", or decidua Sea. IV. Floodings and Abortion. 145 dccidun, from the uterus. 4. Determination of the fluids to other parts. II. Every caufe which prevents the diftention of the uterus, or excites fpafmodic contraaion of its mufcular fibres ; as, I. Extreme irritability, preventing the extenfion of that organ. 2. Violent exertions, as coughing, fneezing, vo- miting, ftraining at ftool: mechanical injuries, as ftrains, falls, &c. 3. Irritation from the confined motion of the foetus, its kicking or ftrugglings. 4. A habitual difpofition to abortion. III. The death of the fcetus; which many be occa- fioned from, 1. Difeafes peculiar to itfelf. 2. An original defea tranfmitted from the pa- rents. 3. External accidents affeaing the mother. 4. difeafes of the placenta, membranes, or cord. 5. Too flight adhefion of the cake or membranes to the uterus. 6. Weaknefs, or want of refiftance, in the tex- ture of the membranes ; or an exceffive quantity of the liquor amnii. 7. Knotty circumvolutions of the umbilical cord. The fize of theobortive ovum in early geftation is as follows: Six weeks after conception, its hvtti is N n?a.df 146 Pathology of Parturition. Chap. II. nearly equal to a pigeon's egg; in eight weeks, to that of a hen ; and in twelve to that of a goofe. Where there is no reafon to dread abortion, every probable mean ought to be employed to relieve pain- ful fymptoms by reft and opiates, to check haemor- rhagy by the means already direaed, and to obviate occafional caufes as much as poffible ; and the wo- man fhould be encouraged to hope as long as there is grounds for it. As abortion, in many inftances, is preceded by no alarming fymptom, till a difcharge of watery fluid, or an exceffive flooding, with clots and portions of the decidua, announce the approaching event; either to remove immediate fymptoms, or prevent the accident that is dreaded, often baffles our boafted fkill; for the circulation in the ovum perhaps had ceafed a confiderable time previous to any threatening fymp- tom of its expulfion. Little, therefore, can or ought to be done by way of treatment, befides obviating plethora, advifing reft of body and tranquillity of mind, and guarding againft every caufe of irritation. Though the mo- ther may fuffer a confiderable fhock from mifcarriage, and it may be fome time before her conftitution be fufficiently reftored for any future fortunate preg- nancy, women are rarely known to fuffer fatally, but from mifmanagement in the early months. Any manual operation to affift delivery, is feldom neceffary at Sea. IV. Ihodlngs and Abortion. 147 at an earlier period than the fixth month of geftation, unlefs the mother's life fhould be in danger from flooding. When this happens, the7 bag may be bro- ken by thrufting the finger againft/it in time of pain, or endeavouring to affift its expulfion when within reach of the finger : but otherwife the delivery fhould be wholly trufted to nature. It is even hazardous to dcftroy the ftruaure of the ovum in the early months : for when it breaks, the fmall fcetus is firit expelled ; and the bag or placenta may be afterwards retained for a week or more, during which time the flooding often continues to be exceffive ; whereas, if the conception comes off entire, the effufion ge- nerally ceafes immediately. - From long retention, the placenta, without cir- culation, is liable to become putrid: it is then expel- led in different portions; and inflammation, excori- ation, or gangrene of the uterus and vagina, often enfues. In thefe circumftances there is a neceflity for keeping the parts clean, by frequent bathing, or by injeaions thrown into the vagina ; and bark, with elixir of vitriol, fhould be given freely. Gently ftimulating glyfters, to promote the contraaion of the uterus, in cafes of retention of the placenta where there is no great flooding, are often ufeful. As women who have once aborted are liable to a repetition of that accident from a fimilar or very tri- fling occafional caufe, it ought to be guarded againft by 148 Pathology of Parturition.. Chap. II. by every poffible means. With this view, the ma- nagement during pregnancy fhould be properly regu- lated. SECTION V. Management during Pregnancy. nTTIE regulations during pregnancy may be refer- -*■ red to the following rules. 1. Tiie ftriaeft temperance and regularity in diet, fleeping, exercife, and amufement, are neceffary to be obferved by thofe who have reafon to dread abortions. 2. Overheating, irregular paflions, and coftivenefs, fhould be conftantly guarded againft. 3. The hazard of fhocks, from falls in walking or riding, from bruifes in crowds, of frights from buftle, fhould be avoided with the utmoft eircumfpec- tion. 4. The drefs of pregnant women ought to be lodfe and eafy. Tight lacing is injurious at every period of geftation. In the early months, by pre- venting the uterus from rifing out of the pelvis, it endangers mifcarriage, and is ftill more hazardous in the advanced ftages. Jumps, without knots, buck- les, or whale-bone, fecured with ftraps of broad tape or ribbon, fhould be had recourfe to foon after con- scption, and worn conftantly. 5. Preg- 4 Sea. V. Management in Pregnancy. 149 5. Pregnant women require free, pure air; their inclinations fhould be gratified by every reafonable indulgence; and their fpirits kept up by cheerful company and variety of objedts, that their minds may be always compofed and happy. 6. If complaints then occur, they fhould be trea- ted nearly as at other times, with the precautions formerly fuggefted of avoiding all great evacuations and violent exertions. Draftic purges, ftimulating glyfters, emetics towards the term of quickening, or any other critical period, ftrong diaphoretics or diure- tics, fhocks from elearicity or the cold bath to thofe who have not been accuftomed to them, the hazard of accidents from riding or failing, and of the confe- quences of irritation from the aaion of blifters or the abforption of flies in particular circumftances and conftitutions, ought to be carefully guarded againft. In the early months, abortions might be readily oc- cafioned from fuch hazardous expedients; and in the latter, the moft alarming and dangerous flood- ings. 7. Laftly, With a view to prevent abortion in cafes of habitual predifpofition, in plethoric habits, or in thofe of an oppofite temperament, occafional caufes muft be obviated, and the particular fault in the conftitution correaed. N2 PART. PART III. LABOURS. INTRODUCTION. § I • General Obfervations. HEN the uterus will admit of no greater diftention, without a material, or probably fatal diforder, from its impeding the feveral funaions, labour enfues. At this period, the organization of the fcetus is fufficiently evolved to enable it to continue its exift- ence ; for as it derives no injury from a longer de- lay, fo it can furvive a flight acceleration of this im- portant change. ' The period of geftation varies in the feveral clafTes « of different animals. The mare, the cow, the ewe, and the goat, are reftriaed, each within its proper limits. In the human fpecies, ninekalender months feem necelfary for the perfeaion of the foetus; that is, nearly 39 weeks, or 273. days, from conception. The term does not, however, appear to be fo ar- bitrarily eftablifhcd, but that Nature may tranf- grefs w A § !• Of Labours in genera/. 151 grefs her ufual laws ; and, as many circumftances frequently concur to anticipate delivery, it certainly may in fome inftances be protraaed. Individuals of the fame clafs of quadrupeds, it is well known, va- ry in their periods of pregnancy. May we not from analogy, reafonably infer, that women fometimes exceed the more ordinary period ? In feveral to- lerably well attefted cafes, the birth appears to have been protraaed feveral weeks beyond the common term of delivery. If the charaaer of the woman be unexceptionable, a favourable report may be given for the mother, though the child fhould not be pro- duced till nearly ten kalendar months after the ab- fence or fudden death of her hufband. Labour is " an effort of nature to expel the con- " tents of the gravid uterus." It is chiefly accom- pliflied by the fpafmodic contraaion of the uterus itfelf. The diaphragm, mufcles of the abdomen, and others concerned in refpiration, and all the muf- cles of the body, are called in as auxiliary powers. Thefe efforts alternate with intervals of eafe ; and the exertions, or paroxyfms, continue till the child is propelled, and the uterus completely emptied of its contents. The immediate caufe of labour feems to be, " Irrita- " tion, from previous diftention of the uterus, com- *' preffing the foetus and waters." The uterine con- tents 152 Of Labours in general. Introdd tents being propelled againft the orifice, the muf- cular ftruaure of that organ will be ftimulated into aaion, and labour-pains confequently enfue. The final caufe of labour is, the birth of tho child. Spurious pains frequently occur towards the latter end of geftation. Their caufes are a flight degree of irritation of the uterus from exceffive ftretching; fpafmodic affeaions of the abdominal vifcera; or, any ftimulus communicated from the inteftinal canal, as colic from coftivenefs and other caufes. They of- ten nearly refemble labour, and ought to be carefully; diftinguifhed from it. They are more vague and irregular, both in fre- quency and force, than thofe arifing from genuine labour ; they do not produce any fenfible change on the orificium uteri ; they are not attended with any1 confiderable difcharge of the ropy mucus, which; fometimes precedes, and always accompanies, the: firft ftage of real labour. They are generally con- - fined to the lumbar region, or to the belly, without ftriking down the thighs; they are commonly moft•- troublefome towards evening, occafion inquietude and reftlefsnefs in the night, and abate in the morning.. They are further known to be fpurious, by the re- lief procured from glyfters and opiates. Genuine labour is known to ape-roach from the cir- cumftances which ufually precede it: the progrefs is marked < § I. Of Labours in General. 153 marked by the duration, force, and frequency of the pains ; by their effeas on the general fyftem ; more particularly by the dilatation of the uterine orifice, and protrufion of the water and child. Tire fymptoms of approaching labour are, the fubfi- ding of the abdominal tumor at the fuperior part ; hence, at firft, a relief from weight, preffure, and uncafinefs formerly felt ; afterwards, a difcharge of ropy mucus from the vagina, fometimes tinged or ftreaked with blood, commonly ftyled the fhews; then, flight pains of the belly or loins, frequent mic- turition, tenefmus, fometimes colic or diarrhoea, extreme reftleffnefs, alternate rigours and hot fits. The throes of labour ufually commence with pain in the region of the loins, which fpread round for- wards and downwards, and again extend from the belly to the pubes, fliooting down the thighs. At firft they are vague, more flight and tranfitory ; but gradually increafe in force, and recur at more regu- lar intervals. Sicknefs of the ftomach, retching, and vomiting, alternate rigours and hot fits, in fome inftances ac- company the earlieft fymptoms of labour ; in others, horripulatio occurs in the progrefs, and feems then to be occafioned by the preffure of the head of the foetus againft the irritable uterine orifice. Pyrexia, in young plethoric women, is a frequent attendant of labour ; for, with increafed pain, the face becomes flufhed, the pulfe full, ftrong, and ac- celerated 154 Of Labours in General. Introcf. celerated, along with dry parched mouth and fauces, and the other fyuiptoms of fever, ftyled by authors febris parturiens. Ifchuria, or fuppreffion of urine, and fometimes an involuntary difcharge of faeces,. enfue. The progrefs of labour generally proceeds in the fol- owing manner. In confequence the great difcharge of lubricating moifture, the genital parts are firft relaxed, and then gradually begin to dilate. The membranes alfo gra- dually feparate from die: internal furface of the uterus; and, by its fpafmodic contraaions, the membranes and contained water is protruded in form of a foft, yielding bag, before the prcdnting part of the child. In the abfence of the pain, the waters retreat; the membranous bag is relaxed, or flaccid ; and the childr if within reach, can be dhtinaiy felt through. When the pain recurs, the membranes become tenfe and turgid ; fpread out more and more ; and, advancing.. lower and lower as the pains increafe in force and fre- quency, they gently and fafely ftretch and dilate the the paffages preparatory to delivery, in a manner which no human artifice can poffibly imitate. When that important end is accomplifhed, the flender bag yeilding to the propelling force, gives way, and the contained fluid is evacuated. In a natural eafy labour, the progrefs of the head of the fcetus through the pelvis correfponds with the pro* § I. Of Labours in general. *55 protrufion of the membranes and dilation of the foft parts. The head advances in a mechanical manner, its large axis being generally applied to that of the pelvis. When the vertex is nearly arrived at the lower circumference of the bony cavity, the membranes give way ; foon after which, the pains are renewed with increafed force. The vertex advances through the axis of the vagina ; the occiput gradually emer- ges from under the arch of the pubes ; and the foft parts at the bottom of the pelvis beginning to be pro- truded in a form of a tumour, the os externum is radually dilated. As the occiput rifes from below the pubes, the face is turned towards the concavity of the facrum ; the forehead preffes againft the moveable coccyx ; the vertex now protruding without the os externum and the ftimulating exertions becoming fo exceffive as to throw the whole frame into the moft violent agitation, the os externum is forced open, and the head of the child propelled. After fome interval of eafe, the pain, in a more moderate degree, recurs, and continues till the child is completely delivered, the fhoulders making the fame mechanical turns with 1 the head. When the woman has fomewhat recovered the fhock, the uterus again renews its contraaions; and by a more gentle and moderate exertion of the fame power by which the membranes were feparated and protruded and the child was propelled, the pla- centa 156 Of Labours in general. Introd. centa is detached from, its adhenfion to the womb, forced downwards to the orifice, and expelled. This is the manner and progrefs of natural eafy la- bour. But a variety of circumftances frequently con- cur to difappoint our hopes, and render the birth te- dious and painful. The original pofition of the foe- tus in utero; the bulk, fhape and folidity of the head; the age, conftitution, and previous condition, as well as prefent health and management of the patient; the aaion of the uterus itfelf, confidered as a hollow muf- cle ; the rigidity of the os tincae ; the conftruaion and capacity of the pelvis ; the texture of the mem- branes ; the tightnefs or conftriaion of the vagina; the refiftance of the os externum, &c. occafion an aftonifhing variety in the degree of pain, the pro- grefs or duration, and manner of termination of la- bour. Praaitioners fhould therefore be cautious of giving an opinion refpeaing the time of delivery, at leaft till the progrefs be confiderably advanced. A judgment of the duration and event of labour is chiefly to be derived from the force, continuance, and recurrence of pains; from the refiftance of the os tincae, or the contrary ; from the period when the membranous bag is ruptured ; from the pofition of the child's head, and relative proportions that ob- tain between it and the pelvis. Young women, apparently well prooortioned of a § I. Of Labours in general. 157 a lax fibre and healthy conftitution, nay be prefumed tohaveeafy, favourable labours. We may expea the delivery to be tolerably eafy and expeditious, when the pains come on regularly; when the child prefents properly ; when the membranes begin early to form a bag, and protrude the os tincae ; when it is thin, foft, and yielding, and is felt by the touch to dilate fen- fibly by the force of the pains ; when the head can be felt thro' the membranes during the rendllion of ^ain, advances progreflively through the pelvis, preceded by the amnion tumor and the rupture of the mem- branes, when the head can be felt to prefs againft the orificium uteri. But, even in thofe circumftances, the progrefs of labour is often unexpeaedly interrupted, by the remiffion or diminiflied force of pains for a confidera- ble interval; by the conftriaion of the vagina after the os tincae is completely dilated ; or, by the rigidi- ty of the external parts, though no obftacle fhould occur from any defea in the conftruaion of the pelvis. In fome inftances, the progrefs is retarded by the early rupture of the membranes, flow dilatation of the os tincae, feeblenefs of the throes , and a variety of other caufes. Nothing can therefore be more dif- ficult, than to afcertain, or guefs at, the time necef- fary to accoinplifh the wifhed-for event. The more ordinary limits of a natural eafy labour are from fix O to 15$ Of Labours in general. Introd. to twelve hours; it is, however, fometimes com- pleted within two hours, and fometimes requires fe- veral days. But the firft labour is generally, from obvious caufes, the moft painful and tedious. § 2. Divifion of Labours. HPHE ancients, as far as can be colleaed from -*- their writings, divided labours into two kinds, Natural, and Preternatural. The firft included head, or, according to fome, head and breech, prefenta- tions ; and all others were implied in the latter. Dead children feem to make a third diftinaion, and are direaed to be delivered in a particular manner by fharp hooks. In different authors we find different arrangements, and the claffification is ftill arbitrary. That ofDr smellie appears to be leaft liable to exception. He refers all labours to three general clatfes: ifi. Natu- ral ; 2ifv, Laborious ; and, ylly, Preternatural. He calls thofe cafes natural, where the head prefents, and the child is expelled by the natural pains ; labori- ous, when the head prefents, but the birth is uncom- monly protraaed, or requires the interpofition of art; and preternatural, when any other part but the head firit prtf tits, or when the feet are delivered before the head. A great variety of divifions and fubdivifions, how- ever A § 2. Divifions of Labours. 159 ever, ftill prevail among modern praaitioners; as, Natural and Non-natural, Slow and Lingering, Dif- ficult and Laborious, Preternatural, Wrong and crofs Pofitions, Perilous, Mixed and complicated Labours, &c.; and different explanations have been gi- ven by different authors to the fame terms. Such indefi- nite diftinaions ferve to involve the fubjea in obfcuri- ty, and to miflead and embarrafs inexperienced prac- titioners. All diftinaions ought to be reftriaed to thofe cafes merely which require a different mode of praaice. With this view, labours may with propriety be re- ferred to Dr Smellie's general divifion of three claffes; Natural, Laborious, and Preternatural : And each of thefe may be fubdivided into two or more different claffes ; which alfo comprehend a confide- rably variety of particular cafes. I. Natural include, 1. Expeditious and eafy, 2. Tedious and lingering, lobours. II. Difficult or ftriaiy laborious labours compre- hend, 1. Thofe cafes where the hand alone is fufficient to afford the neceffary afliftance. 2. Where instruments muft be ufed. III. Preternatural parturition comprehends, 1. Feet and breech cafes. 2. Crofs births. 3. One 160 Of Labours in general. lntrod. 3. One or both of the fuperior extremities protru- ded before the head. 4. All other cafes that require the child to be turned; as floodings, prolapfed cord, &c. § 3. Management of Labours. TN all labours three diftina periods, or ftages, -^- imy be mark-.d. 1. The dilatation of the orificium uteri. 2. The delivery of the child. 3. The feparation and expulfion of the placenta and focundines. Of thefe the firft is by much the moft tedious, and the management is nearly the fame in all labours : for, whatever time may be neceffary to accomplilh it, this firft ftage fhould, in every inftance, be trufted to nature ; dangerous floodings, (very rarely local iLfeasin the foft parts) only excepted. The third ftage feldom requires much afliftance from art. In the fecond ftage chiefly, a variety of manage- ment in different circumftances becomes neceffary. We fhall firft give a few direaions for the treat- ment of Natural Labour in its three feveral ftages; and then conciftly direa the variety of management in the particular Cafes of the other Cbffes. CHAP. Chap. I. Of Natural Labours. 161 CHAP. I. Method of Treating Natural Labours. SECTION I. Expeditious and Eafy Labours. FIRST STAGE. Dilatation of the Orificium Uteri. /^\N the commencement of labour, and previous ^-^ to any attempt to affift it, the neceffary ap- paratus fhould be prepared. The room fhould be lofty, the bed equally diftant from a confined fitua- tion, and a current of air ; the curtains, and every part of the furniture, fhould be thin and incapable of retaining either moifture or fmell. The coverings of the (fleets fhould be carefully adapted to prevent the blood or the waters, from penetrating through them. The patient fhould be permitted to walk, or reft in her ufual poftures, till the os uteri is dilated, and the pains be frequent and preffing : fhe fhould then be placed on her fide, with her knees drawn up ; and, in advanced labour, they may be feparated by O 2 a nil. I*._____ 162 Of Natural Labours. Chap. 1. a pillow, and a refiftance given to the feet by an afliftant. Before fhe is placed in this pofition, every indelicacy, by frequent touching, is highly improper. It is afterwards more effential, and fhould never be negleaed immediately after the rupture of the mem- branes ; for the child's arm, or any portion of the umbilical cord which may threaten to prefent, may then be replaced with eafe. Having obviated every caufe which may impede labour, and guarded againft every thing which may difturb or irritate the patient, we fhould wait with patien e till nature has protruded the head of the child, or the membranes filled with their fluid. If we inter- pofe tefore, it fhould only be to apply a warm cloth to the os externum, or a preffure to the loins, if the pains are violent. The firft ftage of labour is then accomplifhcd. SECOND STAGE. Delivery of the Child. IF the membranes have not been before rupturedj. it fhould now be done by the finger of the Accou- cheur ; and a remiffion of pain generally enfues* It returns, however, as foon as the watery fluid is \\ difcf argtd ; and the perinaeum is foon after diften- ded by the preffure of the vertex : but, under proper management. Sea.I. Expeditious and and Eafy Labours. 163 management, no bad confequences follow from the diftention, unlefs the labour is rapid or tedious. In the former cafe, the parts of the mother have been lacerated; and, in the latter, violently in- flamed, in confequence of the long-continued pref- ure of the child's head. When the parts are violently ftretched, the peri- naeum may be gently fupported during a pain, and a counter-pretfure is generally recommended when the labour is rapid.; but it fhould be remembered, that this fupport is only ufeful as it retards the lahour, which is often inconvenient, and fometimes dangerous* A laceration of the perinaeum is a very rare occur- rence, and generally the confequence of previous difeafe. It is therefore doubtful, how far a hazar- dous expedient is to be recommended to obviate an uncertain accident. After the head is delivered, there is feldom any danger ; the fhoulders accommodate themfelves to the paffage ; and the birth may then be fafely faci- litated by the hands of the Operator, if any afliftance fhould happen to be necelfary. The child fhould be immediately removed, as far as the cord will permit ; if it is twitted about the neck, body, or limbs, it muft be di fen gaged, and, after the child has fhown figns of life, the cord muft be tied. If the child has fuffered from the compref- fion of the head, the firing may be fafely fuffered to bleed 164 Of Natural Labours. Chap. I. bleed a little, or, if it appears to have been lately dead, the ufual ftimuli fhould be employed *. THIRD STAGE; ok Separation and expulfion of the Placenta and Secundines. MANAGEMENT OF THE PLACENTA. HAving given the child to the nurfe or one of the attendants, the next objea of our regard is, the Management of the Placenta. The fame powers which expel the fcetus, are again, after a fhort interval, renewed, but in a leffer decree, to exlude the fecundines. Their ftruaure is, however, different from the more folid mafs of the foetus. The uterus fometimes contraas unequally; the os tincae is more irritable than the fundus ; and the mufcular fibres round the edge of the orifice fometimes contraa fo quickly, that the aperture foon diminilhes, and may for a little time prevent- the cake from palling after its adhefion to the uterus is diffolved. From the unequal or partial contraaion of the mufcular fibres of the uterus where the pla- centa * For a more minute detail of the apparatus of the bed, drefs of the patient, and other particulars relating to the Management of Natural Labours, fee Tnatife of Midwifery for the ufe of Fmah Praclitioncrs. mwr- Sea. I* Expeditious and Eafy Labours. 