>3 TF8 **$ ' Surgeon General's Office AN ESSAY ON THE MEANS OF LESSENING PAINS OF PARTURITION BY PETER MILLER, OF PHILADELPHIA; LATE HOUSE SURGEON OF THE ALMS HOUSE AND HOUSE OF EMPLOYMENT. /^3 3 In our attempts, therefore, to improve and extend the means of lessening them, we do but develope the kind and benevolent dis- position of the Creator of the world to the human race. Rush. /& PHILADELPHIA: *Ui, AUIUOK. BY HUGH MAXWELL, XO, 25, XORTII ^ AN INAUGURAL DISSERTATION <^ ^ FOR ^t THE DEGREE OF DOCTOR OF MEDICINE: SUBMITTED TO THE EXAMINATION OF THE REVEREND JOHN ANDREWS, D. D. Provost, (pro tempore), THE TRUSTEES, AND MEDICAL PROFESSORS OF the UNIVERSITY OF PENNSYLVANIA, ON THE FIRST DAY OF JUNE, ONE THOUSAND EIGHT HUNDRED AND FOUR. / XP/f- ^sL^^ ££ t^^M^'/i^fr^'• TO PHILIP SYNG PHYSICK, M. D. THIS ESSAY IS INSCRIBED AS A SINCERE TRIBUTE OF RESPECT FOR HIS ABILITIES, AND GRATITUDE FOR THE FRIENDLY ATTENTION WITH WHICH HE HAS HONOURED HIS PUPIL THE AUTHOR. TO WILLIAM SHIPPEN, M. D, PROFESSOR OF ANATOMY, SURGERY AND MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, THIS ESSAY IS LIKEWISE RESPECTFULLY INSCRIBED BY HIS FRIEND THE AUTHOR. ALSO, TO JOHN CHURCH, M. D. AND MR. SAMUEL ELDREDGE, MERCHANT, THE FOLLOWING PAGES ARE INSCRIBED AS AN ASSURANCE OF THE RESPECT AND ESTEEM ENTERTAINED FOR THEM BY THEIR FRIEND, THE AUTHOR. AN ESSAY THE MEANS OF LESSENING PAINS OF PARTURITION. The Diseases peculiar to the female sex, and more especially those connected with a state of pregnancy are highly interesting, and have, at all times, excited the greatest attention of physicians. It appears to be peculiarly hard, that the fairest and loveliest part of the creation should suffer more than an equal share of the evils that afflict mankind. They not only participate in almost all the diseases to which man is liable; but are also subject to a long train of suffering and distress in consequence of complying with a duty imposed upon them by the great author of nature, for the purpose of propagat- ing the human race. They have therefore, a strong claim, not only to our sympathy; but also to every exertion that can be made to alleviate their pains. We accordingly find that medical men very early began to investigate the nature of their complaints, and to propose suitable remedies for their removal; but although great progress has already been made, there yet remains a wide field for improvement. Numerous treatises have been published on the art of midwifery, in which the greatest attention has been paid to the operative part; but an attempt to lessen the pains of parturition, appears to have been almost entirely neglected. We cannot account for this neglect in a more satisfactory manner than by supposing, that all those who have written on this subject were of opinion that pain is necessarily connected with parturition. That practitioners have held such an idea is sufficiently obvious: hence we find an eminent accoucheur, Dr. Osborn, ob- serves, that "woman is necessarily exposed to great pain, difficulty, and danger in parturition."* Again, "it is the intention of nature that la- bour should be a slow, deliberate, and painful operation."! And another, not less distinguished * Essays on the Practice oi Midwifery. Page 28, f Ibid: Page 49. 13 For his abilities, Dr. Denman, says, that " it is natural for women to have slow and painful la- bours."* This doctrine of the necessity of pain, appears to be founded, first, upon tha,t passage in the sacred writings which declares, that:' in sorrow thou shalt bring forth children," and which was announced to the mother of the human race, as a punishment for her disobedience: and, secondly, upon the erect po- sition of the human body.f It having been supposed necessary that nature should have formed such a structure of parts a.s would counteract the effects of gravity, and prevent premature labour. And though these ends are obtained, yet the means she has em- ployed create those obstacles which impede deli- very, and are unavoidably the eause of the excru- ciating pains which the unhappy sufferer is com- pelled to endure. That labour is frequently a tedious and pain- ful operation will not be denied; but that pain should be a necessary consequence of the form and struc- ture of the human body, or that the Supreme Being should have enjoined it as a curse upon the female Deuman's Midwifery. Vol. % p. 482. f Ofcboru's Essays, Fu^e 10. Denman's Midwifery.Vol. 2. p. 13. 