165 centa is attached, one portion may be feparated be<- fore another: all which render a variety of mana- gement, in peculiar circumftances, neceffary. Hence the oppofition of fentiment of authors on the fubjea ; fome recommending as a general rule, to precipitate the extraaion immediately aiter the delivery of the child, left the uterus fuddenly do- ling, ihould render the operation difficult and hazar- dous ; while others advife, in all cafes, to truft the management entirely to nature. The middle courfe is in general, the moft fafe and proper ; and both extremes fhould be equally guarded againft. As the feparation is accomplifhed by the fpon- taneous contraaion of the uterus, more or lefs time will be neceffary, according to the previous ftate of geftation, duration and management of the preceding part of labour, condition of the woman immediately after, and a variety of other occafional caufes which may impede orpromote the aaion of the uterus. In moft cafes, the adhefion is diffolved within half or three-fourths of an hour after the birth of the child. The contraaion of the uterus is moft expe- ditious, and of confequence the placenta moft eafily and quickly feparated, after a firft pregnancy, when the woman is in good health, and when the labour has been properly managed. The contraaion of the uterus is more flow and imperfea, and confequently the t66 Of Natural Labours. Chap. I. the adhefion of the cake more tenacious, in prema- ture births, when the woman's health is impaired from previous indifpofition ; in cafes of tedious and difficult labours,—of languor or faintnefs after deli- very,—and when hafty attempts have been officioufly employed to force the extraaion. The diminifhed bulk, and fhifting of the abdomi- nal tumor, which may be felt by the application of the hand externally, afford the beft means of informa- tion when to attempt expediting the expulfion of the fecundines; and, in general, enable us to judge whe- ther any other child be retained in utero. The approach of the birth of the placenta is com- monly announced by the difcharge of fome clotted blood, and by a flight degree of uterine nifus, called by the women grinding or griping pains. Then is the lime to aflift the expulfion ; which ought to hz per- formed in this manner. ' The cord muft be twitted round the fingers of the left-hand, fo that a firm hold is obtained; two fin- gers and the thumb of the right-hand fhould alfo be applied, to grafp the cord within the vagina. The advantage of a pain, when it occurs, fhould always be taken. The cord muft be pulled from fide to fide, and backwards towards the perinaeum, endeavouring to drag in fuch a direaion as to bring the central part of the cake through the axis of the uterus and pelvis, and defining the woman to employ her own exertions ^A Sea. I. Expeditious and Eafy Labours. 167 exertions moderately by bringing a deep infpiration and bearing down gently; but, violent efforts of coughing, retching, fneezing, or ftraining, fhould be conftantly avoided, left dangerous floodings or deliquia might follow. It is known to advance, by the lengthening of the cord, and the ftraining of the wo- man. When the bulky part of the mafs arrives at the os tincae, the inverted cake, preffing againft the orifice in a globular form, fometimes gives confi- derable refiftance. This obftacle may be removed, either by paffing up two fingers of the right-hand, guided by the cord, to bringdown the edge ; or by waiting a few minutes, then pulling gently at the cord with the left-hand, and preffing on the fubftance of the cake with the fingers of the right, higher and higher till the edge can be brought down, which muft be grafped firmly, the funis being ftill extended with the other hand. The whole fubftance of the cake, with the membranes, being at laft entirely dif- engaged, are to be gradually extraaed, put into a bafon, and removed. But, if the placenta does not advance when ths cord is fully extended, and the woman fuffers confi- derable pain, the operator muft immediately defift ; left, by carrying the attempt further, floodings might be occafioned, the cord be ruptured, or the uterus inverted. A foft warm cloth fhould then be applied to the os externum, and the patient allowed to reft •for U 168 Of Natural Labours. Chap. I. for five minutes. If it does not yet advance, ten or fifteen minutes more fhould be waited for ; and, in the interval, a moderate degree of preffure on the ab- domen, in different direcfions, may promote the contraaion of the uterus, and affift the feparation. By gradually proceeding in this manner, and pati- ently waiting for the contraaion of the uterus, the placenta will be produced fo low, that the centre can be felt, the edge brought down, and the extraaion fafely accomplifhed. The introduclion of the hand into the uterus to fe- parate the adhefion, or affift the expulfion of the after-birth, is not perhaps abfolutely neceffary in one of feveral hundred cafes. However cautioufly per- formed, it occafions a confiderable degree of pain ; the very apprehenfion of an expedient fo harfh and unnatural, infpires the utmoft dread and horror, and not unfrequently caufes deliquia or fits. It is cruel and barbarous to employ a painful mode of afliftance, it is criminal to hazard the confequence of violence, where the fame end may be obtained by gentle means, perhaps by waiting an hour or two extraor- dinary. In every view, the operation of introducing the hand to remove the placenta fhould only be em- ployed in the moft urgent cafes. It muft, however, be acknowledged, that the pla- centa cannot alway? be removed by pulling at the cord. It may be ruptured: A prof ufe flooding in- dicates Sea. I. Expeditious and Eafy Labours. 169 dicates the neceffity of the immediate interpofilion of the artift ; for while he deliberates, the patient may fink: the uterus may be fpafmodically conftriaed over or upon the cake, and prevent its advancing: or, The cake may be retained from extraordinary or morbid adhefion to the uterus. We ihall coniider each of thefe cafes feparately. 1. Method of removing the Placenta when the Cord is ruptured. The cord may be torn by the careleifnefs of the operator, from its feeblenefs in premature births, or from its putrid ftate when the child has been fome time dead. In the laft cafes, the rope is never to be trufted. Time fhould be given for the cakes to be difengaged and forced downwards ; and the cord fhould only be ufed for a guide, to condua the fin- gers to prefs on the placentary mafs, in the manner direaed, when it is advanced as far as the os tincae. When there is no rope for ;a direaion to "the hand, and it appears neceffary to remove the placenta on ac- count of the apprehenfion or anxiety of the woman, or any threatening fymptom of danger, the hand muft be gently infinuated into the uterus, and the ragged membranes round the edge of the placenta fearched for. If it cannot be difengaged by bringing down the edge, let the hand be conveyed to the thick P protruded i/° Of Natural Labours. Chap. I. protruded centre ; and by fpreading out the fingers, then bringing them together fo as to grafp the cake in the palm of the hand, and repeating the attempt again and again, the ftimulus of the hand will pro- mote the contraaion of the uterus. The cake being at length entirely detached, is to be cautioufly and gradually brought down, and removed. 2. Method of ex trailing the Placenta in Cafes of Flooding. A mo fuse hacmorrhagy fupervening the delivery ✓of the child, is alarming and dangerous; if it does not foon ceafe, fatal fyncope will probably enfue. Though it feem to abate, if the woman be low and faint, the relief may be fallacious; and is perhaps occafioned by part of the placenta forced down at the cervix uteri, and by plugging up the orifice prevents the effufion exttrnally. The confequences to be dreaded can only be pre- vented by removing the placenta ; for, while one portion adheres and another is detached, there is Ut- ile chance that the flooding will flop till the uterus be put into a condition for contra£ting. The hand of the operator is to be gradually, but with a certain ckgree of courage and refolution, introduced into the uterus, taking the navelftring for a guide, and ga- thering the fingers together in a conical manner. If the placenta feems attached to the oppofite fide, the hand Sea. 1. Expeditious and Eafy Labours. 171 hand already introduced muft be withdrawn, and the other palled in its ftead ; or if, from its adhefion to- wards the upper part of the womb, it appears to be without the reach of the hand, the pofition of ths woman muft be altered, and fhe muft be fhifted from onefide to the other, from the fide to the back, crofs the bed, or placed on her knees and elbows, accor- ding to the particular circumftances of the cafe. The placenta, by its firmnefs, can be readily dif- tinguilhed from loofe clots of blood ; and, from the womb, by its foftnefs and want of feeling. It may be difengaged by infinuating the fingers between it and the womb, through the membranes, when the feparated edge of the cake can eafily be come at. If it cannot, the thick middle part of the placentary mafs fhould be grafped firmly, fpreading out the fin- gers and gathering them together upon it, and in that manner gradually endeavouring to difengage and bring it away. It is dangerous to ftrip or peel it from the womb, by placing the fingers on the outfide of the membranes, as authors generally advife; for, by that means, where the womb has loft its con- tractde power, a fata 1 deluge may be occafioned. 3. Management of the Placenta in Cafes of Spafmodic Contraction of the Uterus. Little hazard is to be dreaded from this caufe of retention ; as by waiting.for fome time, perhaps fe- veral -^ I?2 Of Natural Labours. Chap. I. J veral hours o; longer, the fpafm will be removed, the equal contraaion of the uterus reftored, and the I placenta by the fiiccefsful efforts of nature difengaged and expelled. Though it might perhaps be the fafeft praaice, both inthis cafe and when the cord is torn, to delay the interpofition of manual affiftance even for a day «-r two, when the cake will probably be expelled in time of fleep, foon after waking, or forced off du- ring the effort of paffing urine; yet there is ahvc-a hazard of having the woman before the after-birth is de- livered. She may fuffer from anxiety and agitation : or a flooding from partial feparation may enfue, and life itfelf be quickly exdnguifhed. If the operator cannot ftay conftantly with tie pa- tient, nor any afliftant be procured, the beft practice is to give a full dofe of opium, as 40 or 50 g«9 L. " L.; and when the is compofed, and begins to be \ drowfy,. if the cake cannot be brought away by puU * ling at the cord, and uterine efforts are in vain wait- ed for, the hand of the operator may then be intro- duced into the uterus in a conical manner, and the conftriaion gently and gradually be overcome. The ; cake will probably be found moftly loofe and difen- gaged, which muft be firmly grafped in the hand and Tcmoved. 4. Ma- I Sea. I. Expeditious and Eafy Labours. 173 4. Management in Cafes of morbid Adhefion of the Cake. The placenta is liable to become difeafed. It fometimes partially or wholly degenerates into hyda- tides, becomes fcirrhous, cartilaginous, more rarely bony. Either of thefe ftates is probably originally preceded with fome degree of inflammation ; in con- fequence of which the intermediate conneaing mem- brane between the cake and the uterus is deftroyed, and a coalition formed between them. Of all the caufes of retention, this is the moft dif- ficult and dangerous. The cafe is intricate and per- plexing. If the placenta remains, and nature fails to expel it, the woman generally dies from uterine inflammation and gangrene. She is often alfo the unhappy viaim of the unfuccefsful attempt of the operator : for the uterus has been torn by the offici- ous or unfkilful efforts of the petitioner; or mortal floodings, inflammation, or gangrene have enfued. If, in thefe circumftances, we fhould wait for the natural expulfion, the woman may be quickly de- ftroyed by flooding, from partial feparation. If we attempt to force a feparation of the adhefion, by tearing the placenta from the uterus with the fingers while that organ is in a ftate of atony, a fatal deluge from the deftruaion of vafcular fubftance may enfue before the hand could be withdrawn from the uterus. P 2 Th« 174 Of Natural Labours. Chap. L- The beft and fafeft praaice, in thefe alarming ca- fes, is to defer our attempts as long as poffible : then, but before the putrid procefs commences,, to infinuate the hand with the utmoft caution and ten- dernefs; attentively examine the cake, by feeling every part of its fubftance ; carefully avoid tearing by force at that place where the difeafed hardnefs or fcirrhofity is ; feparate cautioufly that portion which is loofe and foft and which yields to gentle efforts: the reft muft be left to nature ; to be expelled with the cleanfings, or deftroyed and difcharged by means of fuppuration. Upon the whole, it is hazardous to precipitate the delivery of the placenta, or to truft in alarming or difficult cafes the imperfea efforts or limited powers tf nature. From over hafly or violent attempts to force the cxtraaion, the moft dreadful accidents, as inflammation, laceration, or inverfions of the ute- rus, and mort-1 haemorrhagies, frequently happen. From the retention of the fecundines, malignant, putrid, or miliary fevers, and fatal floodings, have often alfo been occafioned*; of which I have known feveral inftances. * J'ide Mr White's valuable treatife, Directions for Managing the Placenta, particularly Cafes nth, iath, 13th, t4th and 15th; and Mr K.'rUand's Treatife of Child-bed Fevers, par- ticularly p. ijS—164. SEC- Sea. II. Tedious arid Lingering Labour. i%$ SECTION II. Tedious and Lingering Labour* A Labour, though ftriaiy natural, with refpea to the pofition of the child, the management, and termination, may be tedious and lingering in the progrefs or duration of its different ftages. This is exceedingly diftreffing to the patient, perplexing and vexatious to the praaitioner. When the labour is protraaed beyond the more ufual limit-; the woman becomes anxious anddejea- ed ; the pains occafionally remit and recur with fre- quency and violence, or alternate with imperfea and irregular intervals of eafe ; the progrefs is flow and imperceptible ; her fpirits are exhaufted from reft- leffnefs and apprehenfion, or while the pains abate fhe infenfibly falls into fhort but unrefrefhing num- bers. After a long and obftinate conflia, by the reiterated fucceffion of feeble efforts, the head of the fcetus moulds itfelf to the paffage; the crannial bones are compreffed ; the vertex lengthens out, forming a foft conical tumor; the refitting yield to the propelling powers: and the birth, after perhaps a period of two or three complete days, is at laft,. however, fafely accomplifhed. The l7& Of Natural Labours. Chap. I. The caufes of lingering labour may be referred to the following. I. In the Mother. i. Anydefea, more immediately in theaaionof the uterus, or auxiliary powers of parturition which impedes the force of the labour pains. 2. More remotely, univerfal debility, from a. Flooding, diarrhoea, or other debilitating evacuations. b. Epileptic fits. c. Crampifh fpafms. d. Sicknefs, lownefs and faintnefs. e. Fever, from inflammatory diathefis, or im- proper management. /. Sudden or violent emotions of the mind. 3. Local impediments interrupting the paffage of cf the child ,a s, # 1. In the bones affeaing the dimenfions of, the pelvis. 2. In the foftpar ts ; as, a. Conftriaion or rigidity of the os tincae. b.---------------------------of the va- gina and os externum. c. Scirrhous or poylpous tumors. d. Tumefaaion from hardened faeces in the reaum. Stone Sea. II. Lingering Labour. .177 e. Stone in the urethra. /. Diftention of the bladder from urine. g. Frolapfus of the uterus, vagina, or reaum. /I. In the Child ; as, I. The bulk and unufually complete oflificati- onof the head ; or, 2. Is unfavourable pofition. 3. Tne bulk or improper defccnt of the lh.Juld.TS. III. From the Secundines and Water ; as, 1. The rigidity or weaknefs of the membranes. 2. An excefs or deficiency of the liquor amnii. 3. The length or fliortnefs of the cord. 4. The improper atachment of the placenta. As thefe caufes exift fingly or combined, the la- bour will be lefs or more difficult and painful. Moft of the*obftacles now mentioned are to be fur- mounted by patience and perfeverance. If the labour is otherwife natural, though from peculiarity of ha- bit and a variety of particular circumftances it fhould prove tedious, the fafeft and beft praaice, in general, both for mother and child, is to truft the manage- ment wholly to nature. The difficulty is frequently owing merely to the refiftance of the foft parts; hence ftrong robuft wo- men fuffer more than the nervous and delicate. In the former 178 Of Natural Labours. Chap. I. former, the parts are tenfe and rigid, and ftretch (low- ly. In the latter, they are more relaxed, foft, and yielding. The firft require the cooling, fedative plan ; the latter, light nourifhing food, in fmail quantities, often repeated, with the moderate ufe of cordials and anodynes. In either cafe, tranquillity fhould be promoted, by keeping the patient quiet and eafy; by conftantly avoiding fatigue, buide, and noife ; at the fame time foothipg and comforting her with the beft affurance of a happv delivery. We fhall concifely treat of thefe feveral caufes. I. In the MOTHER. i. Any defea in the adion of the uterus itfelf con- fidered as a mufcular organ, or of the auxiliary Powers of parturition, impairs the force of the labour-throes ; or, in other words, renders the pains feeble and trifling. The over-diftention of the uterus impairs the ac- tion of its mufcular fibres, and may for fome time prevent thofe fpafmodic efforts by which the os tin- cae is opened and the fcetus expelled ; there may be alfo other caufes Of Natural Labours. Chap. If. nus, and retained with the hand in time of the pain. II. In the CHILD, the labour may be protraaed from, I. The Bulk and Offification of the /W—There may be either a natural difproportion between the head and body, or the fwelling may be occafioned from a colleaion of water in the head, or be the con- fequence of the child's death. From the ftruaure and in dee of the pelvis and head in a natural ftate, it is evident, that a head of a lar- ger fize, having the bones foft and moveable, will pafs ihrough the pelvis with lefs difficulty, and occa- sion lefs pain in the birth, than a fmaller head, ha- ving the beip.e^ more folid, and the futures more firm- ly conneaed. A large head may be fufptcUd when the vertex does not lengthen out by the force of the pains (as it commonly does in lingering labours); when the progrefs of the labour is fufpended, though the pains continue to be ftrong and frequent, aUer the foft parts are fufficient1 v dilated ; when the wo- man is in good health, and there is no other apparent caufe to account for the protraaion. When the fwelling proceeds from a colleaion of water in the child's head, it may be known by the head prefenting at the brim of the pelvis in a round bulky form, by the diftance between the bones of the head* Sea II. Lingering Labtur. if/i head, and by a foftnefs and fluauation evident to the touch. When the child has been long dead, -the head and body often fwell to a great fize. This may be known from the hiftory of the cafe; from a parti- cular puffy feel of the prefenting part of the child ; from the difcharge of putrid waters, fometimes mix- ed with the meconium of the child ; and from the feparation or peeling of the outer fkin of the head when touched: Though it may be here obferved, that the moft probable or fufpicious fymptoms of the child's death are often deceitful. From whatever caufe the head is enlarged, if the difficulty arifes from that circumftance, and the force of the pains proves infufficient to pufh it forwards ; if it has made no fenfible progrefs for feveral hours after the waters, were difcharged, and the os uteri is fully dilated ; and if the pains fhould begin to remit or flacken, and the woman to be low, weak, or de- jeaed ; it will then be neceflary to have recourfe to the affiftance of art. (l.) The unfavourable Pofition of the head.—The head of the child may be fqueezed into the pelvis in fuch a manner as not to admit of that compreffion neceffary for its paffing through die bony cavity. Where the pelvis is well ibrnsd, and. the head of an ordinary fize, aduou:;! 'x fhould pr?fent in the moft awkward and unfavourable pofiuun, it w'l yet advance; 192 Of Natural Labours. Chap, I. advance; and nature, under proper management, will, in moft cafes, fafely accomplifh the delivery. The labour will unavoidably be more painful and laborious; but, whatever time may be required, there is lefs hazard either of the mother or child, than if delivery had been haftened by the intrufion of offi- cious art. But if the woman be weak or exhaufted, and the pains trifling; if the head of the child be large, the bones firm, and the futures clofely conneaed; or if there be any degree of narrownefs in the pelvis; a difficult labour may be expeaed, and the life of both mother and child will depend on a well-timed and fkilful application of the furgeon's hands. The unfavourable pofition of the head may be re- ferred to two kinds, which include a confiderable variety. 1 ft, IVhen the Crown inflead cf the Vertex prefents. 2dly, Face-Cafes. Firft, When the Fontanella, or Open of the Head, inpad of the Vertex, firft prefents to the touch, a more painful or tedious labour may be expeaed: for the head does not take the fame mechanical turns in patting through the pelvis as in natural labour; the face either originally prefents to the pubes, or 'takes that direaion in palling. The bulky crown is forced within the brim of the pelvis with more diffi- culty ; Sea. II. Lingering Labour. 19$ culty ; the progrefs of the labour is more flow and painful; and, when the head has advanced fo far that the crown preffes on the foft parts at the bottom of the pelvis, there is much greater hazard of the tearing of the perinaeum, than when the lengthened- out vertex prefents: but, if no other obftacle occurs, the labour, notwithftanding, will, by proper ma- nagement, generally end well ; and much injury may be done by the intrufion of officious hands. Secondly, Face-Cafes. Of laborious births, face-cafes are the moft diffi- cult and troublefome. From its length, roughnefs, and inequality the face muft occafion greater pain ; and, from the folidity of the bones, it muft yield to the propelling force of labour throes with mure diffi- culty than the fmooth moveable bones of the crani- um. Our fuccefs in delivery in thefe cafes will chiefly depend on a prudent management, by care-* ly fupporting the ftrength of the woman. The variety of face-cafes are known by the direc- tion of the chin ; for the face may prefent. iff, With the chin to the pubes. 2dly, To the facrum. xdly, and tfhly. To either fide. The rule in all thefe pofitions is, to allow the la- bour to goon till the face be protruded as low as poffible. It is often as difficult and hazardous to pufh back R the 194 Of Natural Labours. Chap. I. the child, and to bring down the crown or vertex, as to turn the child and deliver it by the feet. Sometimes a fkilful artift may fucceed in his at- tempt to alter the pofition, when he has the ma- nagement of the delivery from the beginning; or in thofe cafes where the face is confiderably advanced in the pelvis, may be able to give afiiftance by pat- ting a finger or two in the child's mouth and pulling down the jaw, which leffens the bulk of the head; or, by preffing on the chin, to bring it under the arch of the pubes, when the crown getting into the hollow of the facrum, the head will afterwards pafs eafily. But, in general, Face-cases fhould be trufted to nature ; and interpofition by the hand, or inftruments, is feldom advifable or even fafe. (3) The Bulk, or improper Defcent of the Shoulders through the pelvis, rarely proves the caufe of protradt- od labour. The head is always pretty far advanced before any obftruaion can arife from this caufe; and, if the head has already paffed, in a pain or two the fhoulders will follow. The fame reafoning will alfo apply with regard to the aperture of the uterus itfelf. If the head paifes freely, in like manner will the fhoulders: the os uteri rarely, if ever, is capable of contracting upon the neck of the child, and thus pre- venting the.advance of the fhoulders ; and, fhould this prove the cafe, what can we do but wait with pati- ence? After the delivery of the head, if the woman falls Sea. II. Lingering Labour. 195 falls into deliquia ; or if, after feveral pains, the fhoulders do not follow, and the child's life be in danger from delay; we fhould naturally be induced to help it forward in the gentleft manner we are able, by paffing a finger on each fide as far as the axilla, and thus gradually pulling along: or, if this method fails, the fhoulders may be difengaged by preffing on the fcapuja. III. The third general caufe of Tedious or Lin- gering Labour, arifes from the Placenta, its Apendages, and the Liquor Amnii. 1. The Membranes may be too pong or too weeik.— From the former of thefe caufes, the birth is, in fome inftances, rendered tedious ; but, as the fame effea is more frequently produced by the contrary, and the confequences are much more troublefome and dangerous, praaitioners fhould be exceedingly cautious of having recourfe to the cimmon expedient of breaking them till there be a great probability that the difficulty proceeds from that circumflance; and, even then, it ought not to be done till the parts be completely dilated, and the head of the child well advancecrin the pelvis. Many inconveniences enfue from a premature evacuation of the waters : for the parts then become dry and rigid: the dilatation goes on more flowly ; the 196 Of Natural Labours. Chap. I. the pains often either remit, or become lets ftrong and forcing, although not lefs painful and fatiguing; the mouth of the womb which was previoufly thin and yielding, may be obferved to contraa, and to form a thick ring, for fome time obftinately refilling the force of the pains ; the woman's ftrength lan- guifhes, andher fpirits are overcome and exhaufted ; and, at laft, the child's head becomes locked into the pelvis, merely from want of force of the pains to propel it. An inconvenience of too gre;:t rigidity of the mem- branes is, that the child at full time may be pro- truded, inclofed in the complete membranous bag, furrounded with the waters. But fuch inftances fel- dom occur. When the whole ovum is thus protru- ded at once, there is hazard of flooding from the fudden detachment of the placenta and membranes. It fhould, therefore, be prevented by breaking the membrane?, when they advance and fpread out at die os externum, and the head of the child follows in the fame direaion. The method of breaking the membranes is, ts pinch them between the finger and thumb ; to pufh a finger againft them in time of a pain ; to run the ftilct of catheter through them ; or, when there is hi- de water protruded, and they are applied clofe in coniaa with the child's head, they muft be deftroyed by fcatching with the nail ; but care ought to be taken Sea. II. Lingering Labour. 197 taken left the fcalp of the child's head, covered with mucus, fhould be miftaken for the membranes. 2. The Waters may be too copious, or too fparing.— The firft is inconvenient ; for, by this means, the,,. I weight of the water gravitating to the under-part of the membranes in time of a pain, may burft them too early, and occafion the difadvantages before- mentioned. An extraordinary quantity of Water—may overftretch the womb, and prevent or weaken the pains. Such a caufe of protraaion may be fufpeaed,- if the firft ftage of labour goes on very flowly, if the woman be very big-bellied, and if much time be fpent before the head of the child becomes locked in the bones of the pelvis. In thefe circumftances, if the pains fhould ceafe or become trifling, the membranes may be ruptured with fafety and advantage. Little orns Water—is fometimes contained in the membranes. The parts, then, ftretch with more difficulty and pain, and muft be lubricated from time to time with butter or pomatum, in the manner mentioned under the article of Rigidity of the foft Parts. 3. The Cord may be too. Jhort-, or too long.—The extraordinary length of the. cord, by funning folds round the child's neck or body, may prove the caufe of protraaed labour: but there is generally fufficient R 2 length 19S Of Natural Labours. Chap. I. * length to admit of the birth of the child fafely ; and it is time enough, after the child is delivered, to ] flip the noofe over the fhoulders and head. AfteFthe head is protruded, the fhoulders are feldom prevented from advancing by folds of the cord round the neck ; and it very rarely becomes neceffary to pafs a finger j between the child's neck and the cord, in order to divide the cord while the child is in the birth; a praaice that may be attended with trouble and hazard. Another inconvenience of the great length of the cord, though it may alfo proceed from the low at- tachment of the placenta, isr j The prolapfus or falling down of the Cord, doubled, j before the Child's Head.—A circumftance which often proves fatal to the child ; for, if it be not reduced by 1 pufhing it up within the uterus, beyond the bulky | head of the child, and prevented from returning with- i the fingers, till the head, by the force of the pain, defcends into the pelvis, the circulation ivillfoonflop \ from the preffure of the cord between the head and pelvis, and the child will infallibly perifh. If this method of reducing the cord fhould fail, or if the j pains be too quick and forcing to admit of the at- I tempt, a warm cloth fhould be applied to the os ex- g ternum o\er the cord, to cover it from the cold, an* | the natural pa'.ns fhould bev.aited for j if the pains be very ftrong and forcing, and the progrefs of laboor quick, the child may yet be born alive. Seme advife to- Sea. II. Lingering Labour. 199 to preferve the child, by turning and delivering by the feet ; but it is, at beft, a precarious expedient: for new difficulties may afterwards occur ; the operation of turning is painful and hazardous ; and it would be extremely criminal to expofe the mother's life to danger, when there is no certainty of preferving the child. The navel-ftring is, fometimes, naturally thick and knotty ; or thickened, and of confequence fhort- ened, by difeafe. If this happens, part of the pla- centa may be feparated as the child advances, and a flooding enfue; or, the firing may be aaually ruptured, and occafion the death of the child ; but fuch inftances are very rare. 4. The fourth caufe is, The improper attachment of the Placenta over the Orifice of the Womb, and is a more dangerous circumftance than any other ; for, if the delivery be not fpeedily accompli filed, blood, from the feparation of the placenta, will pour out fo profiifely, that the unfortunate woman will \$ry quickly fink under it. This unhappy event can be prevented by no other means but by an expeditious de- livery. The alarming fituation of the woman will be fufficiently indicated *by the appearance and ra- pid increafe of flooding, and by the foft pappy feel of the after-birth to the touch. One half-hour's de- lay, or, lefs, may in fuch circumftances prove fatal to die mother and the child j therefore the friends fhould imme- 200 Difficult Labouus. Chap. II. immediately be apprifed of the danger, and the earlieft afiiftance be procured*. Thus, in all labours merely lingering, the delive- ry, under proper management, will end favourably; the head, in the moft awkward pofition, where the pelvis is tolerably well proportioned, will collapfe by preffure ; and, though the progrefs for fome time may be flow and gradual, the termination of labour is of- ten as fafe for the child, and the recovery of the mo- ther as expeditious, as if the birth were accomplifh- ed by a few pains. CHAP II. Of Difficult or filriftlyLaborious Labours. DIFFICULT or flriclly laborious Labours,' are " thofe in which nature is unable to per- " form her office, and requires the aclive afiiftance «' of an artift, though the pofition of the child is na- ««■ tural." They comprehend, I. Thofe cafes where the Hand alone is fufficient. for the purpofe. II. Where inftruments muft be ufed. S p C- • See methcd of deli very in flooding cafes, clafs 4th of Preter- natural Labours. TBea. I. Cafes requiring only the Hand. 201 SECTION I. Laborious Cafes requiring the Hand alone. THE hand alone affords the fneceffary afiiftance in laborious parturition ; i. By turning the child in alarming floodings, be- fore the head is wedged in the pelvis. How this is to be performed will be explained under the chapter of Preternatural Labours. 2. By reducing the umbilical cord, when protrud- ed before the head.—In the fame fituation, the child may be fometimes turned: but this is only to be at- tempted after every method to reduce the cord hath failed ;—when there is a reafonable profpea of faving- the child ; and,—when turning can be praaifed with perfea fafety to the mother. 3. -By altering the pofition of the head in face-cafes, with a view to bring down the fmooth cranium ; which fhould only be attempted when the face remains above ihe brim of the pelvis,with deficient or trifling pains, and the woman's life is in danger by floodings, convulfions, or from fome other caufe. More fre- quently affiftance may be then given, by pulling down the jaw, with a finger or two introduced into the child's mouth, in order to bring the chin under the arch of the pubes, when the pains are infufficient to protrude the head in that pofition. 4. When one, morefeldom both, of the fuperior extre- 202 Difficult Labours. Chap. If. extremities prefent along with the head. In thefe circumftances, the earlieft opportunity that the ftate of the uterus will admit of fhould be taken, to pats the head well lubricated, in a conical manner, in the abfence of pain, through the vagina and os uteii; endeavour gently, but at the fame time with courage and refolution, to thruft back the child's hand and aim above the prefenting head, to retain there with the fingers till a pain comes on, by which the head will be forced into the pelvis, the return of the arm prevented, and the delivery will be afterwards fafely and naturally a.complifhed. But, if the pains are ftrong and frequent ; if the head is already wedged in the pelvis ; if the wo- man appears to be well formed, efpecially if fhe has formerly had children, and the.labour was natu- ral and eafy ; if the head advances with the pains, and the hand of the foetus is clofe preffed between its head and the pelvis; in thefe particular cireumfiance*. the delivery fhould be trufted wholly to nature. SECTION II. Instrumental Delivery. Instrumental Delivery is of four kinds: I. Where the child is intended to be extrac- ted without doing any injury to it or the mother. II. Where the foetus muft be deftroyed by dimi- nifhing r Sea. II Infirumental delivery, 203 General rules for ufing the Forcefs. 1. The forceps fhould never be employed till the firft ftage of labour be completely accomplifhed ; till the head of the child is protruded below the brjira of the pelvis ; and till, by the continued preffure of the head, the tumor of the perinaeum is in fome degree formed. 2. As the fafety of the mother is our only apology for ufing inftruments, the forceps fhould never be employed but in the moft urgent and neceflitous ca- fes : as, for example, when the woman is much fpentor exhaufted : when the parts are fwelled, a- long with fuppreffio urine; when the pains are weak or trifling, or have ceafed entirely, and are not likely to recur; or when the is threatened with convulfions, floodings, or faintings. 3. The contents of the reaum and bladder fhould be emptied in all cafes where inftruments are employ- ed to affift the delivery. 4. The pofition of the head fhould be exaaiy known before attempting to apply the forceps. 5. The pofition of the woman muft be regulated by the prefentation of the child's head. In the fim- pleft and ealieft of the forceps cafes, when the head is fo far advanced as to prefs confiderably againft the. perinaeum, and the ears are nearly lateral ord.ago-jd, fhe may be placed on Jier back or fide, with her S breech . * - ' T>7 'V... 204 Difficult Labours. Chap. II, breech over the edge of the bed; but, when the head is higher in the pelvis, and the ears towards the pubes and facrum, the fide, with the knees drawn up to the belly, as in natural labour, is the moft commodious pofition both for the patient and opera- tor. 6. The parts of the woman muft be gently ftrebftv ed and well lubricated with the hand gradually introduced into the vagina, and the operator fhould be able to touch the ear of the child with one or more fingers, before he attempts to introduce the firft blade of the forceps. 7. The Accoucheur being placed on a low feat, or in a kneeling pofture, let the right hand be flowty pafled through the vagina into the pelvis, and fearch for the ear of the child, which will always be found under the ramus of the ifchium, towards the pubes, or diagonally. 8. He muft then, with the left-hand take up the firft blade of the forceps, previoufly lubricated, and warmed if the weather is cold, and condua it along the palm of the right-hand, between it and the head of the child, till the point of the clam reaches the §ar. The handle muft be held backwards towards the perinaeum to dire& the point in the axis of the pelvis. 9. It muft then be infinuated very flowly by a wriggling kind of motion, and the point kept dofe to Sea. II. Inpumental Delivery. 203 nifhing its bulk, with a view to preferve the life of the mother. III. Where the dimenfions of the pelvis are enlarged to procure a fafe delivery to the child. IV. The extraction of the fcetus by the Caefari- an Sea ion. § 1. Cases where the Child is intended to be ex- tracted without injuring it or the Mother. THE mechanical expedients for this purpofe are, 1. The Scoop Lever, or fingle blade of the For- ceps. 2. The Double Lever, or Two-bladed Modern Forceps. I. The SCOOP or Simple Lever—the boafted fecretofthe celebrated Roonhysen, is extremely limited in its ufes. _ It may be employed where a flight ftimulus is fuf- ficient to roufe the pains, or where little force is ne- ceffary to alter the pofition of the head, by introdu- cing it in the fame manner and with the fame precau- tions as a blade of the forceps : either at the lateral parts of the pelvis, under the arch of the pubes, or diagonally. But as there is great hazard of bruifing the partsof the mother, by the refiftance of the inftru- meut, unlefs managed with fo much dexterity that the 204 Difficult Labours. Chap. II. the hand of the operator is the fulcrum or fupport on which its aaion turns ; and, as it can only be ufed when the head is fufficiently protruded for apply- ing the forceps, which are preferable both for fafety andjuccefs ; we confider xhsfimple lever as a danger- ous expedient in the hands of a young praaitioner. II. The Double LEVER, or Modern FOR- CEPS Use of the Forceps. The forceps is an inftrument intended to lay hold of the head of the child in laborious births, and to extraa it as it prefents. This inftrument, as now im- proved, in the hands of a prudent and cautious ope- rator, may be employed without doing the leaft inju- ry either to mother or child. The forceps, fince their original invention, have undergone feveral important improvements and al- terations. Thofe of Mr Wallace Johnfton, lately improved, feem preferable to every other. Some- times the head, when high in the pelvis, may be ex- traaed by a long pair, fuch a< the long forceps of Dr Smfllie, Mr Pugh, or Dr Leak ; but their application and powers are difficult and dangerous, and they can only be ufed with abfolute fafety in the hands of an expert praaitioner*. hands * See a figure of the improved forceps in Dr SmelliV s Plates. Sea. 11. Instrumental Delivery. 205 to the head of the child, pufhing it on till it be applied along the fide of the head over the ear. 10. The firft introduced hand muft then be with- drawn, the handle of the firft blade fteadily fecured with it, and the other blade introduced, guided along the left-hand, in the fame flow cautious manner and direaion with the former. 11. The blades being applied over the ears of the child, and the handles placed exaaiy oppofite to each Other, thefe laft are to be brought gradually to- gether; carefully locked ; and, left they fhould flip in extraaing, properly fecured by tying a fillet or garter round them ; but this muft be loofed during the intervals of pulling, to prevent the brain from being injured by the continued preffure. 12. If difficulties occur in the introduaion of the fecond blade, or in bringing the handles together, the refiftance muft not be attempted to be furmounted by fo§ce ; but that blade fhould be withdrawn a lit- tle, and the point fomewhat raifed, by preffing tfie handle to the oppofite fide ; and, if the fecond intro- duced blade cannot be made an exaa antagonift to the firft, it, or if neceffary both blades, muft be with- drawn, and again introduced as already direaed. 13. It fhould be a conftant rule, when difficulties occur in patting the forceps, to introduce the moft troublefome blade firft. The handles ought to be tfxadly oppofite to each other, fo that the locking may 206 Difficult Labours. Chap. II. may be eafily accomplifhed. It is difficult and dan- gerous to attempt turning a blade bv a femi-rotatory motion from the facrum to the lateral part of the pelvis, or vice Vtrfit. 14. In locking the forceps, great care muft' be taken left any part of the woman (hould be included* in the hold. 15. If the handles of the forceps are too clof« together, or at too great adiftance, the hold is unfa- voundd, and they will flip in making the extra&iorfc The proper diftance is nearly a finger's breath; a little more or lefs, according to the variety that oc- curs in the volume and figure of the child's head. 16. Having obtained a favourable hold, the ex- traaion muft be attempted in general with one hand only, while the other is employed to guard the perinaeum. As fafety, not expedition, is the object in view, our efforts fhould be very flowly and gen- tly performed, approaching as nearly to nature as it is poffible for art to arrive. An inconfiderabje exer- tion of mechanical power continued, or frequently repeated, will accomplifh the end as effeaually, and* much more fafely, than by precipitating the birthi with a brutal rafhnefs. i- 17. The motion in pulling mult be equal and uniform in the line of the axis of the pelvis, always '• in a direaion from blade to blade : the operator muft" reft from time to time ; and while there is any ap- ,. :•> e .c ■>. .....• ^d—;v •peaVarirJd' Sea .II. Injlrumental Delivery. 207 pearance of pains, his efforts fhould co-operate with thofe of nature. 18. If the efforts of pulling are flowly exerted, the head in advancing will mould itfelf to the paffage, and make the fame mechanical turns as in natural labour. 19. When the head is difengaged from the bony cavity, the axis or curved line of the vagina muft b« carefully attended to : hence, though the line of aaion in the beginning of the operation is to in- cline the handles towards the perinaeum, as the head advances through the vagina the direaion muft be varied, by gradually raifing the handles towards the woman's belly to difengage the occiput from under the pubes, till the head is entirely extraaed. 20. As the foft parts are protruded, and the ori- fice of the vagina dilated, by the progreffive advance of the child's head, the utmoft caution is then necef- fary to guard the parts from immediate laceration ; or, though they fhould efcape it, the fudden or violent contufion may be attended with unhappy confequence*. The perinaeum.fhould, therefore, be conftantly fup- ported with the hand during the extraction. 21. When the head is compiletely extraaed, the forceps muft be removed blade by blade, and the fubfe- quent part of the delivery finifhed as in natural labour. If the body does not foon follow, or if the pains are deficient or weak, the fhoulders may be difengaged by S 2 prefling 208 Difficult Labours. Chap. II. prefling on the back of the fcapula downwards to the perinaeum, to bring the fhoulders to it and the pubes, or diagonally till one or more fingers can be paffed under the axilla to help forwards in that direaion. 22. If, after feveral attempts the forceps cannot be fecurely applied, or, after a firm hold is obtain- ed, the head does not yield to repeated efforts mode- rately exerted, they muft be dropped, and the delive- ry otherwife managed according to the difcretion and judgment of the praaitioner. Particular Cases. I f the general rules for ufing the forceps are under- ftood, we fhall feldom be at a lofs how to apply them in particular cafes. They may be reduced to two general claffes: i. The fmooth part of the cranium, 2. The face, prefenting. I. The variety of cafes where the Cranium pre- fents, chiefly are, i. Natural Prefentathn, with the head fo far advan- ced that the perinaeal tumor is confiderably formed, the ears of the child nearly lateral, and the face to the coccyx Ti.e Lever, by an expert praaitioner, may be fome- Sea. II. Inpumental Delivery. 209, fometimes in this prefentation fuccefsfully employ- ed. If ihe Forceps are ufed, the woman may be ei- ther placed in the natural pofition, or on her back ; it is fcarce neceffary, then, to tie the handles. When applied, a pain fhould be waited for. With one hand the perinaeum fhould be guarded ; with the other, the handles of the forceps gently raifed towards the woman's belly, to bring the hind-head with a half- round turn from under the arch of the pubes ; the operator at the fame time rifing from his knees, if the woman be placed on her back. 2. The Vertex presenting with the Face laterally in. the Pdvis.—The forceps can be feldom applied with fafety in this pofition till the bulky part of the head has patted the brim, with the vertex prefling a-, gainft the under part of the ifchium, and till an ear can be felt under the arch of the pubes. The ear when felt, will determine to which fide the face points. Let the woman be placed on the oppofite fide where the face is. Let the blade under the pubes be firft applied, with the fore-part of the clam, to the occiput of the child. Let the fecond blade be introduced oppofite to the firft. Bring the handles together, .and fecure with a fillet. Gently 2i» Difficult Labours. Chap. II. Gently move from blade" to blade ; favouring the direaion (of the face to the facrum) which the head as it advances naturally takes; and, as the birth ap- proaches, ufing the proper precautions to fave the pe- rinaeum. 3. Fontanel prefenfations-—are the moft difficult and dangerous of the forceps cafes. Intheprogrefs of thelabour we generally find, when the crown prefents, that the face points to the pubes; but the pofition can be readily learned from the fi- gure of the fontanel and the direaion of the ear. The common fhort forceps can feldom be fuccefs- fully employed here, till the head be confiderably ad- vanced in the pelvis. The forceps fhould never be attempted to be applied in the fontanel prefentations till an ear can be eafily felt. They muft be intro- duced over the ears, and the extraaion conduaed on the general principles; carefully ohferving the direaion which the head inclines to take, and pro- ceeding in the moft cautious deliberate manner, that the parts of the woman may have time to ftretch. When the fontanel prefents, with the crown of the head nearly equal with the brim of the pelvis,,and the face placed to the pubes or facrum, the long ax^ is of the head interfeas the fhort diameter of the pelvis. Though the forceps be applied in this pofition, and a firm hold obtained, it is fometimes impoffible to accomplilh the extraaion ; as the head will Sea. II. Infrumental Delivery. 21 f will neither advance in the fame direaion, nor can the prefentation be altered by pufhing up and ma- king the mechanical turns which Dr Smellie di- rects, without the hazard of injuring the mother. If the common method, therefore fails, the forceps fhould be withdrawn, and the long ones attempted to be applied over the forehead and occiput. As the volume of the head, by the compreffion it fuffers from the aaion of the forceps, wilfbe fomewhat di- miniflied the extraaion may be then fuccefsfully performed, and the child preferved. If this method {hould alfo fail, in preference to the dreadful operation of embryotomy, Dr Leak's double-curved forceps with the third blade may be had' recourfe to. But of this expedient little can be faid with confidence ; for the introduaionof a third blade " into a harrow paffage, when two have already per- haps1 been paffed with difficulty, however ingenious the invention, is not eafily to be put in praaice. All other varieties of cranial cafes muft be treated according to the rules already direaed. II. Face Presentations.—From its length and unequal furface the face will occafion greater pain, and from the folidity of the bones it yields to' the propelling force with more difficulty, than the' uniform moveable furface of the cranium. The' head will, however, in moft cafes, advance in that 1 pofition. 212 Difficult Labdurs. Chap. If. pofition, by the force of the natural-pains, though the delivery will be more flow or painful. I have feldom had occafion, in a well-formed pelvis, to in* terfere in face-prefentations, in any other manner than by introducing two fingers into the mouth, afid pulling down the jaw. As the attempts of the moft expert praaitioners, if too early exerted, may be attended with fatal con- fequences ; and, even when afiiftance is given at the proper time, our endeavours are often difappointed; in whatever manner the face prefents, it fhould be allowed to advance as low as poffible: by which means the accefs will be more eafy ; and the pofi- tion, for the application of inftruments, more far vourable. In thefe awkward pofition?;, the injury occafibn>- ed by officious interference has been often fatal; whereas, if time had been given, and the patient pro- perly fupported, the delivery would have generally ended well. The variety of faci-cases may be reduced to the following. \f, The face prefenting with the chin to the pubes. 2dly, To the facrum. ydly, Laterally. Face-politions are readily known, from the ine- qualities of the furface to the touch; from the pro-* minent Se&. II. Inflrumenlal Delivery. 