14- sex, appears so derogatory to the idea we have of his wisdom and goodness, that we cannot admit it. That a woman may bring forth in sorrow, and yet not be subjected to much bodily pain may very readily be conceived. When she reflects upon the dangers attending the puerperal state, the slow and difficult recovery of some, the death of others : when she considers that half of the human race do not attain the age of seven years, that hardly an half of the remainder arrive to years of maturity, and that even should the fruit of her womb be so fortu- nate as to escape death in its youth, yet that it will be exposed to dangers and temptations in the world to which it may foil a prey, and which may render iife a burden to itself, and a reproach to its parents. Under circumstances like these, it may truly be said that in sorrow does she bring forth. But that it is not the intention of nature that labour should be a painful operation is sufficiently evident from the ease and facility with which many women are delivered. "We know that many women are safely delivered of full sized children so sudden- ly that they have scarce time to call for assistance: that, sometimes waking from their sleep with a slight pain, labour is hurried through in a few mi- nutes, while the woman is almost unconscious of 15 what has happened. Some women, again, have been taken in labour while walking, and have not even had time to be conveyed to any house, cr con- venient place ; but have dropped their burdens where they happened to be first seized. Others, while on a visit, at dinner, or in the midst of some amusement, have been surprised by labour, and have parted with their children with little pain or trouble."* If these facts be admitted, they will prove that pain does not occur in every case of parturition, and hence it will follow, that if all women are not neces- sarily and inevitably subjected to pain, none are ; but that pain or absence of pain must depend upon adventitious causes. We cannot suppose that a Being who has established general laws for the go- vernment of the universe would be partial in this particular. In proof of this we find, that women who live in a certain state of society, in a certain climate, or who follow a particular mode of life, are entirely free from pain. Bruce,f speaking of the women of Abyssinia, says, they do not confine themselves even a day after labour, but wash and return to their • Bland on Parturition. Page 24. f Travels to discover the source of the Nile. Vcl. 2, p 21. 16 work immediately. " A Morlack woman neither changes her food nor interrupts her daily fatigue on account of her pregnancy, and is frequently in the fields, or on the road by herself, and takes the infant, washes it in the first water she finds, carries it home, and returns the day after to her usual labour, or to feed her flock."* It is related by Hennepius,t that " the Spaniards in Brazil, who perform the office of midwives to their teeming con- sorts receive the infant, tear the navel string, and wash and paint it. The lying-in woman does not meet with more indulgence than the infant: as soon as she is disburdened, she goes and washes her- self, and immediately sets about her work without suffering the least inconvenience from it.'' He atsq says, " The wives of the Livonian peasants use the same custom. The women retire to some private place when the time of delivery is at hand* and return immediately after to their Work." " The Moorish women," says Sagnier and Bri&son,J " have no midwives, but are usually alone at the moment of delivery, laid on the ground under an fc Dobson's Encyclopaedia. Article Morlachia. f Ceremonies and Religious Customs of various Nations. Vol 3. p. 20. \ Voyage to the Coast of Africa. Page 494. 17 indifferent tent. They have seen these women de- part even on the day of their delivery, to encamp at the distance of fifteen or twenty leagues." The labours of the Sicilian women are accompa- nied with so little pain and danger, that they appear perfectly well the day after delivery. " For in this happy climate," says Brydone* " child-bearing is divested of all its terrors, and is only considered as a party of pleasure." The Indian women of our own country also possess this happy privilege to a great degree, " When taken in labour while marching with their husbands, they will retire behind a bush, deliver themselves, and in an hour's time rejoin their companions." This testimony in favour of the ease and facility of parturition, sufficiently proves, that it is not the in- tention of the Supreme Being, that it should be a pain- ful operation, and that it would at all times be per- formed with ease and safety, had not mankind, as they became more civilized, introduced customs and modes of living so very different from those of their ancestors. To this alteration, therefore, in their diet and habits of life, we may attribute the pain and dif- ficulty that so frequently attends labour. All the soft parts concerned in parturition in a natural and healthy state, are prepared and disposed to Tour through Sicilv and Malta, Vol. 2, Letter 22. 