213 minent nofe, the fiffured mouth, &c. In thefe pre- fentations, care muft be taken, left, by the preffure of the finger in touching, the eyes fhould be injured. When the face is detained at the brim of the pel- vis, with trifling or deficient pains, and any urgent circumftance occurs to render the interpofition of art neceffary.; it may be fometimes fuccefsfully accom- plifhed by the introduaion of the hand into the pel- vis, to raife up the face and reduce the pofition by bringing down the cranium as already direaed in Lingering Labour. The fuccefs of the praaitioner, in thefe cafes, will depend on the bulk of the head, the make of the pelvis, and the progrefs of the labour ; for, fhould the head be firmly wedged in the pelvis, no force that can be employed with fafety would be fufficient to alter the pofition. Jn fuch circumftances we are fometimes advifed tp turn the the child ; but turning is a troublefome operation to the praaitioner, hazardous to the mo- ther, exceedingly precarious to the child ; and ought, therefore, fcarcely ever to be attempted. In ufing the forceps in face-cafes, the general rules muft be attended to. More particularly let the following direaions be obferved. 1. Before the firft blade of the forceps is applied, let the jaw of the child be pulled down gently with a finger or two introduced in the mouth. 2. Let 214 Difficult Labours. Chap. II ' 2. Let them be applied over the ears, with the locking parts between the nofe and the lip. 3. In extraaing, the operator fhould favour the inclination which the chin takes to the pubes. The chin muft be entirely difengaged from under the arch of the pubes before the round of the head is extra&- ed, otherwife there is great hazard of lacerating the perinaeum. § 2. Cases where the Foetus mufi be destroyed by diminifhing its Bulk, with a view to preferw the Mother's life. Hen the infant could not be fa ved by the mode of delivery employed in the extraction, the operation was termed by the ancients, Embryo- tomy. The objea of this operation is to fave the mother, when the child cannot be delivered in any other man- ner. It fhould never, therefore, be performed, while there is any reafonable profpea of extraaing the child alive ; and fhould, when confiftent with the mother's fafety, be delayed till the child be dead. Extreme narrownefs of the pelvis, or extraordina- ry bulk of the child, are the only circumftances which juftify the neceffity of having recourfe to the horid operation of embryotomy. The chief caufe of difficult labour, is diminiflied capacity of the pelvis from diftortion. For when the brim w Sea. II. Instrumental Delivery. 215 brim, inftead of \\, inches from pubes to facrum, meafures only \\, \\, 2 or 2|, inches, the ufe of the fciffars and crotchet is neceffary ; and it the tranf- verfe diameter comes fhort of 3 inches, the head of the fcetus, unlefs the fize be proportionally fmall or the futures very open, is feldom protruded fo low that the forceps can be fuccefsfuly ufed. We judge of the figure and dimenfions of the pel- vis, by the general make and conftruaion of the wo- man ; by the progrefs of the labour; by the touch. When the fault is confined to the bottom, it will readily be difcovered : e. g. if a bump is felt on the anterior furface of the os facrum, inftead of a conca- vity : if the coccyx is angular towards the pubes ; if the fymphyfis pubis is angular towards the facrum ; if the tuberofities of the ifchia approach too near each other; or if one tuber be higher than the other ; fuch ap- pearances are decifive marks of a faulty pelvis. When the narrownefs is confined to the brim, it can only be deteaed by the introduaion of the hand into the pelvis ; and a confiderable force and repeti- tion of pain will be requifite to protrude any part of the child's head through the fuperior ftrait of the pel- vis. But, if the diftortion be not confiderable, if the ftruaure of the child's head be loofe, by the preffure it fuffers between the pubes and facrum, the head will be moulded into a conical or fugar-loaf form; T by 2i 6 Difficult Labour. Chap. II. by the overlapping of the cranial bones, the fize will be reduced, and delivery accomplifhed in fituations and circumftances where we would little expea it; which fhould make us cautous in the ufe of cutting inftruments, left life be deftroyed unneceffarily. . We have now rejeaed the complicated apparatus of ir:nffecula for ftretching the parts, fcrews, tire-te. ies, hioks, griff.ns talons, forceps with claws, and o- ther hofrid irfrument-s of deftruaion invented by the ancients for the laying hold of and extraaing the child; an ^operation by thefe means fo difficult and dangerous, when the head was bulky and the pelvis narrow, that the woman frequently loft her life in the attempt. At prefent, we endeavour, as much as is neceffary or praaicable, to diminifh the fize of the head, by opening the cranium and evacuating the brain, pre- vious to the extraaion. This is a modern and important difcovery. The inftruments for performing the whole opera- tion confill, fimply, of a Pair of Long Scissars, with a Ckotchet or Blunt Hook. When the ordinary means of delivery have failed, or cannot be employed ; and the expediency of de- ftroving the child to prderve the mother, after the moft deliberate reflection, has been determined; flic muft be placed in the fame pofition, according to Sea II. Injlrumental Delivery. 217 to the prefentation of the head, as direaed in Forceps Cafes. The fame general rules, as far as praaicable, in u- fing the fciffars and crotchet, muft be alfo obferved. Even in the narroweft pelvis that occurs, previ- ous to opening the cranium, the foft parts ought to be completely dilated, when the dilatation can be fafely waited for, and the head of the child fomewhat fixed in the pelvis; for, while the uterine orifice is in a thick contraaed ftate, and the head remains at a diftance, no part having yet been forced within the brim, the application of inftruments is difficult, even in the hands of an experienced praaitioner ; and hazardous under the management of a timid operator. But, if the patient is delicate or weakly, if the pains are frequent and teazing, if the progrefs of di- latation of the uterine orifice be flow, and there is reafon to fufpea confiderable refiftance to the extrac- tion of the head from the diftortion of the pelvis, the opening, with a view to diminifli the volume of the child's head fhould be performed as foon as there is eafy accefs to apply the fciffars. We can then afford to wait, that a convenient interval may take place. between the firft and fubfequent part of the operation ; a material advantage to facilitate the extraaion, and moft eifential to the fafety of the patient. I. Usw 2i3 Difficult Labours. Chap. II. I. Use of the SCISSARS. The fcifir; are chiefly employed for perforating the ■cranium of the foetus, in order to diminifh the volume of the head ; and alfo for opening the cavities of v.vt thorax ani ahdom n, when enhrged from monftrofity or difeafe; or ford ividing or feparating Iuxuriar.t part?. The fciffars employed as a preforator fhould be fy}\) nine incites long ; viz. the bddes three, and the !u!id!es arid bows fix. The poin ts fhould be fharp, not the edgrs. Th:" fhould have a fmall degree of curve touaids the points; and be provided with buttm*, knobs, or rings, inftead of the angular refts coininoniy ufed, which are apt to bruife or wound the parts of the woman *. The method of ufing the fciffars is as follows. Yne k.ft-lr.i-.d of the onrntor muft be flowly in- troduced through the vagina to the prefenting part of thechPd, and along it the points of the fciffars, care- fully guide! till they prefs againft the cranium of the child, which they muft be made to perforate with a boring kind of motion, till they are puflied on as far as the reds; they muft then be opened fully, carefully re-fhut, * See a defcription of the Sciffarsand Crotchet in Dr Smellie'i Tables, Pi. xxxix. N. B. The reference here mentioned always allude to the Edi- tion of thefe Fhtes reduced from the Folio Edition. Sea. II. Inpumental Delivery. 219 re-fhur, half-turned, and again widely opened, fo as to make a crucial hole in the fkull. They muft afterwards be puifhed beyond the refts, opened dia- gonally again and again, in fuch a manner as to tear and break to pieces the bones of the cranium, and deftroy the texture of the brain ; they muft then be flint with great care, and withdrawn along the hand in the fame cautious manner as they were introduced, left they fhould cut or tear the uterus, vagina, or any other part of the woman. After a free opening in the cranium has been made, the brain muft be fcooped out with the fingers, blunt-hook, the fingle lever, or a common fpoon ; and the loofe fharp pieces of bone muft be carefully feparated and removed with the fingers of the operator, or a pair of fmall forceps, that no part of the woman be wounded in the fub- fequent attempts for extraaing the head. The tegur ments of the fcalp fhould then be brought over the ragged bones of the cranium ; and the woman fhould be allowed to reft for twelve, twenty-four hours, or longer, according to her ftrength and other circum- ftances : the bones of the cranium will afterwards collapfe ; and if the patient be not much exhaufted, or the pelvis not exceedingly dittorted, the head, its volume having been confiderably diminiflied, will be protruded by the force of natural pains. If thefe are not fufficient, it mult be extraaed, either by means of two fingers introduced within the cavity T 2 of 220 Difficult Labours. Chap. II of the cranium, or by the blunt-hook introduced in the fame manner, guarding the point on the oppofite fide while making the extraaion. If thefe fail, the crotchet muft be employed ; which, though dange- rous in the hands of a rafh, carelefs, or ignorant operator, may be ufed by a fkillful praaitioner with as much fafety as the blunteft inftrument, and is in faa more manageable than the blunt-hook. II. Use of the CROTCHET and Blunt-Hook. The method of introducing the crotchet is, to condua the point along the hand, like the fciffars, till a fecure hold of the child's head be obtained. It was formerly ufually applied on the outfide of the fkull only : but the hook fhould be always intro- duced within the opening, and the hand of the ope- rator fhould be paffed into the vagina to prefs the fin- gers on the outfide of the cranium oppofite, during the efforts of pulling with the crotchet, left by loo- king its hold it fhould injure the woman ; the con- fidences of which might be very unfortunate or even fatal. Dr Smellie direas the crotchet to be fixed on the outfide of the fkull, which is more difficult and hazardous than the method now employed ; and his direa ions l*d\ Sea. II. Inpumental Delivery. 221 direaions have been, till of late, very generally fol- lowed *. When the hook flips its hold, the loofe pieces of bone muft be carefully feparated and removed with the fingers ; the crotchet muft again be applied a little higher, and the pulling force repeated as before : proceeding in this manner till the fuperior part of the cranium is cut and divided, and the fubftance of the brain difcharged. The chief objeas to be attended to be in the intro- duction of the hook, are, firft to guide the point with the fingers within the opening of the cranium ; then, by moving it backwards and forwards, to per- vade the bone fo as to fecure a firm hold ; and,, laftly, in extraaing, to guard againft the accidents of wounding or otherwife injuring the woman, which might readily happen if it fhould lofeits hold. In the firft part of the operation, for the reafon* already * " Some writers direct us to introduce the crotchet within the fkull, and, preffing one hand againft the point on the outfide, pull along. But this Is a trifling expedient: and, if a good deal of force is ufed, the inftrument tears through the thin bone, and hurts the operators hand, or the woman's vagina, if not both-: Whereas, in the other method, there is much more certainty, and a better purchafe to force along the head, which collapfes and U diminiflied as the brain is difcharged, and never comes down in a broad flattened form, according to the allegations of fome people whofe idea of thefe things are imperfect and confufed," &c. Smtl- rr'j Midwifery, Book iii. feet 7. 122 Difficult Labours. Chap. II. already mentioned, the point.of the crotchet fhould ' never, if poffible, be trufted beyond where the fingers can eafily reach. One blade, in general, is fufficient to be employed for the extraaion. Boih branches can feldom be ufed at once with advantage or fafety. After the brain is difcharged, the blunt -hook may be fiiccefsfully employed as an extraaor, where the pel- vis is not remarkably faulty. The fmall end is to be paifed into the opening of the cranium, and the point to be guarded with great care, by preffing externally on the cranium, oppofite, as in ufing the crotchet. As cafes of extreme narrownefs of the pelvis from diftortion very feldom occur, the head will, in gene- neral, vicldto repeated efforts of pulling, in theman- ner juft now direaed. If this method fhould fail, the crotchet muft be introduced within the opening as before, and fixed in the bails of the fkull where a fecure hold can be obtained ; the handle fhould be covered with a cloth, to enable the operator to take a firm hold ; the point (hould in general be direaed pofteriorly to ■■ the mother ; and in employing the necelfary exerti- ons of pulling, the axis of the pelvis and vagina^ fhould be attended to. The operator fhould then en- deavour to bring down the head by pulling at firft: moderately, and at proper intervals increafing the force ^. Sea. II. Inpumental delivery, 223 force according to the refiftance from diminiflied capacity of the pelvis. He muft referve his own and patient's ftrength, by retting from time to time, ap- plying her with fuitable nourifhment; and, in a word muft perfevere in his endeavours to finifli the extrac- tion in the beft manner the circumftances of the cafe will admit of. ^ In face-cafis, where it is impraaicable to alter the \ pofition, and when the pelvis is much distorted, the < the double crotchet is recommended ; the handles muft be well fecured, kept well backwards towards the perinaeum, and the motion always from blade to blade. It very feldom, however, happens that there is occafion for the double crotchet. by this means the head is flattened in pulling, and prevented from ta- . king the proper direction ; whereas if one blade only be employed, the head is lengthened, and in pulling can better accommodate itfelf to the fhape of the eel- vis as it [ ad'es along. Befides, in face-prefentations, by applying one blade only towards the lateral part, and puiiing ob- liquely to the oppofite fide, the pofition may be al- tered, and eafy accefs at laft obtained to the hairy fcalp, to make the perforation, evacuate the brain, and diminifh the volume of the head. When the head is extraaed, if from extreme nar- rownefs of the pelvis the fhoulders fhould give confi- derable refiftance, a crotchet muft bs fixed in the fhoulder, *24 Difficult Labours. Chap. II. fhoulder, in order to bring down one of the arms, and by pulling.at it and the remaining portion of the head covered with a cloth, eafy accefs will be procu- red to the other arm, which muft be managed in the fame manner. The crotchet muft then be fixed in the trunk among the ribs, the thorax and abdomen opened if neceffary, and the delivery accomplifhed by tearing the child away in pieces. Should it be poffible for a cafe to occur, which by the bye is fcarce within the reach of reafon to com- prehend, an accident which can only happen to an ignorant or very blundering praaitioner, where the vertebrae of the neck have been divided by the crotch- et, and the head fevered from the body, both being ftill retained in the pelvis: In thefe circumftances, the head, if it cannot be extraaed firft, muft be pufli- ed up above the brim of the pelvis, the crotchet or blunt-hook muft be fixed under the axilla, the arms ir.v'd be brought down, and the body extraaed, by fixing the crotchet below the fcapula, on thejternum, or among the ribs * ; a method preferable to that of turning, • Such a cafe actually occurred to the late Mr Robert Smith forgeon ia Edinburgh foon after he began to practife. The parti- cular circumftances of this fingle hiftory, as communicated to mi by Mr Smith hiiv.fclf, are as follows.—A young woman had been feveral days in ftrong labour; the head, he imagined, had origi- nally prcfented in an oblique direction at the brim of the pelvit. Th« patient was fo much exhauftcd when Mr Smith was called, and- Sea. II. Injfrumental Delivery. 225 turning, as fome advife. The head muft afterwards be extraaed with the crotchet. In thofe cafes of narrow pelvis, where it is abfo- lutely neceflary to diminifh the volume of the child's head to procure the extraaion with fafety to the mo- ther, our fuccefs will chiefly depend on a feafonabfe performance of the firft part of the operation. The head fhould be opened, and the brain difcharged, as foon as the dilatation of the orificium uteri will admit of it. The woman may be then fafely allowed to reft for 24 hours or more, even till the compages of the and fhe was otherwife feemingly fo low, that it was doubtful to him whether flie could fupport the fatigue of delivery. The cafe appeared the more difcouraging and unfavourable, becaufe, on touching, he could not determine the manner in which the child prefented, its head having been formerly cut off from the body by an unfuccefsful attempt to procure a delivery ; nor could he even pofitively fay, whether it was a fcetus, or a very Angular mon- ftrous production, from the uncommon feel which the ragged ftump of the neck gave to the touch. Determined, however, to give the woman a chance of life, he fixed a crotchet in the part which prefented, brought down firft one arm, then another; and afterwards, to his aftonifhment, extracted the trunk of a body -with- out a bead. On inquiry, he was informed that a furgeon in the neighbourhood had in vain, after many fruitlefs efforts, attempt- ed to make the extraaion, but abandoned the woman in that fitu- ation, and affured the relations it was not poffible to accmplifh the delivery ; which they had artfully concealed from Mr Smith. The head was afterwards extracted with the crotchet, and-the woman had a good recoverr. 226 Difficult Labours. Chap. II the cranial bones of the fcetus be fomewhat diffolved by putrefaaion; the natural pains, during that pro- cefs, will either be fufficient to accomplifh the birth ; or the head will by their means be protruded fo low, that the accefs will be eafy to apply the crotchet, and little force be neceffary to procure the extraaion. Whereas, if the firft part of the operation (to wit, making a fufficient opening into the cranium for the difcharge of the brain) be too long delayed, the con- fequence of violent mechanical force employed, where the extraaion muft be performed in hafte, may be fa- tal to the patient. For the propriety of this praaice we can appeal to the experience of every praaitioner ; and if argu- ments were necelfary to enforce it, we might refer to various hiftories mentioned by authors, where the head of a foetus in a femi-putrid ftate was expelled by the natural pains, after it had been fevered from the body and retained in the uterus for feveral days ; the unfortunate woman having been abandoned to the moft deplorable date of defpair by the inhuman o- perator. It is aftonifhing, that the rule of obferving an in- terval between the firft and fecond fteps of delivery in fir.bryulcia fhould be regarded, in the writings of the Iateft author on this fubjea, as a trifling infignificant i| precaution, when the facility of the operation to the Sea. II. InpumcntalDelivery. 227 tioner, and fafety of the patient, fo much depend on it*. § 3. Cafes where it is prop fed to enlarge the dimensi- on s of the P E L VI s ts procure a fafe paffage to the Child without materially injuring the Mother. MSigault is chiefly intitled to the honour of • having firft propofed, and fuccefsfully per- formed, this operation. M. Le Roy, however, one of U the * " It has of late become fafhionable in practice, when the head has been opened, and the brain evacuated, to fuffer the re- mainder of the delivery to be effected by labour, or, if this is in- fufficient, to poftpone it for fome hours or longer, in order to fuf- fer the bones of the cranium to collapfe and be pufhed forward, and the woman to be refrefhed. But this delay feems totally im- proper : I. Becaufe the opening of the head fhould not be at- tempted whilft the woman is capable of bearing fo much longer labour, under the expectation, or the hope at leaft, that the ef- fects of fo much farther delay might poffibly bring it within the reach of the forceps. 2. There is no neceffity for greatly fatigue- ing or exhaufting the woman in opening the head, or even in bringing it down, provided it be fufficiently reduced in its fize. 3. If any inflammation has taken place, the forenefs will be greater after the delay. Laftly, Bad fymptoms and accidents may occur during the delay." Fofters Midivifery, p. 171.—The directions in this Treatife for opening the head and extracting with the crotchet, are, in other »efpeds, concife and explicit. Sec from cccxxxii. to end of ccexxxvi. 228 Difficult Labours. Chap. II. the moft eminent teachers and praaitioners of Mid- wifery in France, who divided the honour with M. Sigault, deferves alfo to be here mentioned. He was prefented, at the fame time, with a medal from the Faculty of Paris; introduced, along with M. Sigault, to the king; afiided perfonally at the o- peration, and firft publifhed an account of it. But although the fuccefs of a few cafes fliows that the articulation at the czn\\zg\nom fimphyfis puks is capable of divifion by incifion with fafety to the patient, tearing the bones forcibly afunder by violent cxtcnfion of the thigh?, till they are fo widely fepa- rated as to procure a confiderable increafe in the di- menfions of the pelvis, muft be a precarious and ha- zardous operation : Precarious, in affording fuffici- ent fpace to admit of the extraaion of a living child, where the pelvis is confiderably contraaed from dif- tortion ; and hazardous in its confequences to the mother, when much force has been employed either to obtain a feparation of the bones, or afterwards to accomplifh the delivery, where there is confiderable refift.uice to the extraaion of the fcetus. This is fufficiently proved from the event of feve- ral cafes, particularly of two hiftories related in an inaugural differtation by Dr Bently '■'', where this operation was performed on the living body ; the one * Tcblilhed at Strafburg 1779. See Edinburgh Medical Com- mentaries, part iii. for the year 1780. Sea.II. Inflrumental Delivery. 229 one by Profeffor Sieboald of the univerfity of Wurtzburg in February 1778, the other by Dr Guerard profeffor of anatomy at Duffeldorpe in May following. In the former, little fpace, not more than a finger's breadth, after the utmoft force that could be fafely applied, was procured : and a dead child was with dif- ficulty extracted. Fever enfued after the operation, urine for feveral weeks pafled by the wound, the bones exfoliated, and the patient recovered with dif- ficulty. In the latter cafe, though the bones of the pubes were feparated fully an inch and a half from one ano- ther, the advantage obtained by it was fo immaterial, that the child was with difficulty extraaed piece-meal; the confequence was, that, notwithftanding every poffible cr.rc and attention, the violence employed in forcing the bones was fatal to the woman, who " was fo much reduced and fpent, that fhe died the " roth day after the operation." It has been fuccefsfully pra&ifed, however, fince Sigault's operation, in different parts of France by M. Despres accoucheur in Brittanv, M. Gam eon at Mons in feveral inftances *. M. No- gel * Recherches Hiftoriques, &e. fur la Section de la Symphy- fc du Pubes, par M. Alphonfe le Roy, &c. Paris. 8vo, 1780. 230 Difficult Labours. Chap. II. gsl chirurgien accoucheur t, and others; once in Spain, and once and again in Holland. But it has repeatedly failed in procuring a fafe delivery to the child, and been fatal to the mother ; the bladder has been often wounded, incurable emiffion of urine and other dreadful accidents have followed. We may therefore conclude, that altho' in cer- tain circumftances the divifion of the offa pubis byin- ciiion at the fimphyfis may be praaicable and fafe, the Lp.iration by extenfion is uncertain and hazard- ous. It might perhaps, in fome rare infiances, be the means of prcferving a child who would otherwife be the viaim of the operation of embryulcia ; but as the advantage derived from it by augmenting the tranfverfe diameter of die pedis at the fuperior aper- ture is trifling, it can feldom be fuccefsfully perform- ed vdidi rcfrtct to the child, where the diftortion is fo confiderable as to cLltroy the capacity of the bafin, :.,:d render delivery by the fciffars and crotchet necef- fary ; a method which will always obtain the prefer- ence in every well regulated ftate, and with every humane ^rxdiiion-t, if the Sigauldan operation ex- pofes the life of the more valuable parent to danger. The operation confifts in making an incifion with a f.