3 18 dilate, they therefore make little resistance to the ex- pulsion of the child, which is effected with very little exertion, and almost without pain. But from " ir- regular and improper customs and habits of living" they acquire such a firm and rigid texture, that it re- quires considerable force and time to dilate them. Although all the soft parts concerned in labour, are susceptible of this rigidit}r, yet in general it is more particularly confined to the os uteri, and the strongest and most violent contractions of the uterus, are some- times unable to overcome it. This firm and rigid texture of the os uteri, has been noticed by most writers on the obstetric art as a cause of difficult labour. And we have frequently known parturition delayed for hours and even days in some instances from this cause, when every other cir- cumstance was in favour of a speedy and happy termi- nation of the patient's sufferings. For the purpose of dilating the soft parts and ex- pelling its contents, the uterus is possessed of a strong power of contraction, by which means the liquor amnii and the foetus is pressed against the os uteri, and thus gradually dilate it. This action of the uterus we shall consider as threefold. First. A permanent contraction, by which, like other hollow viscera, it adapts itself to its contents, as the blood-vessels to the blood, and the bladder to the urine. 19 Secondly. The occasional contraction. This it owes to muscular structure. It is a temporary con- traction, and cannot be continued lone; at a time. Thirdly. An irregular, spasmodic, or convulsive action. By the first of these actions, when there is no resistance from the soft parts, the contents of the uterus is expelled. By the second, the os internum and externum is dilated. These two actions we con- sider as the natural, and healthy action of the uterus. The last is a disordered action, arising from great irritability of the uterus—from inflammation of the os uteri and parts adjacent, occasioned by violent pressure of the child's head—or from irritation of the os uteri by frequent examination or attempts to dilate the parts with the hand. This irregular action is never of any service in dilating the parts, or in expelling the foetus, and is generally attended with the most excruciating pain. It frequently occurs after the delivery of the child, and by closing the os tincse or by the contraction taking place in the middle of the uterus, it prevents the accoucheur from extracting the placenta.* It is always overcome with difficulty. In some cases it is * See the writings of Burton, Giffard, Mauriceau, La Motte, Exton, Johnson, Perfect, Deaxe, Denman and Osborn. 20 impossible to introduce the hand, and even dangerous to attempt it. The resistance to the expulsion of the foetus from the rigidity of the soft parts, and the irregular action of the uterus, we conceive to be the principal causes of pain. Hence the indications of lessening pain, are, to give to the soft parts a disposition to duVe, and to restore the uterus to its natural and healthy action. We do not find that any thing has been offered for the express purpose of lessening the Pains of Parturition until very lately.* Accoucheurs believ- ing it impossible to give to the parts their disposition to relax,! contented themselves with confining their attempts to dilate the os tincae, to very lingering or preternatural cases only. OpiumJ and the warm bath have been recom- mended for the purpose of relaxing the uterine parts. But to produce any such effect by opium, it would be necessary to give it in large doses; this might be attended with danger, as it has, when thus exhibited, " been known to produce convulsions. "|| Some ad- vantage might be derived from the relaxing power of the warm bath, but the application of it is attended • See Dr. Rush's letter to Dr. Miller. Med. Repository, Vol. 6. p. 26. f Denman's Midwifery, Vol 2, p. 69. J Mead's works, Vol. 3. p. 137. W Denman's Midwifery Vol. 2. p. 418. 21 with many inconveniences, and its good effects are not certain. We therefore do not consider either of them as proper remedies. The means usually employed were fomentations and mechanical dilatation by moving the hand in a rotatory manner. From the inability of producing a sufficient degree of relaxation by these means, re- course was too frequently had to instruments, by which the life of the child was often destroyed and considerable injury done to the mother. In consequence of the many inconveniences and dangers arising from this mode of practice, Accoucheurs at length thought it most prudent not to interfere, but in all cases (preternatural presentations, or where there was great deformity of the pelvis excepted) to trust entirely to the efforts of nature. Dr. Hamilton* relates a case in which, though the contractions of the uterus were " strong and fre- quent," yet it required two days before the os tincae was sufficiently dilated. And in his remarks on that case observes, that it " shews the advantages of wait- ing patientlyforthe efforts of nature." What, I would ask, are those advantages ? The case proves that nature, left to herself, had power sufficient to expel the child; but surely subjecting the patient to the most exquisite pain for forty eight hours, cannot be * Cases in Midwifery by J. Hamilton, Jun. M. D. Order 1st. case 4th. 22 considered an advantage. It is the more surprising that Dr. Hamilton should advocate this doctrine, as he appears to be well acquainted with the effects of blood-letting in relaxing the os uteri, and recom- mends it in cases where we might apprehend a rupture of the uterus.f That the powers of nature, in a