-Jncl through the common integuments and foft parts, f Anatomic des Parties de la Generation, &c. Seconde Edition Augmcntc'e de la Coupe de la S3 mphife. Par M Gautier DaSo- ry, peie, anatomifte pcnfione de Roi. A Paris 1-78. Sea. II. Inpumental delivery, 231 parts, in the direaion of the commiffure of the offa pubis. The articulation at the cartilaginous fymphy- fis, muft afterwards be divided by the fame inftru- ment. The knees of the patient are to be kept gent- ly feparate by an afliftant. A catheter is direaed to be introduced, to prevent the'accident of wound- ing the bladder in the operation ; and we are advi- fed, for the fame reafon, to make the incifion, both of the foft parts and cartilages, a little towards the left fide. The diftraaion of the bones is afterwards to be attempted, as far as is neceffary or praaicable, by a cautious and gradual extenfion of the thighs. The operation being finifhed, the contraaile efforts of the uterus are to be waited for to expel the child. The patient is afterwards to be confined to bed for feve- ral weeks, a bandage to be applied round the loins, and the management direaed on general principles. But if the natural pains fhould then fail, the fciffars and crotchet muft be ufed ; the child muft be turned ; or the Caefarian feaion had recourfe to. The firft propofition, by deftroying the child, difappoints the original intention of the operation. For, if the mother could be delivered by the crot- chet with fafety, at the expence of deftroying the child, that method will always be preferable to a pre- carious attempt to fave the child, at the hazard of the mother's life. If the pain and danger file fuffers in the new operation, is not to be compenfated by U 2 a mor- 2^2 Difficult Labour. Chap. II. a moral probability of faving the child, the opera- tion is then entirely ufekfs. And again, if it fhould fail to enlarge the dimenfions of the pelvis, and ern- bryulcia be afterwards neceffary, the mother, in that event, is wantonly expofed to the increafed danger arifing from both operations combined, with the ad- ditional hazard from the violence of mechanical force employed to extraa the child, after the parts which fuffer in the firft operation have been wound- ed, and the bones torn from each other. The great ftrefis applied to the nervous aponeurotic parts, at the facrodliac fymphyfis pofteriorly, may of itfelf alfo be fatal to the patient, or prove the caufe of incurable lamenefs, independent of the other ac- cidents incident to the operation. With all deference to an authority which is univer- fally refpeaed, and which in few inftances has been called in queftiun, we muft beg leave to differ in opi- nion from Dr Hunter, whofe fentiments on this fubjea, though in general unfavourable to the opera- tion, incline him to fuggeft, " that the crotchet may " be employed with lately to the mother when ;t " fails." The fecond method, of attempting delivery by turning, with a view to fave the child if the natural pains thould be infufficient to protrude the head, after the boi.os of the pube.» have been divided by Si- gault *s operation, although we are informed it has Sea. II. Inpumental Delivery. 233 has been fuccefsfully praaifed in one or more cafes in the Continent, is a moft dangerous expedient to the mother. The profpea it affords for the fafety of the child in a narrow pelvis, is too remote to encou- rage an experienced praaitioner, who knows the dif- ficulties thai often attend turning in more favourable circumftances, to engage in this troublefome tafk. Such a propofition in this country would be rejeaed with contempt by the generality of praaitioners. The Cefarean feclion is the third method propofed for accomplilhing delivery with fafety to the child, the feaion of the pubes having failed, if the child cannot be eafily extraaed by the crotchet. It hath aaually been praaifed in a fingle inftance, under the circumftances juft now mentioned. It is nredlefsto add, that the unhappy patient foon after died. A recovery, under fuch complicated fufferings, would have been almoft miraculous ; and few praaitioners will be hardy enough, if their mifguided judgement were permitted to rule, to venture a fefcond time on an experiment fo ftriaiy defperate. Dr Leak has, with his ufual judgement, good fenfe, and humanity, confidered the advantages and difadvantages of the Sigauitian operation ; and feems to favour it in preference to the Caefarean fee- tion, becaufe the former " does not carry with it " thofe ideas of cruelty which attend the latter, u wlv.re the patient b, as it were, embowelled alive. " No 234 Difficult Labours. Chap. II. " No formidable apparatus is neceffary, the feaion be- " ing made with expedition, and without pain and " danger: no blood-veifel, nerve, or other parts " effential to life, are wounded; thofe divided being •' only cutis, cellular membrane, and infenlible carti- " lage, from which neither hemorrhagy nor fymp- " tomatlc fever are to be apprehended*." He is therefore inclined to think, that with thofe " who " are difpofed to give this new operation a fair and ju- " dicious trial, as // has already fucceeded, it will again " fucceed." But though, in the body of a dead female fubjea in the Weftminfter lying-in Hofpital, the bones of the pubes after incifion receded 2\ inches without much violence, it does not appear that any confiderable acquifition of fpace in the dimenfions of the pelvis was procured by it. I have had occafion to make the fame experiment in repeated inftances un the dead fubjea with no better fuccefs. Upon the whole, theretore, from all the information we nave yet received of the event of this new ope- ration, we tuve little reafon to adopt it in preference of the method 01 delivery by the crotchet, wherever that inftrument can be ufed with fafety to the mother: and, as the fpace to be gained by it isfcs uncertain as the txaa dimenfions of die child's head before de-s livery * Dr Leak's Practicable Observations on the Child-bed fever, , &c. ^tb edition, p. 2JJ. Sea. II Inpumental Delivery. 235 livery, it would be rath and unwarrantable to adopt an expedient, precarious with refpecf to the child, and highly dangerous to the mother, infubftitution of embryulcia ; which, if not too long delayed, may, in the prefent improved ftate of the art, be employed in moft cafes of diftortion with perfect fafety ro the mo- ther, who is always juftly intided to the firft place in our intentions, and whofe valuable life is the moft in- terefting and important objea ofour regard. § 4. Method of extracting the Child by the Cesarean Section. WHen the child could not be delivered by the natural paftages, or when a woman died un- delivered though the child was probably alive, an o- peration with a view to preferve the mother and child in the firft cafe, and to fave the child in the latter, has been ftrongly recommended. It is fuppofed by many authors to be fafe and jultifiable in the former cafe, but has been warmly reprobated by o.hers. It is ftyled Caefareun Setlion from Julius Caefar, who is faid firft to have received bis appellation from this circumftance of his birth, and in his turn to have conferred it on the attempt. There is much reafon, however, to fi.fpea, that this relation, like many o- ther ftories of Pliny, is fabulous ; and it is more rea- fonable to fuppofe that the name, in faa, was the chief 236 Difficult Labours. Chap. II. chief origin of the ftory. The fame author attri- butes the birth of Manlius Scipio to the fame opera- tion. But in thofe days the Grecian phyficians were held in abhorrence for the cruelty of their operations, and it is fcarcely probable they would then dare to propofe the delivery of the child by an expedient which appeared to be as rath and formidable in the atempt as dangerous in the confequences. If there is any foundation for the ftory, it probably refers to the attempt of faving the child by this ope- ration in cafes of the fudden death of the mother: for there is no certain accounts of its having ever been performed by the ancients on the living fubjea. Books are full of hiftories to fhow that Hifteroto- my has been praaifed with fuccefs by the moderns on various oceafions; yet authors are much divided in opinion on the fubject. Some pofitively deny ' th^t a woman can furvive the daring attempt: while others contend that it is frequently fafe, though se- ncrdiy dangerous; and relate many examples where it has not only been performed with fuccefs, but re- peatedly praaifid on the fine fubjea. iMarckant, Mauriceau, Gulimfau, Pari', Ould, and others of equal authority, have expafs- ly writitn againft it. Sir Fielding Ould calls it '•* a deteltable, bar- " barons, and illegal piece of inhumanity ;" and en- deavours Sea II. Injtrumental Delivery. 237 deavours to prove the improbability, and even impof- fibility, of its fuccefs, from its analogy with other wounds, as well as the anatomy of the parts. He is at great pains to invalidate the authority of Bau- chin, Rousset, La Mott, and other favour- ers of that unparalleled cruelty, by denying the faas they have endeavoured to tranfmit to pofterity in fup- port of it. None of thefe cafe6, he hopes, will gain any credit from the readers of the prefent age. He confiders thefe hiftories as fable and impofture, and concludes " from reafon, theory, anatomy, arid e- " very thing confiftent with furgery, that the Caefa- " rean operation muft be certainly mortal; and " hopes it will never be in the power of any one to '• prove it by experience *." On the contrary, if we could rely on the teftimony of authors, fince the firft accounts of the Caefarean feaion fuccefsfully praaifed by a common fow-gel- der on his own wife in the beginingof the 16th cen- tury *, many well attefted hiftories appear on record in which it is faid to have been fuccefsfully perform- ed. But the accounts which hiftory tranfmits, both of the cafes and caufes for the operation, are fo vague and abfurd, they carry along with them fo little ap- pearance * Ould's Treatife of Midwifery, p. 106, * Vide Bauhin's Appendix toRouffet's Treatife. 238 Difficult Labours. Chap. IF. ptarance of probability, that nothing can be conclu- ded from them ; and, in facf., fuch fabulous hif- tories fhould be received rather with incredulity than confidence. Succefsful events are introduced with much pomp in the writings of authors. One author copies from another, the name is chan- ged, many of the circumftances are difguifed; in this mannei a fingle cafe has given rife to feveral. Authors, on the contrary have been generally filent when the event was unfavourable. Even the teftt- mony of M. S.iumain, Dela Pyronie, La Fayl, of France, and others who have written in favour of the operation *, if we fhould acknowlege the authenticity of the cafes, afford little founda- tion to encourage us to perform it on the living fub- jea. We fhall next, therefore, inquire into thofe cir- cumftances in which the operation is fuppofed to be neceffary, in order to fhow, that, in general they arc infufficient indications for having recourfe to it. Hp re foray, according to authors, fhould be per- formed when the pelvis is faulty ; when the patfages are contraaed by conftriaion from cicatrix, callofi- ties, •See Mem. of the Academyof Sunrerv, torn. I. & II. ; Edin- burgh Medical ElTays; Hei:ter's Surgery ; Burton's Midwifery; Louden Medical Eflays and Inquiries, &c. Sea. II. Inpumental Delivery. 239 ties, or tumors any where about the vagina or os tincae ; when the uterus is torn, and the child e- fcaped partially or wholly into the cavity of the ab- domen ; in cafes of extra-uterine conception ; her- niae of the uterus ; when the pofition of the child is unfavourable for turning ; or, the mafs of the foetus of an extraordinary fize. I. Diminijhed Capacity of the Pelvis, from bad Con- formation of the Bones.—It is only when the hand of the operator cannot be admitted within the aperture of the pelvis, or, in other words, when the narrow diameter at the brim or bottom does not exceed from one to two inches, that this operation is juftified by modern praaitioners in confequence of diftortion. For, when the capacity of the pelvis is fo ftrait as not to permit any part of the child's head to be protruded through the fuperior aperture, not to admit two fin- gers of the Accoucheur's hand at the bottom to con- dua proper inftruments with fafety to open and di- minifh the foetus's head, and fecure a firm hold to procure the exraaion, the Caefarean feaion has been praaifed, or the unfortunate woman become the viaim of the imperfeaion of the art. ^ In the city of London, during about 100 years, of between 50 and 60 women whofe pelvifes have been much diftorted, the Caefarean feaion has only been performed in two inftances, viz. byMrTHOM- X SON 240 Difficult Labours. Chap. II. son Surgeon to the London Hofpital, and by Mr J. Hunter*. In all others the child was delivered by embryulcia ; yet I am well informed not above 5 or 6 of the whole number of women juft now mention- ed, died in confequence of the violence employed in delivering with the crotchet i. Happily fuch a ftruaure as to reduce the capacity of the pelvis within fo narrow limits, very feldom occurs in practice; hence in the prefent improved ftate of the art, the neceffity for the frightful, horrid, and awful expedi- ent of the Caefarean ftaion, muft be very rare and uncommon, even when a bold praaitioner would hazard the performance of it. In the fubjea of the Caefarean feaion, whofe hi- ftory is related by Dr Cooper and Mr H. Thom- son, London Medical Effays and Inquiries, Vol. IV. already referred to, the tranverfe diameter of the pelvis at the brim, to wit, from the upper part of the facrum to the oppofite fymphyfis pubes, mea- fured only -|ihs of an inch. In the cafe related by Dr Cooper, Vol. V. of thefe Effays, the greateft fpace of the tranfverfe cha- racter at the brim did not exceed i\ inch, to wif, from * Fid. London Medical Effays and Inquiries, Vol. IV. V. \ In the former imperfect Edition of this Work, the proportion j of woir.en faved and deftroyed by embryulcia wasreverfed. The j Author was led into this miftake hy miCnformatica from a ref- I pe&able Accoucheur of London. Sea. II. Infirumental Delivery. 241 from the projeaion of the facrum to the fymphyfis pubis; and gradually became narrower at each fide, till it terminated laterally in a fmall point*. At the bottom the rami ifchii were fo much contraaed, that the fpace between them was fomewhat lefs than half an inch. It is obvious to a demonftration, that the volume of the head of a mature foetus cannot, by the operation of embryulcia, be diminiflied to fu:h a fize as to ren- der it capable of patting through a pelvis whofe di- menfions do not exceed either of thofe juft now men- tioned. The following cafe, however, fhowsthe perfeaion to which we have now arrived in the conftruaion of obftetrical inftruments. Dr Kellie extraaed a mature fcetus through the openings ofa diftorted pelvis, whofe dimenfions were thefe : Tranfverfely at the brim from the arch at the facrum to the fym- phyfis pubis, 1 inch |tbs and --^th ; on the right- fide of the ftrait, 2i'jth inches; on the left-fide, i| inch. The woman had been five days in ftrong la- bour before Dr Kellie had an opportunity of fee- ing her. " The head remained above the brim of u the pelvis, and had not then made the fmalleft " progrefs. It was ofa large fvLe, firmly offified ; 14 and the parts in the paffages were fo extremely " tender, f London MedicalEffays and Inquiries, Vol. V. p. 225. 242 Difficult Labours. Chap. II. " tender, that the poor woman, who was fomewhat *• faint and much fatigued by the protraaion of " labour, could not bear the moft gentle examination " without great pain." The Doaor proceeded to perform the operation of embryulcia " by making " a large opening in the cranium, which was effect- " ed with difficulty, on account of the head project- " ing fo much over the pubes that the fhank of the ** fciffars was preffed forcibly againft the perinaeum, " to get the points in a proper direaion." He now left the patient ; and on returning, in 24 hours af- ter, " found the head advanced into the pelvis fo " low, that the jagged end of one of the parietal " bones preffed againft the inner part of the perinaeum, " very near the os externum. By the help of the " blunt-Jiookonly, the head was brought forth, in " little more than a quarter of an hour, amazing- *' ly flattened." The fhoulders and body gave con- fiderable refiftance, but were alfo extraaed with the blunt-hook. It is much to be regretted, that the unfortunate patient, who feemed to do well for a week, " having " imprudently drank freely of raw porter, with fome " people who came to fee her, was afterwards fei- " zed with a violent purging, of which fhe died in " three days*." The f Johr.fon's Midwifery, page 284. Sea.'II.'- Infilrumental Delivery. *243 The above cafe affords, however, an important leffbn of inftruaion to praaitioners of midwifery If, after the patient had been five days in hard labour, the head of a mature foetus could be trufted for 24 hours after opening to the natural pains, and pafs through a diftorted pelvis of the dimenfions above mentioned, fo low as to prefs with the parietal bones againft the perinaeum, and be capable of extraaion with the blunt-hook ;—we need not defpair of at- tempting ddivery with the fciffars and crotchet, where the pelvis comes fomewhat fhort of thefe di- menfions, if the head be opened early. For, by waiting with patience, as long as there is time foritj the head will collapfe, and be protruded fo low by the force of the pains, that the accefs will afterwards be eafy to apply the crotchet; fo that byl pulling with it, and aifiiting with the fingers to adapt the fihall axis of the head to the leaft diameter of the pel- vis, the extraaion will be accomplilhed with facili- ty and fafety. The projeaion of the angle of the facrum towards the pubes, is by much the moft frequent mode of diftortion. In fome initances, the intermediate fpace is fo inconfiderable, that the diameter at the brim is divided, as it were, into two cavities. In this fpecies of diftortion, it is evident, on account of the diftance of, and confequently difficult accefs to, the prefenting part, of the chdJ, that the danger in X 2 embryulcia 244 Difficult Labours Chap. II. embryulcia will be proportionably confiderable: for if the narrownefs at the brim proves an unfur- mountable obftacle to the paffing, and the figure and diftortion at the bottom prevents the introduaion of the hand to direa and apply the proper inftruments with fafety to the mother: in fuch circumftances we muft cither abandon the patient to utter defpair, or by the laft refource of defponding hope endeavour to fave her. It remains, then, to inquire, i. If dividing the bones of the pubes by the lately invented operation, affords a reafonable profpeft'of procuring even a fafe delivery to the mother when it cannot be accomplifhed by embryulcia r 2. Is the capacity of the pelvis, in any inftance, fo mucjpieftroyed, from diftortion, that a dead child ^cannot be extraaed by means of the fciffars and crot- chet ? Firft, Where the pelvis is fo much diftorted, that,. the diminution of the child's head to fomewhat more than half of the ufual fize is infufficient to render deli- very praaicable, Sigault's operation could have little effea to enable the head to pafs unlefs its vo^ lume had been previoufly leffened. Some advantage would then be gained by dividing the bones of the pelvis ; but not fo much as to encourage us to hops that the child would afterwards be propelled by the natural pains, or in thefe circumftances, extraaed by Sea. II. Inpumental Delivery. 245 ihe crotchet, without employing a degree of violence which might probably be fatal to the mother. Secondly,That the aperture of the pelvis is, infome cafes, fo narrow from diftortion, as to prove an un- furmountable obftacle to the paffage of the child by . embryulcia, the hiftories of the Caefarian feaion in- the4th and 5th volumes of the London Effays already referred to, afford ftriking and inconteftible examples. In the pelvis ofa woman on whom the Caefarean feaion was performed by Dr Young, late profeffor of .midwifery in theUniverfityof Edinburgh.thetranfverfe diameter at the brim does not meafure above \\ in- ches at one fide; the bones of the pubes are bent, and refufe admittance to a finger at the arch ; the fa- crum is convex anteriorly; the anchylofed coccyx is angulated ; and the diftance from it to thfctuberofi- ties of the ifchia is fomewhat lefs than i\ inches. In a pelvis of this conftruaion, where the bottorr|, and indeed whole capacity, are affeaed by the dif- tortion, embryulcia could fcarce be attempted. In a colleaion of bones, in my poffeftion, the conftruaion of a diftorted pelvis ofa ftmale fkele- ton is ftill more unfavourable for the opeiauon of embryulcia than any of thofe yet mentioned. The diameters at the brim are almoft entirely deftroyed by the projea.on of the lumbar vertebrae ;nd con- vexity of the facrum ; diftance at one fide fiom iho facrum to the ilium being |ths of an inch only It 24$ Difficult Labours. Chap. II. It is fufficiently apparent, ihat here nothing but the Caefarean feaion could give the patient the moft diftant chance of life from the danger which threa- tened. It is probable, therefore, that a faulty pelvis, whofe fmalleft diameter at the brim or bottom: does not exceed i\ inch, or if, is one- motive for the defperate refource of the Caefarean feaion. The difference in the fize and ftruaure of a child's head may alfo render it neceffary, where the tranfverfe diameter of the fuperior aperture of the pelvis, and lateral one of the outlet, fomewhat exceed the dimen- fions juft now mentioned. Before we inquire into the praaicability of the Cae- farean operation with a probability that the mother: will furwe it, we fhall next endeavour to fhow mat all the other cafes in which it has been perfor- med or propofed are improper indications for it. II. Conftriclion from Cicatrix, Calhfity, and Tu-- mors, any where about the Vagina or Os Tincae.— The vagina and os tincae are often affeaed with conftric- tions from cicatrices, with callofities and tumors; but it is never neceffary to perform the Caefarean feaion on their account. Tumors in the vagina ; may generally be removed with faiety even after the commencement of labour, and delivery happily fuc- cced ; or it may be iometim.es praaicable for the ac- coucheur Sea. Hi Inpumental Delivery. 247 coucheur to pafs his hand by the fide of the tumor, to turn the child, and deliver. There are many in- ftances where, at the commencement of labour, it was impoffible to introduce a finger into the vagina ; yet the parts have dilated as labour increafed, and the delivery terminated happily. At other times the dilatation has begun during pregnancy, and been completed before delivery. A ftriking inftance of this kind is recorded in the Mem. de 1'Acad. des Scienc. 1712, ofa woman whofe vagina was no larger than to admit a common writing quill. She had been married at fixteen, and conceived eleven years after. Towards the fifth month of her preg- nancy, the vagina began to dilate, and continued to do fo till full time, when the was fafely deliverd. Guilemeau dilated, and La Mott extirpated, callofities in the vagina and.os tincae ; when the chil-r dren were fuccefsfully expelled by the force of natu- ral labour. Dr Harvey relates a cafe where the whole va- gina was grown together with cicatrices: nature, after a tedious labour, made the dilatation, and a large child was born. M. La Mott * mentions his having delivered three women, who had not the fmalleft veftige of an orifice through the vagina to the uterus. Dr Simp- son * Traitc des Accouchemens, p. $zf. 245 Difficult Labours. Chap. II. son cut through a callofity of an os uteri which was '' half an inch thick f, &c. Upon the whole, tumors in the vagina, or a- bout the orificium uteri, may be fafely extirpated without danger of hemorrhagy or other fatal fymp- toms, and the delivery will happily fucceed: And, if the vagina be impervious, the os externum fhut up, or the labia grown together, the parts fhould be o- pened witha fcalpcl. If the os externum be entire- ly clofed, if the ca\ ity of the vagina be filled up, or the paffage confiderably obftruaed by the tumors, calle- fity, or conftriaion from cicatrix, and there is no rea- fon to fufpeaafault in the pelvis, of which a judg- ment may be formed by the common marks cf defor- mity, under-fize, or a rickety habit; it is by much the beft praaice to open a paffage through the va- gina, and deliver the woman in the ordinary way. If there be no defea in the pelvis, the head of the child, or any other bulky part that prefents,. will advance in this direaion till it meets with a re- fiftence in the foft parts : the teguments, in that cafe, will be protruded before the childs head, in j form of a tumor, when a fimple incifion downwards j to the perinaeum, in the direaion of the axis vaginae will remove the caufe of difficulty, by relieving the head ; the child will afte; ,ards fafely pafs, and the-| wound will heal without any bad confequence. Wheni] $ i f Edinburgh Med. Effap, Vo. III. Sea. II Inflrumental Delivery. 249 When there is any defea in the foft parts, which prevents the accefs of the finger into the vagina, the head of the child may be readily felt, and the ftate of the parts in fome degree judged of by the introduaion ofa finger into the anus. III. Lacerated Uterus is another caufe, for which this operation has been recommended. The uterus may be ruptured from the crofs prefentation of the child in time of pregnancy, when the uterine fibres do not readily yield to the diftending caufe, or from mechanical violence in attempting delivery. Thefe cafes are generally fatal ; and the life of the mother can feldom be faved by the Caefarean feaion, after the foetus efcapes through the torn uterus into the cavity of the abdomen ; becaufe inflammation and fphacelus have generally affeaed the parts of the uterus that fuftained the preffure, previous to the rupture $ if otherwife, convulfions or other fatal fymptoms foon enfue, from the quantity of blood, waters, &c. poured into the cavity of the abdomen. When the child cannot be extraaed by the natural 'paffages, tremors, fingultus, cold fweats, fyncope, and the death of the mother, for the moft part fo quickly follow, that it will at leaft feem doubtful to a humane praaitioner, how far it would be advifable, after fo dreadful an accident, the woman apparently in the ag- onies of death, rafhly to perform another dangerous operation, 25° Difficult Labours. Chap. II operation, even with a view to preferve the child, before he had waited till the mother recru ts or ex- pires. If part of the child be contained within theuteru* and the feet can be reached the beft praaice is to de- deliver by the orifice of the womb. When the whole foetus has efcaped entirely without the litems, the Caefarean operation is recommended as the only means of preferving both mother and child. But if the operation on this occafion be ever allow- able, it may beafked, I. At what time fhould it be performed ? 2. Would it not have the appearance of inhuma- nity, to have recourfe to this expedient immediately after the uterus burfts, when the woman is feemingly ready to expire, although it be the only time when there is a chance of fading the child ? 3. In moft cafes where this accident happens, fhould the Caefarean feaion be made, it is not highly improbable that the mother will furvive fo terrible a laceration ? At 'tail the uncertainty how long fhe may furvive it, feems a confiderable obftacle to the opera- tion under fuch difagreeable circumftances; ne cccidifft videatur, quern firs inferemif. IV Ventral Conception is a fourth indication for this operation, Thefe are either in the ovaria, tubes or ca- vity of the ubdo-uen, and ftldom arrive at great fize; or arc ruaintd, often lor a great many years, with- out Sea. II. Inftrumental Delivery. 251 out occafioning much complaint. The flue of thefe conceptions has alfo been no lefs various than extra- ordinary : for, after having been long retained in an indolent ftate, abfceffes or ulcerations have formed, and they have been difcharged through all the diffe- rent parts of the abdomen *. Moft women feel pain and violent motion towards the term of ordinary delivery, in thefe cafes of ven- tral conception ; if, therefore, the operation be ever neceffary, then is the proper time to perform it. But in general, as the feparation of extra-uterine foetufes from their involucra may occafion imme- diate death in many cafes, in confequence of the vaft haemorrhagy that might enfue from the non- contraaile power of the parts to which they adhere; unlefs they point outwardly, or excite violent fymp- toms, their expulfion fhould be univerfally trufted to nature. V. Herniae of the Uterus are never fufficient indi- cations to induce us to perform the Caefarean fac- tion, as the uterus is very rarely influenced in fuch a manner, that the orifice cannot be reached, and the delivery fuccefsfully made. Many inftances are to be found among Surgical authors, where deliveries, under fuch circumftances, have been happily performed, Y with- * Vid. Mangeti Bibliothec. Medicin. ; Journal De Scavans; Memoir, de l'Acad. des Sciences ; Chapman's Midwifery ; London Medical Obfervations; Dr Duncan's Medical Commen- taries, &c. 252 Difficult Labours. * Chap. II. without having recourfe to fo hazardous an expedient. Mauriceau mentions a cafe, where the uterus in a ventral hernia was pufhed along with the inteftines a- bove the belly, and contained in a tumor ofa prodi- gious fize ; the woman, however, was delivered at the end other lime in the ordinary way. M. La Motte relates the hiftory of a woman in a pre- ternatural labour, whofe uterus and child hang down pendulous to the middle of her thigh ; but whom notwithftanding, he fafely delivered. And DrRuvscH gives a cafe, where the midwife reduced ihe hernia before delivery, although it was prolap- fcd as far as the knee, the delivery was fafely perform- ed, and the woman had a good recovery. The Pofition or Bulk of the Child.—Since the prac- tice of turning the child and delivering by the feet, and the late improvement of obftetrical inftruments, this operation has never been performed on account of pofition, monftrofity, or any other obftacle on the part of the child merely. It will be obvious, how- ever, that the increafed bulk of the foetus combined -with diftorted pelvis, will render the delivery propor- tionally difficult and dangerous: and though we may, from a concurrence of fortunate circumftances be enabled to perform the extraaion by embryulcia in a pelvis fomewhat Uf than the dimenfions menti- oned in Dr Kellil's cafj formerly referred to*, the • VtJc pr.ge 322. Seat II. tnflrumental Delivery. 253 the difference in the bulk of the child may render it impracticable where the aperture of the pelvis fome- what exceeds it. Upon the whole, when, by a careful menfuration with the fingers, the pelvis appears to be faulty to fuch a degreee as to ref ufe paffage to the diminiflied fize of the child's head by embryulcia, and there is no profpea of accompliftiing delivery by the new opera- tion of dividing the fymphyfis pubis by incifion ; in other words, when it appears abfolutely impoffible to deliver the woman by any other means, which is to be determined by a confutation of experienced prac- titioners ; we ought then only to employ the dreadful expedient of culling into the uterus to extraa the child. . That this operation, frightful and hazardous as it moft certainly is, has aaually been performed with fuccefs in a variety of cafes, the writings of feveral authors of character afford the moft unqueftionable ■A *' evidence T. We have reafon, however, to fufpea, that the fdas related in thofe hiftories have beea mifreprefent- cd, or the event of the operation in Great Britain ought not to have been fo univerfally fatal. For, though performed under all the advantages of the im- proved ftate of furgery, which is the boaft of the prefent f See the authors already quoted. 254 Difficult Labours. Chap. II. prefent age, the unhappy patient hath not furvived it in a tingle inftance*. In Edinburgh the Caefarian feaion * H-tying been an eye-witnefs to the operation, and an affift- ant to the operator Mr Chalmers, the laft time it was performed \\ iv, as the cafe was circumftantially related in the laft Edition of this Work, wc have again thought it neceffary to infert the hif- tory. Emsa3Zth Clerk, aged thirty, had been married for feteral years, became pregna;n, and mifcarried in the third month; the expulfion tf the abortion occafioned fo fevere a ftrefs, a» actually to lacerate the perinaeum. Some time after her recovery, fhe was irregular; afterwards had one fhow of the menfes; again conceived; and the child, as fhe imagined, arrived at full time. She was attacked, on Monday the 3d January 1774, about mid- night, with labour-pains; which went on flowly, gradually in- crease till Saturday the T/th, when fhe was brought from the country to the Royal Infirmary here. Upon examination, the pelvis feemed confidently diftorted ; but the body was otherwife well fnaped, tho* of fmall Gze. The os externum vaginae was en- tirely faut up ; nor could any veftige of vagina be obferved, nor »ry appearance of labia pudendorum : Inftead of thefe, there was 91 fmall aperture at the fuperior part of the vul-ra, immediately, under the mens veneris, probably about the middle anterior part •f the fymphyfis pubis. This aperture (which had a fmall procefs on .the fuperior prt, fomewhat refembling the clitoris) was na larger than juft to allow the introduction of a finger ; the meatus urinurius lay concealed within it. A confutation of Surgeons was called, and the Cafarean fecftien was determined on. Having had no ftool nor voided any urine for two days, an injection was attempted to be thrown up ; but it did not pafs, nor was it pof- fible Sea. II. Infirumental Delivery. 255 feaion has been performed five times; viz. twice by Dr Young, once by Mr Robert Smith, once Y 2 by ftble to pufh the female catheter into the bladder. At fix in the evening, the operator made an incifion on the left fide of the ab- domen in the ordinary way, through the integuments, till the peritonaeum was expofed; two fmall arteries fprung, which were foon flopped by a flight compreffion : the wound was then continued through the peritonaeum into the cavity of the ab- domen ; when the bladder appeared flightly inflamed, and much diftended, reaching with its fundus near as far as the fcrobiculus cordis. Another unfuccefsful attempt was made to pafs the fe- aiale catheter: at length a male catheter was procured, which was, after fome difficulty, introduced into the bladder; and the urine evacuated to the quantity of four pounds, high fmelled and fetid. This occafioned a neceffary interruption, for a few mi- nutes, between making the opening into the abdomen and uterus; the bladder collapsing, the uterus, which before lay concealed, now came in view; through which an incifion was made, and a ftout male child was extracted alive ; and immediately afterwards the feevmdines. The uterus contracted rapidly. After cleanfing the wound, the lips were brought together by the quill-future, ancj dreffed fuperficially. The patient fupported the operation with furprifing courage and refolution; and no more than five or fix ounces of blood were loft on the occafion. Being laid in bed, fhe complained of ficknefs, and had a flight fit of vomiting ; but, by means of an anodyne, thefe fymptoms foon abated. She was affected with univerfal coldnefs over her body; which alfo abated, on the application of warm irons to the feet. She then became eafy, and flept for four or five hours. Next morning, the 16th, about two o'clock, fhe complained of tonfidcrablc pain in the oppofite fide : for which fhe was blooded, and 150 Difficult Labours' Chap. II. by Mr Alexander Wood, and once by Mr W. Chalmers, Surgeons. It was alfo performed by Mr and an injection was given, but without effect; for the pain in- creafed, ftretching from the right fide to the fcrobiculus cordis; ■or did fomentations feem to relieve her : her pulfe became fre- quent, fhe was hot, and complained of drought. At 7 A. M. the injection was repeated, but with no better fuccefs ; and eight ounces more of blood were taken from the arm. A third injection ftill failed to evacuate any fasces; the drought increafed ; and the pulfe rofe to 128 ftrokes in a minute. At 11 A. M. the pulfe became fuller, and the refpiration much oppreffed. No ftool nor urine paffed fince the operation. At 12 fhe was blooded a- gain, when the fczinefs appeared lefs than formerly. She now took a folution of fal Glauberi, manna and cr. tart, at fhort in- tervals; fhe vomited a little after the laft dofe, had a foft ftool, and voided a fmall quantity of urine. At 3 P. M. her pulfe was 136 ; and fhe had another ftool, when this faeces were evacuated?, fhe was then ordered two fpoonfuls of a cordial anodyne mix- ture every fecond hour. The vomiting now abated; the pulfe became fmaller and more frequent : fhe paffed urine freely; but the pain and oppreffed breathing increafed. At 7 P. M. her pulfe rofe to 142, and became weak and fluttering; fhe called for. bread, and fwallowed a little with fome difficulty; her drought was intenfe ; the d\ lVnoc.i ftill increafed. She was now muchop- prciVcd, began to tofs; the pulfe funk, and became impercepti- ble : fhe complained of faintifhnefs ; but on belching wind, her breathing was relieved, and the pulfe returned, grawing fuller and fU'OBgtr. The pain of the fide ftill increafed ; two glyfters of warm water with oii were then injected without effect. At 2 P. M. the pulfe became lefs frequent aud fmaller ; fhe com- plained much 01 the paia toward* ta* icro'jitulus cordis; her breath- | Sea. II. Infirumental Delivery. 257 Mr W. Whyte Surgeon in Glafgow, Oaober 1775 : Both mother and child died. And three times in England. ^jaeritur, To what caufe is the unfuccefsful event of this operation to be imputed ? When it proves fatal, to what immediate caufe" are we to afcribe the death of the patient ? Are lacerations of the gravid uterus, when that or- gan is previoufly in an inflamed ftate, along with the confequences of preffure from the fcetus onthe'irritable. vifcera, not univerfally mortal? Why, therefore, fhould a recent wound through' the teguments, peritonaeum, and uterus, be fatal in almoft every inftance * ? Is. breathing was much oppreffed; her belly was tenfe, and fwelled as big as before the operation ; her pulfe was now fmall and fee- ble ; fhe looked ghaftly ; and expired a little after eight, twenty- fix hours after the operation. It is to be regretted that the relations would not permit the bd» dy to be opened.' N. B. From the inaccuracy of the Clerk of the Infirmary, from- whom the outlines of the cafe were received, an extraordinary, blooding, montioned in the Elements of Midwifery, was related. by miftake. * About four years ago, in a cafe where the (houlder of the child had'prefented in an oblique direction at the brim of the pel- vis, the labour had been permitted to go on from the morning to the afternoon; the midwife had miftaken the prefentin<* part for 258 Difficult "Labours} Chap. II. Is it nervous or uterine irritation from cutting that kills ? is it internal hemorrhagy, or the extrava- fation for the breech; and the pains, after a few hours, became fa ftrong and forcing, that fhe expected the child to be propelled with every throe. The patient foon after became reftlefs; tof- fing and delirium enfued. In this fituation I was called in. When the patient was proper- ly fecured by affiftants, I paffed up my hand with difficulty, and difcovered a confiderable rent in the uterus towards the fuperior lateral part of the cervix, through which the fhoulder and arm of the child had efcaped into the cavity of the abdomen. Every at- tempt to infinuate the hand fo high as to reach ome or both feet, with a view to bring them down and deliver, brought on an im- petuous gufh of blood. I was therefore obliged to deliver with the crotchet; and m«re readily adopted this method, as there was little reafon to expect, from the hiftory of the cafe, that the child was alive ; it really appeared to have died the day before. After the feet and body were extracted, the firft arm was readily relieved; but, in bringing down the other, though every poffible precaution was employed, the wound in the uterus was increafed. downwards to the very edge of the os tincae. The placenta was removed by the introduction of the hand in- to the uterus, on account of flooding; and fome portion of intef- tine reduced, which had been forced through the wound of the u- terus, and protruded at the vagina almoft as far as the os exter- rram. This gave me an opportunity of examining the rupture,, which I found already amazingly diminifhed by the contraction of the uterus. I gave the patient an opiate, and took my leave; not expecting again to have feen her in life. She flept comfortably that night; complained for a few days of an uneafy fenfation like after-pains; Sea. II. Inpumental Delivery. 259 fation of fluids into the cavity of the abdomen? Is it in- creafed irritation from pregnancy, the low exhaufted ftate of the patient along with dread apprehenfion? Or, are not the fatal confequences rather to be chiefly imputed, as Dr Monro thinks, to the accefs of the air on the irritable vifcera ? The Dc>aor, after making numerous experiments on different animals, found, that " If a large wound into the abdomen be quickly " clofed and accurately fritched, the animal general- " ly recover?, without fymptoms of danger appear- " ing : but, if the bowels are expofed for a number of " minutes to the cold air, dreadful pain andinflatnma- " tionfucceed, which generally prove fatal;'' ani, on examining the abdomen after death, he found " efftt- " fion of bloody ferum, and adhefion of the bowels " to each other." He therefore has propofed, for twelve years paff, in hisLeaurts," that, in performing the Caefarean " operation, we fhould be careful tbat the vifcerabe " expofed as little as poffible; and that the fides of " the wound fhould be kept contiguous by a greater " number of flitches than are commonly employed in on the fifth day matter in confiderable quantity appeared on the cloths at the pudendum, but without much pain. The difcharge gradually leffened, and her recovery otherwife was nearly as gooi as if no extraordinary accident had happened. 260 Difficult Labours. ' Chap. II. " in wounds in order to exclude the air from the " cavity of the abdomen *." The particular method of performing the operation is defiribed fo fatisfaaorily by Dr Monro, our learned and accurate Profeffor, in his Leaures, that we fliall take the liberty to infert his own words. " By this operation is underftood, an incifion " made firft into the cavity of the abdomen, and " then into the uterus, in order to extraa a fcetus. " If the pvrfon on whom we are to perform it has " been killed by an accident in the laft month of " pregnancy, or has died ofa fever, we need not be " very, exaa about the incifion, ixit muft make it as " quickly as poffible. «« If, however, we are to operate on a living per- " fon, we ought not to attempt the operation if fhe " has ever on any former occafion b-.-en delivered of " a child ; for that is a fure proof that the natural " opening is fufficiently larget. Even if the os " uteri be not fully dilated, it will be better for the " patient to have it dilated forcibly, than to have this opera- * In the imperfect Edition of the Elements of Midwifery, from t:v inaccuracy of the language this opinion appears to have been given as my own. I readily make this acknowledgment of Dr Monro's claim, as I fhould otherwife detract from his deferved praifes. f The cafe of the Csefarean operation mentioned in the Lon- don Medical Obfervations and Inquiries, Vol. V. is an exceptio* to the general rule; but examples of this kind very rarely occur. Sea. II, Inftrumental Delivery. iSt " operation performed, which is attended with the " moft imminent danger. " Next, we ought ttnaiy to examine the ftate of " the bones and of the foft parts, left we imagine " that the bones prevent the delivery ; when, per- " haps, the foft parts only may be in the fault. We " may alfo prefume, that there is a fufficient wide- " nefs in the bones of the pelvis if the patient is not " obferved to have deformity in the other parts of " the body, as a deformity rarely occurs in the pelvis " without rickets or a curvature in the fpine ; though '.' in a few cafes t'fis may happen. But, after all " thefe circumftances have been attended to, and the " operation is determined, next let us confider the " proper fteps to be taken in it. " We firft empty the inteftines, the reaum, and " vefica urinaria, that the patient may not be difturb- " ed too foon after the operation, and that the fize " of the bladder may not interrupt it. We then lay " the patient in a horizontal pofture, that the intef- 14 tines be not pulhid down between the abdominal '• integuments and uterus. In making the incifion, " we muft avoid the large arteries in the containing " parts. If it were to be extended far outwards, " confiderable branches of the circumflex might be " divided ; if inwards, the epigaftric : fo the beft " place is between the recfu mufcles, or upon the " outfide of ttu reaus. The laft place is moft fre- quently 262 Difficult Labours. Chap. IL " quently preferred, and we there readily get into " the uterus. By this means, indeed, the uterus " muft be divided towards its fide, where th- veflels " enter and are moft confiderable ; but we choofe the «4 outfide of the rtaus, becaufe of the vefica urinaria " being in danger of contraaing inflammation from " the incifion. Except the danger of wounding the " fmall turns of the inteftines, there is no great diffi- " culty in performing the operation; yet feveral '• cautions are to be obferved. Operators have not " been aware of the caufes of the danger; and we " have more favourable accounts of the operation •• than we ought to have. We fhall find in praaice, •* that we (lull be more frequently difappointed than " we would imagine from the reports of authors " who have only mentioned the fortunate cafes. In " this city the operation has been performed five " times, and always without fuccefs; tho'fome of " the women, before the operation, were in ordinary " health. The great danger, I am perfuaded, arifes " from the admiffion of the air, as well as from the •• parts divided ; and I luve repeatedly found, in " making experiments upon animals, that if the air " were let in upon the abdominal bowels for a few mi- '« nutes, without any farther injitjy, the animal '• often dies, and always recovers with the utmoft " difficulty : And this ftill more readily happens if a " confiderable quantity of red blood be extravafatcd within be6t.II. Inftrumental Delivery. 263 *' within the cavity, which produces a moft violent 44 inflammation. Therefore the furgeon is not to go " at once into the cavity of the abdomen ; but fhould 44 firft divide the fkin and mufcles, and leave the pe- " rito'naeum entire until the bleeding from the veffels 44 has entirely ceafed : the danger in that way, 1 find " is very much leffened. We then open the perito- " naeum, making firft a fmall incifion, and obferve " if the uterus is contiguous: if it is, we divide it 44 with caution ; and the affiftant, by making a mo- 44 derate preffure, hinders the air from getting into " the general cavity of the abdomen. The difcharge " of blood from the uterus is fmaller than we would " expea. We then cut the membranes, feparate 44 the placenta to extraa the foetus, difcharge the " waters; and, as foon as the foetus and fecundines " are removed, the uterus contraas of itfelf. Then 44 let the furgeon pafs his hand into the cavity of the 44 uterus, and with one or two fingers open the ps 44 uteri, that the blood, naturally difcharging into 44 the cavity of the uterus from the wound, may pafs 44 readily out by the vagina. We then flint the. 14 wound : and, inftead or leaving an opening for the 44 difcharge of matter, we truft to abforption ; for I 14 conftantly find, that a very clofe future contributes " to the cure; fo I would few the containing parts 44 of the abdomen with the glover's flitch, or inter- 44 ruptcd futures at \ths of an inch diftance, making Z the 264 Preternatural Labours. Chap. III. 44 the needles pafs through the fkin and part of the 44 mufcles, but not within the cavity, leaving the 44 peritonaeum entire; or, if there is a confiderable 44 effufion of blood and water, let us flitch all but 44 the under-part, introduce into it a foft tent, and 44 cover the whole with a comprefs. The patient 44 is to be kept on a ftria antiphlogiftic regimen du- •" ring the cure." CHAP. III. Preternatural Labours. LABOURS are ftyled Preternatural, " when any 44 part of the child's body, except the head, *' prefents, or is firft felt by the finger, at the mouth 44 of the womb/' We have already faid, that, in the moft natural pofition, the top of the head prefents.; but the feet and breech often firft appear, and the child is deli- vered in that manner. In other cafes of preter- natural prefentation, the pofition muft be altered; and the child, in the language of midwifery, is then faid to be turned. The caufes of preternatural labours probably are, The motion and ftirrings of the fcetus, either na- - turally, or from fliocks affeaing the mother. For, hi Chap. III. Preternatural Labours. 265 in the early months, the fcetus having once altered its pofition, may be prevented from recovering it by folds of the chord round its body and limbs; and, in advanced geftation, if the breech lhould get under- moft inftead of the head, the child will with difficulty be reftored to its proper pofition, as the quantity of water as conftantly decreafing, and the child beco- mingmore bulky. The pofition of the child in the womb may be alfo influenced by its particular figure and conftruc- tion ; the quantity of furrounding water, the length of the chord, the manner of ftretching of the womb, the fhape of the bafin, and a variety of other circum- ftances. We can fometimes difcover that the child prefents in an unfavourable pofition, even when the labour is but little advanced.—We fufpecl it, 1/?, If the pains be more flack and trifling than ufual. 2dly, If the membranes be protruded in a long form, like a gut, or the finger ofa glove. %dly, If no part of the child can be felt when the orifice of the womb is confiderably opened ; or, \thly, If the prefenting part, through the mem- branes, be fmaller, feels lighter, and gives lefs refi- ftance, when touched, than the bulky heavy head. It can with more certainty be afcertained after the membranes, are ruptured, by feeling diftinaiy the prefenting 266 Preternatural Labours Chap. III. prefenting part. If the child's ftools be paffed with the waters, it is a fign either that the breech prefents, or that the child has been for fome time dead; though there are fome-exceptions to this rule. Preternatural labours are difficult of delivery, or hazardous, from, ifl, The health and conftitution of the woman, ar.d figure and dimenfions of the pelvis. 