simple state of society, and in those in whom a general relaxation of fibre is produced by climate, or particular habits of living, are sufficient for the expulsion of the foetus, has already been noticed. We also grant, that in general she is adequate to the task, in those who, from different modes of life, have produced the rigidity of the soft parts, which Ave have considered as the prin- cipal cause of difficulty; but here she requires a considerable time to effect her purpose, and her patient is subjected to much unnecessary pain, and great anxiety of mind. To view the distress of a fellow creature, from whatever cause it may arise, is to the mind of sensi- bility extremely painful; but there is no situation which excites greater solicitude, or in which our feelings are more interested, than that which we are now considering. Certainly then we ought not to be inactive spectators, when we have it in our power to give almost instantaneous relief, but should make use f Hamilton's Cases, Page 152. 23 of those means by which a mitigation of suffering may be obtained. And more especially when the means to be employed would not only produce pre- sent relief, but also prevent future danger. But there are cases in which nature requires such a considerable time to accomplish the delivery, that by waiting for her efforts irreparable injury is fre- quently the consequence. From great rigidity of the os uteri, and strong and violent contractions of the uterus, there has occurred; 1. Rupture of the uterus.* 2. A laceration of the os uteri, f 3. A protrusion of the os uteri before the head of the child, which, in some cases has been divided be- fore delivery could be effected. J 4. From long continued pressure of the head upon the soft parts, has arisen inflammation and mor- tification, which has sometimes proved fatal, and in other cases, though the patient has survived, she has been subject to an involuntary discharge of feces or urine through the vagina. || • Noticed by Foster, Dease, Denman, and J. Hamilton, Jun. f Perfect's Cases. Case 142. Foster's Midwifery, page 246. JAnnals of Medicine for 1798. Page 351. || Dease's Midwifery. Page 38 and 75. Clarke's practical Essays, p. 63. 24 5. From frequently repeated and violent con- tractions, the uterus becomes exhausted, an atony succeeds, and even though the soft parts should then become relaxed, the powers of the uterus are insuffi- cient to expel the foetus. In some such cases we must have recourse to instruments, nor does the in- jury end here ; from an inability of the uterus to con- tract, an hemorrhage supervenes, which is generally fatal to the patient.* And when we add to these, the risk of convul- sions,! rupture of blood-vessels,:}: or laceration of the perinaeum,fj all of which have happened and may again happen under similar circumstances, we cannot suppose that any great advantage can be derived from " waiting patiently for the efforts of nature." Having pointed out the ill consequences arising from a rigid state of the soft parts, and an irregular action of the uterus, we proceed to the consideration of the means by which these evils may be remedied. We shall notice first. Such as are necessary during gestation, and which will prevent a morbid irritability of the uterus, and enable the soft parts to retain their disposition to di'ate. And secondly. The means to * Hamilton's Cases. Order 2. Case 1st. f Denman, Vol. 2. p. 403. % Ibid. Vol. 2, p. 50. ff Foster, age 246. Dcase, page 35. Denman, Vol. 1. p. 67 and 3S3 25 be employed at the time of parturition, by which we may effect a dilatation of the soft parts and restore the uterus to its natural and healthy action. From the stimulus of distension, the indulgence of the appetite, and a deficiency of exercise, during the period of uterine gestation, there is a constant ten- dency to a plethoric disposition, this, if not actual disease, is the cause of most of the irregularities of the system attendant on pregnancy, and lays the foun- dation for the causes of pain and difficulty in parturi • tion, already mentioned. Hence it becomes necessary to pay particular attention to the state of the system, and when symptoms of disease occur, to be early in administering remedies for their removal. As most of the complaints of pregnancy arise from this pletho- ric disposition of the system, it will be proper in al- most every instance to meet them with the lancet. The safety of blood-letting in pregnancy is already sufficiently established, and although it is not neces- sary to bleed when there is no symptom of disease present, yet if we wish to conduct our patient in such a manner as to ensure her an easy labour, it would be highly improper to neglect blood-letting when these symptoms do occur. The remedies to obviate this plethoric disposi- tion, are first. A low diet. The appetite during pregnancy is frequently con^idciably increased, and much mischief has accrued from an inordinate indul- 4 26 gence of it. It will not only be necessary to lessen the quantity of food, but also to attend to its quality. Animal