26'Vy, The bulk of the child's budy, and manner of prtfer.ting. idly, The time which has paffed fince the waters were evacuated; for, if that has been long, the womb is rnric ftrongly contraaed, and the prefent- ing part pufhed on, and more firmly locksd in the pelvis. 4thly, From a plurality of children; from the chord falling clown before the prefenting part; betrig entangled with its limbs; or from profufe Hood- ing. The variety of preternatural petitions may be re- duced to the following claffes. I. When one or both of the lower extremities prefent ; as one or both feet, knees, or the breech. • II. When the child lies crofs the pelvis in a rounded or oval form, with the arm, fhoulder, fide, back or belly, prefenting. III. One Clafs I. Preternatural Labours. 267 III. One or both arms protruded before the head. IV. Premature or flooding cafes, or where the navel-ftring falls down double before the prefenting part, and the child's life is in danger from its com preffion. Each clafs of this general divifion includes a vari- ety of particular cafes. By giving a few examples of each clafs, a general idea of the manner of treating the whole will be formed.—It is, however, neceflary to obferve, that, though delivery, in fome preterna- tural cafes, may be eafy, it is always precarious, and often difficult. CLASS I. When one or both Feet, Knees, or the Breech, prefent. Case i. rT",HE fimplefl and eafieft cafe of preternatural la- bour is fuppofed to be, when the child prefents with the feet: but there is fometimes danger left the •head fhould be retained after the delivery of the body, which is lefs when the child prefents double; though, even in that pofition, a firft child frequently lofes its life. We are often able to difcern the prefenting part long before the membranes break, and it is of great Z 2 confequence 268 PretimaturalLabours. Chap. III. confequence to difcover eaily how the child lies; but, in making the neceflary examination, care muft be taken not to prefs the finger againft the mem- branes in time of a pain. When the pref nting part is at a diftance, or the pofition of the child appears doubtful or obfeure, the woman flrould be fhifted from her fide to her back, examined in a fitting po- fture at the pubes where the pelvis is fhallow, or on her knees. A hand is often miftaken for afoot; but the latter may be readily diftinguifhed from the for- mer by the weight and refiftance it gives to the touch, by the fhortnefs of the toes, and the length of the heel. If hen one or both feet prefent in the paffage, little more ought to be done than if the labour were ftria- iy natural, till the orifice of the womb be fuf- ficiently dilated, and the prefenting part advanced at or without the os externum. The woman muft then be placed either on her fide, with the breech o- ver iheedge of the bed, and her head obliquely to the oppofite fide ; or, on her back crofs the bed, fup- ported by an affiltant in the bed to raife her head and ihouldcrs, and an affiftant at either fide of the bed on a low feat, whofe office is to fecure the woman's feet, to feparate her knees, and prevent her from fhifting. When any difficulty in extraaing the head may be fufpeaed, or when the praaitioner is I not very dexurous in the art, the latter pofture is pre- ] ftrable. It is alfo, in general, for young praaiti- oners . ClafsT. The Feel Prefenting. 269 oners, the beft pofition, in all thofe cafes where it is neceffary to pafs the hand into the uterus, to make the delivery by turning the child. When the parts are thus fufficiently open, or the feet, by the force of repeated pains, at, or protruded without, the orifice of the vagina, the operator may then take hold, firft of one leg, grafping it firm? ly above the ankle, and gently endeavouring to pull it down in the time of a pain, not in a ftraight line, but from fide to fide, or from pubes to facrum ; when the pain remits a warm cloth is to be applied to the os externum, and the return of the pain fhould be waited for. The other leg is then to be taken hold of and pulled down in the fame gradual gentle manner with the former : by puiiing alternately firft by one foot then by the other, there is lefs ha- zard of injuring the uterus , than if an attempt were made to bring down both feet at once ; and the paf- fages, being thus gradually ftretched, will be better prepared lor the delivery of the bulky fhoulders and head. When the feet are fufficiently advanced for it, a warm cloth fhould be wrapped round them ; which will enable the operator to take a firmer hold, and defend the child from the hazard of injury by the ex*- traaion. But the cloth fhould be fo applied as to leave the toes expufid ; for they are the proper direaion for turning body. If they already point to the facrum, the child 270 Preternatural Labours. Chap. III. child is to be brought along in the fame direaion, till it ftops from the refiftance of the fhoulders. But if, inftead of pointing backwards, the toes fhould point to the fide or belly, the child's body muft be gradual- ly turned, till the belly be applied to the back of the mother, and the back of the child to the mother's pubes. The proper time to begin to turn, is a little before the breech advances to the os externum. The turn fhould not be made all at once, but gradually ; the child's body muft be firmly grafped with both hands, pufhing a little upwards, then turning to one fide in time of the pain, carefully obferving and favour- ing that line of direaion which the child naturally inclinesto take. The attempt muft be repeated du- ring every pain, till the child's body be turnedround, and the face applied to the facrum of the mother. The motions of the child's head and body do not al- ways exaaiy correfpond. Therefore, after the bel- ly of the child prefles againft the perinaeum of the mother, a quarter-turn extraordinary is ftill neceffa- ry, which muft again be reverfed before the operator begins to extraa. By that means the arm will be prevented from getting under the face, the broad fhoulders will,be applied to the wideft diameter of the pelvis, the face will be turned towards the angle of the facrum, and readily follow in th^t^ireaion. When the breech is entirely protraJw without the Clafs I. The Feet Prefenting. 271 the os externum, the child muft be taken hold of by grafping firmly with the thumbs above the haun- ches, and the fingers fpread over the groins; the ■ extraaion muft be gradually performed, moving from fide to fide, preffing a litlte downwards to- wards the perinaeum, and waiting for natural pains, or refting from time to time. As the belly ad- vances, the operator muft Aide up his hand, or two finders, and very gently draw down a little the um- - bilical cord, left, being tenfe and overftretched, the circulation might be interrupted, and the life of the child deftroyed, which often happens where this pre- caution is negleaed. After the breech is protruded, and the navel-firing begins to be comprefied, from the os tincae grafping it like a ring, the delivery muft be conduaed with all the expedition that the mother's fafety will ad- mit of. When the child is advanced as far as the breaft, its farther progrefs is prevented by the arms going up by the fides of the head. This obftacle muft be removed in this manner: The child's oody ought to be fupported by the left-hand of the opera- tor, which muff be paffed under the breaft of the child, in fuch a manner that the child, may reft on the palm and arm of that harfd; the child muft then be drawn a little to one fide, that two or more fingers of the right-hand may be paffed at the op- pofite fidtir.i«to the pelvis, over the back of the * fhoulder. "27* Preternatural Labours. Chap. III. fhoulder, as far as the elbow, to bring down the arm obliquely along the breaft, gently bending it at the fore-arm, in fuch a manner as to favour the natural motions of the joint. Having then fhifted hands, the other arm muft be difengaged, and brought down in the fame manner. Both arms of the child being relieved, the wo- man may be allowed to reft a little till another pain or two follow; when, by bearing down in the time of the pain, the head will generally be forced down and delivered. But, if the woman be much exhau- (ted, and the head does not quickly follow, the child will be loft from the preffure of the navel^ftring. The pulfation of the arteries in the chord fhould regulate the time for extraaing the head: while the pulfation is ftrong, there is no hazard from delay; if the pulfation be weak or languid, more efpecrally if the chord begins to be cold and flaccid, the extrac- tion muft be quickly performed, otherwife the child will be deftroyed. The extraaion of the head in preternatural labours, is often the moft difficult and dangerous part of the delivery. The caufe of refiftance, when it does not advance, is chiefly owing to its confinement between the facrum and pubes, when the bulky part of the head is detained at the brim, or at the lower part, by the chin catching on the facro-fciatic liga- jraents. The method of delivery is to introduce two fingei-s Clafs I. The Feet prefenting. 273 fingers of the right-hand (which hand and arm at the fame time muft fupport the body of the child) into the mouth, and pull down the jaw towards the breaft; then applying the other hand with the fingers fpread, foas to prefs down the fhouloers, the operator muft rife from his feat, and pull in Vdireaion from pubes to facrum with confiderable lorce, alternately raifing and depreffing the head till it begins to yield, fo that, the chin being conftantly preffed to the breaft, the face will defcend from the hollow of the facrum : the delivery muft then be finifhed, by bringing the hind-head from under the pubes with a half-round turn. During thefe efforts, an affiftant muft be direaed to prefs on the perinaeum ; and, whenever the cir- cumftances of the cafe will admit of it, the exertions of the operator fhould coincide with the natural throes of labour, by which the extraaion will be greatly facilitated. If the pofition be unfavourable, the face, if poffi- ble, fhould be turned towards the facrum, by pufh- ing up the head, or by preffing on the chin ; if the mouth cannot be reached, the preffure fhould be made any where on the lower-jaw; if the difficulty arifes from the folds of the chord round the legs, thighs, body, or neck of ihe child, thefe muft be dif- engaged in the eafieft manner poilible. The contrac- tion of the orificium uteri round the child's neck rarely 274 Preternatural Labours. Chap. IIL rarely proves the caufe of the refiftance, except when the feet are pulled down too early, or in premature labours, when it may be gently ftretched with the fingers, and further endeavours fhould be delayed for fome time. If the head does not v.eld after repeated efforts, in the manner direaed, there is a neceffity for refting fome time; as the head does not fo foon collapfe, and mould itfelf to the paiTage, in preternatural as in natural prefentatiops. Whatever obftacle prevents it from advancing, it will ftill be prudent to reft for a little; and, after a proper interval, renew our ex- ertions by thus alternately refting, and attempting to cxtraa, the head will yield, and the child may be fa- ved, after a confiderable exertion of force has been ufed. If the caufe of refiftance appears to be the extraor- dinary bulk of the head from hydrocephalus, the te- guments may be burfted by the the force of pulling, by thrufting a finger through them, or by perforating the cranium with the long fciffars. If by th-i violent exertions employed, there is ha- zard of diflocating the cervical vertebrae, and fepara- tin" the body from the head, the operator muft cau- tioufly deiid from pulling, an d wait for the con- tritions of the uterus, employing his exertions du- ring the time of pains only. If the head is ofa monftrous fize, or the pelvis very Clafs I. Preternatural Labours. 275 very faulty, the former muft be opened with the fcif- fars at the bafis of the fkull, and the extraaion after- wards performed with the crotchet. The fingers of the operator introduced into the mouth, or preffing on the upper or lower-jaw, wiil be fufficient to accomplilh the extraaion of the head where there is no great difproportion between it and the pelvis ; fo that the forceps will feldom be necef-^ fary. In more difficult cafes, the crotchet muft be ufed. Cafe 2. When one foot only is protruded into the Va- gina, the other is fometimes detained bv catching on the pubes, and, if eafily come at, fhould be brought down, always obferving to humour the natural mo- tion of the joint; but, if the leg fhould be folded up along the child's body, or of difficult accefs, the at- tempt is not only troublefome, but dangerous, as there is hazard of tearing the uterus. It is lefs ne- ceffary, as the breech will be either naturally forced down by the afiiftance of pains, or by pulling at one leg only. Cafe 3. When one or both knees prefent, the legs of- ten cannot be brought down, till the breech be gent- ly raifed and pufhcd a little back into the pelvis. Cafe 4. If the feet fhould offer along with the breech, it mult be cautioully thruft back, while the former are fecured and brought down, till the pofition be A a rcdu- 276 Preternatural Labours. Chap. III. reduced to a footling-cafe, and the delivery otherwife managed as already direaed. Cafe 5. The Breech. The varieties of the breech are, \fl, The fore-parts of the child placed to the pu- bes of the mother; idly, To the facrum.; ^dly, To either fide. Sometimes the pofition of the breech may be dif- covered before the membranes break; but after- wards with more certainty, by the meconium of the child accompanying the waters ; and by feeling the buttocks, thighs, or genitals of the child to the touch. In whatever manner the breech prefents, the de- livery fhould be fubmitted to nature, till the child be advanced fo far, that the feet can be laid hold of and brought down. If the fore-parts of the child be already placed towards the facrum of the mother, no- thing elfe is neceffary but to fupport the child till it advances fo low, by the force of the natural pains, .that the feet can be readily and fafely brought down. If the fore-parts of the child be placed anteriorly or laterally to the mother, when the child is fo far advanced that it can be laid hold of and wrapped in a cloth, the mechanical turns muft be made, and the delivery finilhed, as directed in footling-cafes. There is much lefs hazard, in general, in allow- ing Clafs I. The Breech prefenting. 277 ing the child to advance double, than in precipita- ting the extraaion, by pufhing up to bring down the feet, before the parts have been fufficiently dilated : a praaice difficult and troublefome to the operator ; painful, and fometimes dangerous to the mother; and by which the child is expofed to the rifle of ftran- gulation, from the retention of the head after the de- livery of the body. If the child be fmall, though doubled, it will eafily pafs in that direaion ; if large, though the labour fhould be painful, the natural throes are lefs violent and dangerous than the pain occafioned, firft, by introducing the hand with a view to turn ; and, 2dly, by pufhing up the child in order to lay hold of the feet and bring them down. If the child advances naturally, it will be lefs expo- fed to fuffer ; if it fhould not advance, there is this advantage, that the parts of the mother will be pro- perly prepared, when the ftrong pains are abated, for paffing the hand into the pelvis, to raife up tfre breech, fearch for the feet, bring down one or both, and deliver. The propriety of this mode of.treatment'is fupport- ed by the pains being often ftronger in breech-cafes than in natural labour ; but it cannot be followed when the mother is weak, and the pains are trifling ; when fhe is affeaed with floodings or convulfions; when the child is of a very large fize, or the pelvis narrow ; when the umblical chord falls down, and is 2"j% Preternatural Labours. Chap. III. is comprc-fled between the thighs of the child, or be- tween the child and the pelvis, and cannot be redu- ced above the prefenting part. The prolapfus of the navel-ftring generally ac- corrpaniesil.at pofition of the breech, where the child prefents wilh its fore-parts to the belly of the mother. S.imuimes the chord can be reduced, and the child's life preferved : hc.\, if the breech be far advanced, nod the pains Hrong, it is not only difficult, but Iia- xa;dm«, to pufh up the child ; who can feldom, in feich circumlfances, be preferved. It is better, therefore, to let the child come as it will, if there are pains, rather than hazard the more important Lie o'i the mother by attempting to pufh up and turn it. But, in all doubtful and perplexing cafes, when ihere is time for it, the advice of a more fki'ful praai- tioner ought to be taken. WThen the breech is fo far advanced, that a finger er two can be paifed under the bended thigh, as far as the groin of the child, aliitance may be given wilh advantage, by alternately pulling, firft at one f:d:, then at the other, in time of the pain. But <>jeat care ought to be taken not to miftake the ihoulder for the breech, and not to injure the child by violent pulling, or unequal preffure. Such errors have often been commmittcd, and the confequences have been fatal. In breech-cafes, the greateft caution is ncceffarT, when Clafs II. Crofs Cafes. 279 when the genital parts prefent, left the child fhould be injured by too frequent touching. CLASS II. When the Child lies crofs in a rounded or oval form, with the Arm, Shoulder, Side, back, or Belly, prefenting. TN the former clafs, though the birth may fome- -*- times, when the child is fmall, be accomplifhed without manual affiftance ; when the child liesacrofs, no force of pain can make it advance in that pofition; and without proper aid, both mother and child would perifh. Ifafkilful praaitioner hath the management of the labour from the beginning, the child may gene- rally be turned, in the worft pofition, without much difficulty : but, when the waters have been for fome time evacuated, and the uterus is ftrongly contraaed round the child's body, turning will be difficult and laborious to the operator; painful, and even dange- rous, to the mother. For it ought to be confidered, that the »reat difficulty and hazard of turning, are chiefly owing to ihe refiftance which the uterus gives ; not fo much to the pofition of the fcetus. When the water, in whole, or in part, is retained, there is eafy accefs to reach the feet and bring them down ; but, in proportion as the water is evacuated, the ute- rine cavity becomes lefs fpacious, and turning is A a 2 render- 280 Preternatural Labours Chap. III. rendered both troublefome and dangerous. It was the old praaice, in preternatural labours, to endea- vour to make the head prefent ; but, on account of its bul.;, it could feldom be done, and the force em- ployed in making the attempt was often attended with fatal confequences. The method of delivering by the feet is the moft important modern improve- ment in the pradtice of midwifery ; an improvement to which many thoufands owe their lives. When the child lies in a tranfverfe pofition, the management is very fimple. We muft gently pafs the hand into the uterus, to fearch for the feet, bring them down with the utmoft caution, and finifh the delivery as direaed in footling-cafes; for which pur- pofe the following rules fhould be obferved. Rules for turning the Child. i. The woman muft be placed in a convenient pofture, and kept fteady by affiftants, that the opera- tor may be able to employ either hand, as the cir- cumftances of the cafe may require. 2. Though the beft pofture for the operator, in general, as well as the patient, is the left fide, with her breech placed over the edge of the bed, and her knees kept feparate with a folded pillow, it.will be fometimes neceffary to turn her to her back ; and in thofe cafes where the child's feet are of difficult accefs, or where they lie towards the fundus uteri, the wo- man fhould be placed on her knees and elbows. 3. The Clafs II. Crofs Cafes. , 281 3. The orificium uteri fhould be enlarged fo much as to admit the hand to pafs freely ; and the ftrong pains fhould be abated, before any attempt be made to deliver. 4. It is of great confequence to endeavour to learn the pofition of the child, and to attend to the fhape and dimenfions of the pelvis, before attempting to make the delivery. 5. In preternatural cafes, every poffible means ought to be ufed to preferve the membranes as long as poffible. If they fhould break before the hand is introduced, and the ftate of the parts will admit of it, the hand fhould be quickly after paffed; part of the water being thus retained, the operation of turn- ing will be greatly facilitated. But, if the waters be drained off, and the uterus rigidly contraaed round the body of the child, warm oil fhould be injeaed into the uterus, to leffen the rigidity of the parts, and a full dofe of laudanum fhould be exhibited, pre- vious to any attempt to procure delivery. 6. The hand and arm of the operator muft be lu- bricated with pomatum, before attempting to intro- duce it into the vagina; the fingers muft be gathered together in a conical form, and the refiftance of the os externum be overcome by very flow a.id gradual degrees. 7. In paffing the hand into the uterus, it ought to 2*2 Preternatural Labours. Chap. III. to be done in the gentleft manner, but with a cer- tain degree of refolution and courage. The paffages fhould be well lubricated with butter, or pomatum ; the line of the vagina and pelvis carefully attended to ; the movements of the operator muft be flow and gradual; and thus, by giving time, the utmoft rigi- dity in the foft parts may be overcome. 8. The hand ought to be introduced only during the remiffion of pain ; when the pain comes, the ope- rator fhould flop, otherwife there is great hazard of pufhing the hand, or fome part of the child through the fubftance of the uterus. 9. The hand fhould, if poffible, be introduced by the fore parts of the child, as the feet are generally folded along the belly ; and both feet, if eafily come at, fhould be laid hold of. 10. In pufhing back any part of the body of the child to come at the feet, the palm of the hand, or broad expanded fingers, muft be ufed. This part of the operation fhould be performed always during the remiffion of pain, which fhould alfo be obferved in bringing down the legs; but in making the extrac- tion of the body, when the legs are in the proper line of direaion, the efforts of the artift ought always to co-operate with thofe of nature. 11. As the breech advances through the pelvis, the child, if not already in the proper pofition, muft Clafs II. Crofs Cafes. 283 muft be gradually turned with the fore-parts pofteri- orly to the mother. 12. Praaitioners in midwifery fhould be cautious of giving credit to any report of the child's death ; for moft of the fymptoms are fallacious. Children are often born alive when there is little reafon to expea it: Therefore, in pufhing up, bringing down the legs, or extraaing the body, the child fhould never be treated roughly, but handled with the greateft delicacy. 13. When the hand is within the pelvis, and there is a neceflity for paffing it pretty high in the uterus to fearch for the child's feet, the proper direaion is not precifely in the line of the navel, as Dr Smel- LiEadvifes; but inclining it a little to one fide, to avoid the prominent angle of the facrum, by which more room will be gained, and lefs pain given to the woman ; for the womb preffes ftrongly there. 14. When the hand is interrupted in paffing, by the fpafmodic contraaion of the uterus, we muft defift from further infinuation, till the conftriaion of the uterus is fomewhat abated. 15, If the hand cannot pafs beyond the prefent- ing part of the child to come at the feet, inftead of ihrufting back the prefenting part with violence, it fliould be, as it were, firft raifed up in the pelvis, and then moved to the oppofite fide. By this means, diffi- 284 Preternatural Labours. Chap. III. difficulties, otherwife infurmountable, may be re- moved, and great danger often prevented. 16. When both feet cannot readily be ob'ained, the foot and leg of the prefenting part fhould be endeavoured to be firft brought down. Hence more room will be procured for fearching for the other foot, and the extraaion will be performed with moreeafe and fafety. 17. If the fecond foot cannot readily be found or brought down, the child may be extraaed with the utmoft fafety by one foot only, provided we proceed flowly in the operation. 18. When the foot or feet begin to protrude with- out the os externum, let them be covered with a foft cloth, and the advantage of the natural pains improved to affift the extraction. 19. In all preternatural labours, when the child is delivered as far as the breech, the ftriaure of the navel-ftring fhould be removed, by gently drawing it down a little, as already direaed. 20. As the breech advances towards the os exter- num, the proper means for guarding againft lacera- tion of the perinaeum muft be attended to. 2r. Th.' arms are to be relieved, and the head extraaed, in the manner already direaed in footling- cafes. 22. Children delivered hy the foot, are not only often ftill-born, but the body is fometimes fepara- ted Jk r i Clafs II. Crofs Cafes. 