food, strong drinks, spices, and all substances of a simulating nature, should, in a great measure, be avoided, and a diet of fruit, vegetables and milk should be enjoined. The easy labours of the Indian women of America, have very properly been ascribed by Dr. Rush'* to their scanty diet. In the follow- ing case its good effects are apparent. CASE I. D. W. aged twenty five years was admitted preg- nant into the Alms-house on the 14th December 1802. In consequence of an ulcer on her neck she was ordered into the surgical ward, and was confined to a low diet, consisting entirely of vegetable substances, until the 12th of January 1803, when she was taken in labour: it came on so suddenly, that there was scarcely sufficient time to remove her to the lying-in room before she was delivered, and with so much ease, that it was observed by a medical student pre- sent, that it might be truly called a case of parturition without pain. Immediately after her delivery she arose, made up her bed and undressed herself, with as much unconcern as if nothing had happened to her. * Med. Repository, Vol. 6. page 26. 27 This patient was not confined an hour to her bed either from debility or disease. Secondly....Exercise. It is observed by Aris- totle " that those women who take most exercise endure uterine gestation and labour with greater ease and safety."* This observation has been confirmed by most of the succeeding writers on midwifery. Hence we account for the more easy labours of the women residing in the country, than of those in cities. And to the combination of exercise and scanty diet,. may be attributed the little pain and difficulty attend- ing parturition among the female slaves of the Southern States. Thirdly....Laxative medicines. These should be administered two or three times a week, for a month or six weeks previous to parturition. Their efficacy in disposing the parts to dilate is evident from the advantages following the use of sweet oil among the women of Turkey, which is supposed by Dr. Rushf to act merely as a purgative. For the purpose of ascertaining its effects the Ol. ricini was prescribed in the following case. • Introduction to Smellie's Midwifery, page 16, f Med. Repository, Vol. 6. page 26 28 CASE II. December the 1st. 1802, I was requested by Mrs. M. C. to attend her at the time of parturition, which she supposed would take place in about six weeks. She was thus early, she said, in her applica- tion, because in all her previous labours she had suf- fered extremely from the duration of labour and the intensity of pain with which it was attended; and if any thing could be done whereby she might obtain an alleviation of pain, she would willingly comply with any directions that I might give for that purpose. I desired her to take ioz. of the ol. ricini every other day, and continue the use of it until the time of partu- rition. During the six weeks she made use of 12oz. On the 10th. January 1803, I was sent for, but before I arrived at the house, she had parted with her child. The information which I received, was, that she had sent for me on the approach of the first pain, that be- fore that pain had left her the membranes were rup- tured; that it was quickly succeeded by another which expelled the child, and that the pain she expe- rienced was so trifling, that she could not say she had suffered any. But as practitioners are seldom consulted respect- ing the regimen to be observed during gestation, and 29 frequently are not called until the moment when their assistance becomes necessary, they are precluded from advising the measures recommended for the prevention of the causes of pain and difficulty. We therefore meet with these causes, and must attempt their removal at the commencement of labour. We now proceed to the consideration of the means mentioned under our second general head viz. Such remedies as may be employed at the time of parturition, for the purpose of effecting a relaxation of the soft parts and restoring the uterus to its natural and healthy action. They are first—Blood-letting. This of itself is fully adequate to the purpose, and is the best remedy we can employ, it not only produces present effects in lessening the pains of labour, but extends its beneficial influence to the prevention of subsequent dangers. In cases where blood-letting is objected to, perhaps some advantage might be derived from, secondly—Nauseating doses of emetics. Of this remedy wc can say nothing from experience, but from observing the relaxation that has frequently fol- lowed nausea and vomiting in difficult cases, and from the common observation of the old women " that a sick labour is an easy one," we have been led to sup- pose, that much benefit might be obtained from adopting a mode of relief pointed out by nature. So great a degree of relaxation is produced by nauseat- 30 ing medicines, that they have been recommended by Dr. Ph} sick* when blood-letting is objected to, in cases of luxation where the reduction of the bone is prevented by muscular contraction. Blood-letting for the express