285 ted from the neck, and the head left behind in the cavity of the uterus ; an accident which can only happen by the raflinefs, negligence, or unfkilfulnefs of the praaitioner. The caufes chiefly are, ift, The putrid ftate of the child's body in confequence of its death ; 2dly, The neglea of the operator to make the proper turns when extraaing the body ; i^dly, The narrownefs of the pelvis, or bulk of the child's head. To prevent it when the child's body is putrid ; the operator fhould never attempt to extraa the head till two fingers be introduced into the mouth ; and by pulling down the jaw, and preffing on the fhoul- ders, while an affiftant preffes gently on the woman's belly, and the woman herfelf bears down in the time ofa pain, the extraaion may generally, unlefs when the pelvis is narrow, be effeaed. 23. If the head fhould be aaually feparated and left behind in the womb, and cannot be extraaed by introducing two fingers into the mouth and wait- ing for the affiftance of pains, and the forceps fliould fail, the crotchet muft be ufed. The me- thod is to keep the head fleady by the preffure of an affiftant on the woman's belly, the head is opened with the fciffars, and extraaed with the crotchet according to the rules already given. By attending carefully to the above rules, lacera- tion of the uterus, floodings, convulfions, inflam- mation, *86 Preternatural Labours. Chap. III. mation, and their confequences, may be prevented, and the child's life often preferved, even when it prefents in the moft awkward pofition. We proceed to confider a few particular cafes Cafe i. The Arm prefenting.—This pofition occurs frequently. It is of fome confequence to form a ge- neral notion how the child lies, before the operator fits down to deliver. The right-hand, by a little at- tention, may be readily diftinguifhed from the left, if we lay hold of the child's hand, in the fame man- ner as in fhaking hands. It is often in the power ofa fkilful praaitioner to prevent the hand from coming down, or to reduce it when it protrudes. But, if the arm be forced into the paffage fo low that the fhoulder is locked in the pelvis, it is needlefs to give the woman the pain of at- tempting the reduaion, unlefs when the head can be made to prefent, as the hand of the operator can be paffed into the uterus by the fide of the child's arm, which will of courfe return into the uterus, when the feet are brought down into the vagina. As the head, in this cafe, cannot eafily be made to prefent ; in order, therefore, to make the delivery by turning the child, the hand and arm ofthe operator, well lu- bricated, muft be conduaed into the uterus by the fide of the child's arm, along the breaft and belly of the child, towards the oppofite fideof the pelvis, where the head lies. If any difficulty occurs in coming at the p Clafs II. TJje Shoulder prefenting. 287 the feet, the hand already introduced muft be with- drawn, and the other paffed in its ftead. If ftill the hand cannot eafily be pufhed beyond the child's fhoul- der and head, the prefenting part muft be gently rai- fed up, or cautioufly fhifted to a fide, that one or both feet may be taken hold of, which muft be brought as lowas poffible, pufhing up the head and fhoulders, and pullingdown the feel, alternately, till they advance into the vagina, or fo low that anoofe or fillet can be ap- plied ; and thus, by pulling with the one hand by means of the noofe and pufhing with the other, the feet can be brought down, and the delivery finifhed in the moft complicated and difficult cafes. The method of forming the noofe is, by paffingthe two ends of a piece of tape or garter through the mid- dle when doubled ; or, if the garter be thick and clum- fy, by making an eye on one end, and paffing the other extremity through it. This muft be mounted on the points of the fingers and thumb of the hand of the operator, who muft take hold of the child's foot, flip it over the foot and ankle, and fecure it by pulling at the other extremity. Cafe 2. The Sh.ulder.—Great care ought to be ta- ken that it may not be miftaken or tie buttock. The fhoulder will feel haider and more bony than the full thick fleihy hip ; a m rk which ma:. be tak n along with the others form.rly mentioned in Breech-ca- fes. B b Though 2o8 Preternatural Labours. Chap. III. Tho' the child fhould originally prefent with the fhoulder, when the orificium uteri is dilated, the arm if not prevented, may readily be forced by the repeat- ed efforts of the labour-throes into the paffage. In proportion as the prefenting part advances, and the fhoulder becomes locked in the pelvis, delivery by turning will be mcrre difficult and hazardous. Except the child be of a very fmall fize, and the hand preffed clofe to the fide of the head, it is impof- fible for the head and arm to pafs together; it is, therefore, cruel and barbarous to pull the arm in or- der to deliver the child in that way. The arm has been often torn from the body, and the mother has died in the attempt. Cafe 3. The Side.—This is difcovered by feeling the ribs. Cafe 4. The Back.—This is difcernedby feeling fome part of the fpine or back bone. Cafe 5. The Belly—It is known by the foft yield- ing fubftance of the part, and by the falling down of fome portion of the umbilical chord. These three prefentations, viz. the fide, back, and bcih, more rarely occur, as the uterus will with dif- ficult v admit of fuch pofitions. When any of thefe parts do prefent, they feldom advance much beyond the brim of the pehis, and the child is in general as eafily turned as in other prefen- tations which more frequently occur. The Clafs III. The Arm Prefenting. 289 The belly, from the difficulty with which the legs can be bended backwards, unlefs the child be flaccid, putrid, or before the time, will very feldom direaiy prefent; if it does, it will be early and eafily difco- vered by the prolapfus of the chord, and there will be no difficulty to come at the feet, and deliver. The rule in all thefe cafes is, to infinuate the hand into the uterus, in the gentleft manner poffible, when the ftate of the parts will admit of it, to fearch for the feet, bring them down, and deliver, agreeably to the direaions already given for that purpofe. CLASS III. One or both Arms prefenting, and the Head flowing nearly in the fame direclion. THE moft difficult and laborious of the preterna- tural labours occur,—Woen the child lies longitu- dinally in the uterus, with the arm or Jhsidder prefect- ting, and thehcad more or lefs over the pubes, or repng on one fide, at the brim of the pelvis, the feet towards thefundis uteri, the waters evacuated, and the uterus clofely contrasted round the child's body. When the arm protrudes in this manner, it ought, if pcflible, to be reduced, and the head brought down into the pelvis; for it is often equally difficult and dangerous to deliver by the feet, and fometimes ut- terly impraaicable. Afkil- 29° Preternatural Labours. Chap. III. Afkilful praaitioner, having the management of the delivery from the beginning, will often be able to prevent the protrufion of the arm, which ought to be attempted as foon as poffible after the rupture of the membranes. If he fails, and the arm fhould be forced down, the earlieft opportunity fhould be taken to reduce it. If fuccefsful, it will prevent much future trouble ; it will be a happy circum- ltance for the mother, and may be the means of preferving both her life and that of the child. With this view, when the pofition of the woman is adjuft- ed, the hand of the operator, well lubricated, muft be infinuated thro' the vagina into the uterus, con- duaed by the child's arm, till it reaches as far as the axilla or fhoulder. The fhoulder muft then be raifed up, and fhifted, as it were, obliquely, to the fide of the pelvis, oppofite to that to which it inclines. By this means the pofition of the child will be fome-what altered, and the arm drawn up within the vagina, fo that it will be afterwards no difficult tafk to reduce it completely. But, fhould this method fa;!, an attempt may be made to pufh up the fore-arm at the elbow; and, in bending it, great care muft be taken to avoid over-ftraining, or diflocating the joint. Thefe attempts muft only be made in the intervals of pain : when the pain recurs, the operator ought immediately to defift ; for, by pufhing in time of the pain, or in an improper di- reaion, Clafs III. The Arm prefenting. 291 reaion, the uterus may be torn, and the moft fatal confequences foon enfue. In whatever manner the reduaion of the child's arm fhall be acccmpiiihed, if any method proves fuccefsful, it muft be retained in the uterus by the hand of the operator, till the child's head, by the force of the next pain, fills up the pelvis, and pre- vents its return ; otherwife the arm will be protruded as often as it is reduced. But, if the orificium uteri be not fufficiently open- ed to admit of the reduaion of the protruding arm with fafety ; if, as the arm advances, the head reclines to one fide of the pelvis, the throes of labour are violent, and the intervals fhort; it would then be as dangerous to the patient as difficult to the operator, to attempt delivery by manual exertions; for the fpafmodic contraaions of the uterus coun- teraa every artificial effort; and if much mechani- cal force be ufed, the uterus is in hazard of aaual la- ceration. In thefe circumftances, regardlefs of the anxiety of the patient, or the importunities of the attendants, the operator fhould defift for fome time from further efforts ; a large dofe of liquid laudanum fhould be given, as from 50 to 70 gutts ; and when the parts are fufficiently dilated, and the ftrong for- cing pains abated, his attempts fhould then be renew- ed, either to reduce the arm, or infinuate his hand beyond it to come at the feet, bring them down, B b 2 and 292 Preternatural Labours. Chap. III. and deliver. If thefe attempts fliould fail, he may endeavour to alter the pofition of the child, by fixing a noofe on the arm, and pulling by it. More eafy accefs may be then obtained to the anterior parts of the child, by which the hand can be conduaed to the feet. But, if every method fhould prove ineffec- tual either to reduce the arm or bring down a foot, and the woman's life is in danger, the head of the child, if it caifbe reached, muft be opened; after a proper interval, a crotchet introduced ; and the extraaion made by pulling at it and the protruded arm. Should the head be without reach of the fciffars, the crotchet muft be fixed on the trunk or thorax, with a view to bring down the breech or feet; by fecuring a firm hold of the arm, and pulling by the cortchet, the delivery muft, in that manner, be accomphfhed ; a mode of praaice which fhould only be had recourfe to when the pelvis is faulty, or the patient's life in immediate danger. Ik the longitudinal contraaion of the the uterus, when an arm prefents, and the fhoulder is advanced in the paffage, fo that the feet cannot eafily be come at, Dr Denman advifes 44 to pull the body lower 44 down by the arm, and the difficulty will be lef- " fened or removed." 44 There is, happily (he adds), 44 no neceffity of turning the child in thefe circum- '• fiances; for it will be born by the effea of the 44 powers Clafs HI. The Arm prefenting. 293 44 powers of nature only. In fuch cafes the child 44 does not come double, but the breech is the firft 44 part delivered, and the head the laft, the body turn- 44 ing upon its own axis." He adopts this opinion from four cafes which oc- curred in his own praaice, and feveral fimilar hi- ftories related by others ; in all which, however, the child was dead. He therefore infers, " That, in cafes in which 44 children prefent with the arm, women would not 44 neceilarily die undelivered, tho' they were not af- 41 fitted by art." He concludes his obfervations with this important remark. 44 The benefit we are to derive in praaice from the 44 knowledge of this faa is, that thecuftom of turn- 44 ing and delivering by the feet, in prefentations- 44 of the arm, will remain neceffary and proper in all 44 cafes in which the operation can be performed with 44 fafety to the mother, and give a chance"of prefer- 44 ving the life of the child ; but, when the child 44 is dead, and when we have no other view, but 44 merely to extraa the child, to remove the danger. " thence arifing to the mother, it is of great impor- 44 tance to know, that the child may be turned fponta- " neoufly by the aclion of the uterus *." Dr * See DrDENMAN's Aphorifms refpecSting the Distinction and Management of Preternatural Prefcntation.—A fmall fyllabus which contains fome of the moft important practical rules of the art. 294 Preternatural Labours. Chap. III. Dr Den man's remark is new to me. In a cafe where the powers of nature have been ufually confi- dered as defperate, it is new, perhaps, only becaufe the praaitioner has thought it ufelefs to wait for them. But though curious, as it fhows what nature in her ftruggles can perform ; and though furprifing, as it apparently contra'dias the laws of motion ; it feems to me unneceffary, as in the numerous arm- prefentations which I have attended, the child has for the moft part been preferved, and the woman has feldom fuffered any material injury from the delivery. I have therefore continued to praaife the meihod which Ihavejuft recommended; and, in the moft intricate prefentations, have generally fucceeded in making the delivery by fixing a fillet on the arm, and altering the pofition in the manner mentioned, when every other method had failed. I have never yet known a cafe to occur where the pelvis was tolerably proportioned, in which I could not either obtain accefs to the feet to deliver by turning, or reduce the aim and bring down the head ; and have, in feveral cafes, fuccefsfully turned where the pelvis was coniiderabiy diftorted *. It * In prefence of the Gentlemen who attended my Lectures - laft fummer, I delivered a woman in the public lying-in ward, Royal Infirmary ; the circumftances of the cafe were as follows. The arm of the child prefented, and had been in the paffage, with Clafs III. The Arm prefenting. 295 It may be neceffary, however, to ftate the princi- ples of this operation, that we may be aware how far to truft the unaffifted efforts of the conftitution. The longitudinal contraaion of the uterus, is one of thofe blind and indifcriminate attempts which na- ture fometimes makes to free herfelf from a burden. When her powers are exhaufted, thefe efforts are di- miniflied, and the uterus is relaxed. In thefe cir- cumftances, then, if we can fix the arm, the body will of itfelf turn as on an axis ; and the heavier part, or the breech, will come downward and be deli- vered: The arm is fixed by drawing down the fhoul- der; but it will be obvious, that the natural falling clown of the breech will immediately draw it back again ; and it is in this way that the child does not ultimately come down double. This operation can be eafily imitated on machinery, if the aperture is con- ical to fix that part which reprefents the arm; and it is in this way clear, that the contradiaion to the laws of motion is apparent only. In the manner we havejuft flated, this mode of de- livery with the waters drained, from the preceding evening. The pel- vis was confiderably diftorted, and the crotchet had been ufed in her former deliveries. The woman is of an under-fize, of a feeble conftitution, and the paffages were fo tight as to cramp the hand when introduced into the pelvis. By gradual ftretching, and gen- tle infinuation, I with fome difficulty reached a foot, and accom* plifhed the delivery without the afiiftance of any inftrument. 296 Preternatural Labours Chap. III. livery may feem to be preferable; but various cir- cumftances diminifh its advantages. DrDENMAN has very properly limited it to the delivery ofa dead child, and we may add a well-proportioned pelvis: but, even there, we exhauft the powers of nature, without an adequate advantage ; efpecially if we re- flea, that, in this exhaufted ftate, an inconfiderable increafe of the ufual difcharges may prove fatal. Thefe faas may, however, teach us, not to at- temp the extraaion by turning too early ; for by a little delay till the ftrong pains are abated, it will be more praaicable, and my fuccefs has fully confirmed its fafety. When loth arms prefent, the delivery muft be con- duffed much in the fame manner as when one only prefents. The former cafe is nearly as eafily mana- ged as the ihe latter, as the head feldom advances far in that pofition, being locked in the pelvis, as it were by two edges ; fo that the arms can either be reduced, with a view to bring down the head, or there will be eafy accefs to come at the feet, to bring them down and deliver *. CLASS • During an extenflve practice, I ha-e only feen two inftances ip. which b*tb arms prefented ; and they occurred in Twin Ceil.. Jh Clafs IV. Method of Turning. 297 CLASS IV. Method of turning the Child while the Membranes are whole, or foon after their rupture.—Method of Delivery in Flooding Cafes, and when the Navel- firing, prefents. HEN the membranes remain entire till the foft parts of the mother are fo much dilated, that the hand of the operator can readily find admit- tance ; or when the hand can be paffed within the u- terine cavity, immediately after the membranes break, fo that great part of the water may be retained ; the delivery may be accomplifhed, in the moft unfavour- able cafes, with eafe and fafety. But, when the waters have been long evacuated, and the uterus is rigidly contraaed round the body of the child, the cafe will prove laborious to the operator, painful to the mother, and dangerous to her and the child. When there is reafon to fufpea a crofs-birth, which can often be known, either by feeling the pre- fenting part through the membranes or by fome of the figns already mentioned, the woman fhould be managed in fuch a manner that the membranes may be preferved as long as poffible ; for this purpofe fhe fhouid be kept quiet in bed, and placed in that pof- ture leaft favourable for ftraining, or the exertion of force, in the time of a pain. She fhould be touched as w 49^ Preternatural Labours. Chap. III. as feldom as poffible, till the orificium uteri be fuf- ficiently dilated. She fhould then be placed in a pro- per pofition for delivery, that the hand of the opera- tor may be gently infinuated in a conical form, with the fingers gathered together, through the vagina in- to the uterus. The hand muft be paffed on the out- fide of the membranes between and the uterus, in a direaion towards the fundus. The membranes may then be broken, by pinching them between a finger and thumb, or by forcibly thrufting a finger againft them in time of a pain. The hand muft now be direaed where the feet may reafonably be expeaed to lie ; one or both of which muft be taken hold of, and brought down. If the membranes fhould be rup- tured in the attempt, the hand muft be paffed up in- to the uterus as expeditioufly as it can be done with fafety. Part of the waters being thus retained by the introduced arm, the operation of turning will be greatly facilitated. If the membranes fhould be ruptured before the o- rifi-ium uteri be fufficiently opened to allow the hand to pafs, even in thefe circumftances, it is neceffary that the woman be kept quiet in bed, and the fame precautions fliould be ufed as if the membranes were entire; for the retention ofa fmall quantity of wa- ter is of great confequence in turning. After the hand is introduced into the cavity of the uterus, if the placenta fhould be found to adhere at that Cfefs IV. Delivery in Flooding Cafes. £99 that fide, and to interrupt the hand of the operator from paffing, it muft be withdrawn, and the other hand be introduced at the oppofite fide. Method of Delivery in Flooding Cafes. Floodings, as already explained, proceed from a feparation of fome portion of the placenta, or fpon- gy chorion, from the internal furface of the uterus. But the moft dangerous haemorrhagies arife from a feparation of the cake when attached to the cervix, or over the orificium uteri *. Floodings, before the 7th month of geftation, may be often checked by the management formerly di- reaed ; after which period, however, there is al- ways confiderable danger. And, as it is fometimes neceffary to deliver, even when no part of the placen- ta can be reached with the finger, the conftant atten- dance of the praaitioner is requifite, and the utmoft judgment to catch the proper time of proceeding. There is hazard in attempting delivery too ear- ly, while the os uteri is clofe and rigid. When the woman, from 'lofs of blood, is fomewhat funk, the uterine orifice is more relaxed and dilatable. The time can only be determined by conftantly flaying with the patient, and examining the ftate of the os uteri occafionally. In fo critical a fituation, the C c neglea * See the article Flooding in Pathology of Parturition. 3°° Preternatural Labours. Chap. III. neglea of half an hour, or lefs, may be fatal to the mother and child. The beft praaice in this cafe is, firft, to wait on; giving opiates at proper intervals, and keeping the woman quiet and cool. If poffible, delivery fhould never be attempted till pains occur, and the mem- branes begin to protrude. Pains may be brought on, or increafed, by gently irritating the os tincae. The membranes may then be broken by pufhing a fin- ger, or the catheter, thro' them ; the water, gufh- ing out, the womb contraas and ftops the bleed- ing. We can now fafely wait for fix, twelve, or twenty-four hours, if neceffary, till the pains recur, and then deliver according to the prefentation. But, if the flooding fhould not then abate, or if the pofi- tion of the foetus be unfavourable, the hand muft be paffed into the uterus, the feet of the child taken hold of and brought down. The uterus now con- traaing, foon ftops the flow of blood, or prevents an exceffive difcharge : therefore, after the feet are brought down, the body of the.child fhould be extraa- ed by very flow and gradual efforts; left, from too fudden evacuation of the uterine contents, fatal fainting* or convulfions might enfue. Flooding, from the attachment of the placenta at the crlficium uteri, will be fufficiently indicated by its alarming appearance and rapid increafe, and by the foft pappy feel of the cake to the touch; though, when Clafs IV. Delivery in Flooding Cafes 301 when there is little dilatation of the os tincae, it will be neceffary to introduce the whole hand into the vagina, in order, more certainly, to be able to feel the placenta with a finger introduced within the os internum. In thefe unhappy cafes, there is no method of faving the woman, but by immediate delivery. We are fometimes obliged to pafs the hand at an opening made through the body of the placenta; but, if poffible, the hand fhould rather be infinuated at the fide of the cake, where the leaft portion is attached, to go into the uterus, break the mem- branes, fearch for the child's feet, bring them down, and deliver. In fome inftances, before the orificium uteri can be fufficiently opened to admit the hand of the ope- rator to pafs, the whole cake will aatially be difen- gaged and protruded ; but the feparation and expul- fion of the placenta, previous to the birth of the child, is, for the moft part, fatal to the mother. Much of our fuccefs, in thefe alarming cafes of flooding*, will depend onpying with the zvoman, and trying the dilatability of the orificium uteri from time to * See Mr Rigbv's valuable Treatife on this Subject already referred to.—See alfo Dr Leak's obfervations on the nature and Treatment of Uterine Haemorrhagies before and after delivery. Practical Obfervations on the chiiu-bed Fever, <3cc. jth Edition, p*2i3. 302 Preternatural Labours. Chap. III. to time : for, after fhe is funk to a certain d egree, the mufcular fibres of that organ lofe their contraaile rower, the flow of blood increafes, and, if neglea- ed, flie foon dies; fo that the prefenceof the operator tan only fave her. In cafes fo ftriaiy critical and hazardous, two praaitioners fhould therefore be called, for one ought to be in conftant waiting. Prolapfd Funis—A preffure on the umbilical cord, pcthaps tor ten minutes, by interrupting thecircula- tation, will be fufficient to dtfivoy the life of the child. A ccoldr.cfs and want of pulfation in the cord, is the moft infallible fign of the child's death; therefore, if any portion of the former be protruded before . any bulky j art of the child, there is hazard of the lofs of the child, unlefs the labour be foon over. The danger can only be prevented by rc-placing the cord, and retaining it above the prefenting part ! of the child, till it be fo far protruded by the force uf the pain, as to prevent the return of the cord ; | or, the child muft be turned and delivered by the feet, j (for the forceps cannot be ufed till the head be well ..chanced in the pelvis.) But it is often difficult to reduce the cord, and much more fo to turn the child. For, if the pains be ftrong and frequent, the confe- quence of fuch attempts may be fatal to the mother. If the child be of an ordinary, or fmall fize, and the pelvis be well formed ; if the labour goes on quick- Clafs IV. Delivery in Flooding Cafes. 303 ly, and efpecially if the woman had formerly good deliveries ; the child may yet be born alive. If, on the contrary, the child exceeds the ordinary fize, or the pelvis comes fhort of its ufual dimenfions, turning would prove a dangerous operation to the mother, and there is little profpe