purpose of lessen- ing the pains of parturition, was first recommended by Dr. Rush.f It was adopted by several practitioners of medicine with the happiest effects. Of its efficacy we can speak from experience. The following cases which we have selected from a number of others, will shew in the most striking manner the great utili- ty derived from the use of it. CASE III. In November 1801,1 was desired by Dr. De Wees to visit a woman who had been in labour nearly two days, on arriving at my patient's I received the follow- ing account from the midwife in attendance. The woman she said was large and fat, in labour with her first child, and twenty eight years of age, that she had been in labour thirty six hours, at the commencement of which every thing appeared to do well, that the labour though slow gradually progressed until the • M. S. Lect. on Surgery. f Med. Repository Vol. 6, page 26. 31 head of the child had passed the os tincae, after which notwithstanding the pains were strong and frequent, no further progress was made. In this situation she had passed the twenty four hours previously to my arrival. On making an examination, I found the head firmly wedged in the vagina, the external parts very firm and rigid, and it was with difficulty that I could in- troduce two fingers into the os externum. It was here evident, that the rigidity of the ex- ternal parts was the sole cause that retarded the birth of the child. I therefore immediately determined to bleed my patient in order to effect a relaxation of the parts. My intention was to bleed ad deliquium animi, but after drawing off forty eight ounces of blood and finding there was no tendency to syncope, I stop- ped the bleeding to examine the state of the parts. I now found that they were very much relaxed, and that the head was slowly advancing. Yet so per- fectly easy was the patient, that it could not be ascer- tained from external appearances that the uterus was contracting. I then requested the midwife to take the seat that I might tie up the arm, and before this was effected my patient was delivered of a large healthy child, and declared that she did not experience the least degree of pain during its expulsion. This was at that time to me a very interesting case, and from it, may be deduced the following in- ferences. 32 That a large quantity of blood may be drawn without injury to the patient. That it is not necessary to bleed until fainting is induced, in order to effect a relaxation of the parts, or to restore the uterus to its natural or healthy action. That after the resistance from the rigidity of the soft parts is removed, the permanent contraction of the uterus is sufficient to expel the child. That when a relaxation of the soft parts is effect- ed and the uterus restored to its healthy action, partu- rition will take place with very little pain. CASE IV. In December 1802, I was requsted by A. B. to visit his wife who was then he said in labour, on my arrival I was informed, that she had had several severe pains, but that they had teft her, and she was now easy. On making an examination per vaginam, I found the os uteri very little dilated and its edges ex- tremely hard. I proposed bleeding, which was readily assented to. She had heard she said of its good effects, from several of her neighbours whom I had attended, and wished to try the experiment. I accordingly took from her twenty four ounces of blood. Having a case at the same time to attend to in the Alms-house, I was under the necessity of leaving 33 her, but desired they would send for me immediately on the return of her pains. I heard no more of this patient until the next day, when on meeting her hus- band, and inquiring after his wife, he informed me, that about one hour after I had left her, she had a return of her pains, that she requested him to go for me, but that before he could leave the room the child was born. On visiting this patient afterwards, I learnt that the pain she experienced during the expulsion of the child, was considerably less than that she had suffered previously to her being bled. CASE V. E. R. aged twenty eight years, was admitted into the Alms-house on the 3rd. of February 1803. A few hours after her admission she complained of slight labour pains, which gradually became weaker and at length entirely subsided. An injection was given, and at 10 o'clock P. M. I took from her 20 oz. of blood, and left her with directions to have me called as soon as her pains should return. About 2 o'clock A. M. of the 4th, I was called by the nurse, but before I could reach the room, although not more than ten minutes had elapsed, I was informed that the child was born. This patient declared 5 34 that she sent for me the moment she experienced the least degree of pain; that she had felt but two or three slight pains before the child was born ; and also, that she had suffered much more in a former labour from one pain, than she had in this, during its whole continuance. CASE VI. M. C. aged thirty years, became in labour on the morning of the 27th. January 1803. During the whole of this day her pains were strong and fre- quent, yet had so little effect in dilating the os uteri, that on the morning of the 28th. it was only suffici- ently dilated to ascertain that the vertex presented. From this time to 12 o'clock, she suffered consi- derably from the violent contractions of the uterus, but notwithstanding this strong action, the os uteri remained inflexibly hard and tense, and was not di- lated to more than the size of half a crown. She now lost 12 oz. of blood, this however produced no effect; at one o'clock the os uteri retained its pristine rigidity. I now drew off 20 oz. more of blood. So immediate was the dilatation that in ten minutes she was safely delivered. From the foregoing cases we may infer, that blood-letting at the time of parturition is a safe, 35 easy, and effectual means of lessening the pains of labour. This inference is confirmed by a number of other cases in which we have employed that remedy for this purpose ; in no instance did any ill consequence arise from the use of it, and in every case the patient had a speedy and happy recovery. Case fourth and fifth will shew the impropriety of leaving our patients after a large bleeding. Blood-letting to be effectual must be copious. We have not observed in any instance that a less quantity than twenty ounces has produced any great effect upon the os tincae, but in those cases where the patient lost from twenty to forty ounces, it fre- quently acted as a charm in producing an immedi- ate dilatation of the soft parts. We should there- fore repeat the operation, when we find that no effect is produced by the first bleeding. There are however exceptions to this as a gene- ral rule ; from those " who have been debilitated by previous disease, or by accidental evacuations of any kind" it would not be necessary to take so large a quantity, the parts being disposed to dilate, easily yield to the slightest impulse. Hence we find that labours in the last stage of chronic diseases are generally attended with but little pain. It may be objected to this practice, that copi- ous blood-letting would occasion syncope, whereby 36 the uterus might lose its power of contraction, and consequently there would be an inability to expel the foetus. Such an accident we believe would not occur, unless considerably more blood than neces- sary was taken. We have used blood-letting for the purpose of lessening pain in a number of cases, and in no instance was a faintness induced. The system during pregnancy, and at the time of partu- rition, will bear the loss of blood in larger quantities without its producing faintness, than at any other time. From a mere disposition to f.iint we would apprehend no danger. " Blood-letting lessens sen- sibility but not irritability."* And the uterus " acts, or makes its efforts to act, in sleep, during faintness, and sometimes even after death."f In this state of the system, such a complete relaxation takes place, that the permanent contraction of the uterus would be sufficient to expel the child. In those cases in which blood-letting was em- ployed at the commencement of labour, it generally suspended the action of the uterus for some time : during this suspension of action the parts assumed their disposition to dilate, and on the return of the uterine contractions, the delivery was accomplished * Rush's M. S. Lectures. f Denman's Midwifery, Vol. 2. page 33*. 37 in a short time, and attended with very little pain. But in cases where it was not employed until twenty- four or thirty hours after the commencement of la- bour, its effects were immediate. Nor is the lessening the pains of parturition the only advantage we derive from blood-letting. By the use of this remedy we prevent all those acci- dents which have been enumerated as arising from the rigidity of the soft parts, and the irregular action of the uterus. By blood-letting we prevent the premature rupture of the membranes, and thereby have the assistance of the waters in dilating the parts. It facilitates the delivery of the placenta by preventing spasmodic contractions of the uterus. It prevents after pains, puerperal fever and mania. In preternatural presentations, blood-letting by removing the spasmodic action of the uterus, and relaxing the parts, very much facilitates the intro- duction of the hand, and delivery of the child. And in cases where there is a deformity of the pelvis, though we cannot by bleeding hasten par- turition, yet by its relaxing effects, it will enable us to make use of the necessary means, with more ease to our patients as well as ourselves. To the medical Professors of this university, for the instruction I have received from their truly 38 valuable lectures, I return my most grateful thanks. And that each of you Gentlemen may long enjoy that honour and happiness which you so deserved- ly merit, from your indefatigable exertions in the promotion of useful knowledge, is my most fervent wish. THE END Meet- Hist". MO I20H ★ * ARMY * * MEDICAL LIBRARY Cleveland Branch ■ir* % ~ ''*^ ■ „ 'v^lfc .^ *?a ^^"^ O' $'Sfr '*W ^Wb-